The

Reference Manual
of Pediatric Dentistry

Definitions
Oral health policies
Recommendations
Endorsements
Resources
2022– 2023

®
®
© 2022 American Academy of Pediatric Dentistry

211 East Chicago Avenue, Suite 1600

Chicago, Illinois, 60611

ISBN 978-1-7334978-4-8 (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; 2022:266-72.

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 *

Homa Amini Amy Kim

Matina Angelopoulou
Soraya M. Beiraghi
Enrique Bimstein
Erica Ann Brecher
Tegwyn H. Brickhouse
Erin Ealba Bumann
Dan Burch III
Erica M. Caffrey
Jung-Wei Anna Chen Francisco J. Ramos-Gomez
Donald L. Chi
Judith R. Chin
Charles E. Clark
Matthew Cooke
Carolyn B. Crowell
Yasmi O. Crystal
Jennifer L. Cully
Vineet Dhar
Keri Discepolo
Kimon Divaris
Kevin J. Donly
Catherine M. Flaitz
Scott Goodman
Elizabeth Gosnell
Jennifer Hill
Catherine Hong
Shijia Hu
Janice G. Jackson
Elva V. Jordan
Carolyn A. Kerins Maria Regina ( Ninna ) P. Yuson
John W. Kersey, Jr.
Gajanan V. Kulkarni
Naomi Lane
Randall K. Lout
Man Wai Ng
Anne C. O’Connell
Mitali Y. Patel
Kimberly Kay Patterson
Priyanshi Ritwik
R. Glenn Rosivack
Brian J. Sanders
Robert J. Schroth
Allison Scully
Rachael L. Simon
Julio E. Sotillo
Thomas R. Stark
William V. Stenberg †
Jenny Ison Stigers
Harlyn Kaur Susarla
Thomas Tanbonliong
Janice A. Townsend
Adriana Modesto Vieira
Karin Weber-Gasparoni
Jessica Webb
Anne R. Wilson
J. Timothy Wright
Patrice B. Wunsch
Sabina S. Yun
Derek S. Zurn

* As of May 2022. 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
Revised 7 Overview
Reaffirmed 10 Strategic Plan
Revised 12 Research Agenda

Definitions
15 Dental Home
16 Dental Neglect
17 Medically-Necessary Care
18 Special Health Care Needs

Oral Health Policies

21 Dental Home
23 Medically-Necessary Care
Revised 29 Social Determinants of Children’s Oral Health and Health Disparities
34 Care for Vulnerable Populations in a Dental Setting
New 41 Diversity, Equity, and Inclusion
45 Workforce Issues and Delivery of Oral Health Care Services in a Dental Home
50 Teledentistry
Revised 52 Child Identification Programs
54 Oral Health Care Programs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
58 Oral Health in Child Care Centers
Revised 61 School-Entrance Oral Health Examinations
64 School Absences for Dental Appointments
66 Emergency Oral Care for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
Revised 67 Role of Dental Prophylaxis in Pediatric Dentistry
70 Use of Fluoride
72 Use of Silver Diamine Fluoride for Pediatric Dental Patients
76 Use of Xylitol in Pediatric Dentistry
Revised 78 Interim Therapeutic Restorations (ITR)
Revised 80 Management of the Frenulum in Pediatric Patients
New 86 Pacifiers
90 Early Childhood Caries (ECC): Consequences and Preventive Strategies
94 Early Childhood Caries (ECC): Unique Challenges and Treatment Options
Revised 96 Dietary Recommendations for Infants, Children, and Adolescents
Revised 101 Snacks and Sugar-Sweetened Beverages Sold in Schools
103 Tobacco Use
108 Electronic Nicotine Delivery Systems (ENDS)
112 Substance Misuse in Adolescent Patients
117 Human Papilloma Virus Vaccinations
119 Intraoral/Perioral Piercing and Oral Jewelry/Accessories
121 Prevention of Sports-Related Orofacial Injuries
127 Use of Dental Bleaching for Child and Adolescent Patients
Revised 131 Use of Lasers for Pediatric Dental Patients
135 Obstructive Sleep Apnea (OSA)
Revised 139 Pediatric Dental Pain Management
142 Minimizing Occupational Health Hazards Associated with Nitrous Oxide
144 Hospitalization and Operating Room Access for Oral Care of Infants, Children, Adolescents, and Individuals with Special Health Care Needs
146 Hospital Staff Membership
Revised 148 Model Dental Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
152 Third-Party Reimbursement for Management of Patients with Special Health Care Needs
Revised 156 Third-Party Reimbursement of Medical Fees Related to Sedation/General Anesthesia for Delivery of Oral Health Care Services
160 Third-Party Reimbursement for Oral Health Care Services Related to Congenital and Acquired Orofacial Differences
163 Third-Party Reimbursement of Fees Related to Dental Sealants
Revised 165 Third-Party Fee Capping of Noncovered Services
167 Third-Party Payor Audits, Abuse, and Fraud
171 Role of Pediatric Dentists as Both Primary and Specialty Care Providers
172 Transitioning from a Pediatric to an Adult Dental Home for Individuals with Special Health Care Needs
176 Patient Safety
181 Selecting Anesthesia Providers for the Delivery of Office-Based Deep Sedation/General Anesthesia
184 Ethical Responsibilities in the Oral Health Care Management of Infants, Children, Adolescents, and Individuals with Special Health Care Needs
186 Patient’s Bill of Rights and Responsibilities
Revised 188 Using Harvested Dental Stem Cells
190 Infection Control

4 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 Recommendations
Clinical Practice Guidelines
195 Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs
205 Use of Pit-and-Fissure Sealants
222 Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions
236 Use of Non-Vital Pulp Therapies in Primary Teeth

Best Practices
Revised 253 Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents
Revised 266 Caries-Risk Assessment and Management for Infants, Children, and Adolescents
273 Prescribing Dental Radiographs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
277 Perinatal and Infant Oral Health Care
282 Adolescent Oral Health Care
292 Oral Health Care for the Pregnant Pediatric Dental Patient
302 Management of Dental Patients with Special Health Care Needs
310 Oral and Dental Aspects of Child Abuse and Neglect
317 Fluoride Therapy
321 Behavior Guidance for the Pediatric Dental Patient
340 Use of Protective Stabilization for Pediatric Dental Patients
347 Use of Local Anesthesia for Pediatric Dental Patients
353 Use of Nitrous Oxide for Pediatric Dental Patients
359 Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures
387 Use of Anesthesia Providers in the Administration of Office-Based Deep Sedation/General Anesthesia to the Pediatric Dental Patient
Revised 392 Pain Management in Infants, Children, Adolescents, and Individuals with Special Health Care Needs
Revised 401 Pediatric Restorative Dentistry
415 Pulp Therapy for Primary and Immature Permanent Teeth
424 Management of the Developing Dentition and Occlusion in Pediatric Dentistry
442 Acquired Temporomandibular Disorders in Infants, Children, and Adolescents
451 Classification of Periodontal Diseases in Infants, Children, Adolescents, and Individuals with Special Health Care Needs
New 466 Risk Assessment and Management of Periodontal Diseases and Pathologies in Pediatric Dental Patients
485 Management Considerations for Pediatric Oral Surgery and Oral Pathology
Revised 495 Use of Antibiotic Therapy for Pediatric Dental Patients
Revised 500 Antibiotic Prophylaxis for Dental Patients at Risk for Infection
Revised 507 Dental Management of Pediatric Patients Receiving Immunosuppressive Therapy and/or Head and Neck Radiation
517 Informed Consent
521 Recordkeeping

Endorsements
531 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: General Introduction
536 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations
552 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth
561 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 3. Injuries in the Primary Dentition
576 Policy on the Management of Patients with Cleft Lip/Palate and Other Craniofacial Anomalies

Resources
580 Dental Growth and Development
581 Growth Charts
587 Body Mass Index (BMI) Charts
589 Recommended USDA Food Patterns
592 Healthy Beverage Consumption in Early Childhood
594 Childhood and Adolescent Immunization Schedule
604 Speech and Language Milestones
606 Pediatric Medical History
New 609 Systemic Diseases and Syndromes that Affect the Periodontium
612 Chairside Guide: Silver Diamine Fluoride in the Management of Dental Caries Lesions
Revised 614 Acute Traumatic Injuries: Assessment and Documentation
Revised 616 Acute Management of an Avulsed Permanent Tooth
618 Pediatric Airway Assessment
Revised 620 Preparing for Your Child’s Sedation Visit
Revised 622 Procedural Sedation Record
Revised 624 Postoperative Instructions for Extractions/Oral Surgery
Revised 625 Record Transfer
626 Release for School Absences
Revised 627 Common Laboratory Values
Revised 628 Useful Medications for Oral Conditions
Revised 636 Management of Medical Emergencies
Revised 638 Severe Acute Respiratory Syndrome Coronavirus 2 and COVID-19
639 Basic Life Support /Cardiopulmonary Resuscitation
Revised 640 Delineation of Privileges

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 5

Introduction
Overview
Strategic Plan
Research Agenda

Overview
Definitions and scope of pediatric dentistry
“Pediatric dentistry is an age-defined specialty that provides
both primary and comprehensive preventive and therapeutic
oral health care for infants and children through adolescence,
including those with special health care needs.”1
To become a pediatric dental specialist, a dentist must
satisfactorily complete a minimum of 24 months in an ad-
vanced education program accredited by the Commission on
Dental Accreditation of the American Dental Association.
Such programs “must be designed to provide special knowl-
edge and skills beyond the D.D.S. or D.M.D. training...”2 The
curriculum of an advanced program provides the dentist with
necessary didactic background and clinical experiences to pro-
vide comprehensive primary oral health care and the services
of a specialist. Pediatric dentists provide care, conduct
research, and teach in a variety of clinical and institutional
settings, including private practice and public health. They
work in coordination with other health care providers and
members of social disciplines for the benefit of children.
The primary focus of most dental specialties is a particular
area of dental, oral, or maxillofacial expertise. Pediatric dentist-
ry encompasses a variety of disciplines, techniques, procedures,
and skills that share a common basis with other specialties
but are modified and adapted to the unique requirements of
infants, children, adolescents, and those with special health care
needs. By being an age-specific specialty, pediatric dentistry
encompasses disciplines such as behavior guidance, care of
patients with medical conditions and physical and develop-
mental disabilities, supervision of orofacial growth and
development, caries prevention, sedation, pharmacological
management, and hospital dentistry, as well as other traditional
fields of dentistry. These skills are applied to the needs of chil-
dren throughout their ever-changing stages of development
and to treating conditions and diseases unique to growing
individuals.
The American Academy of Pediatric Dentistry (AAPD),
founded in 1947, is the membership organization representing
the specialty of pediatric dentistry. Its members put children
first in everything they do and aim to achieve the highest
standards of ethics and patient safety. They provide care to
millions of our nation’s infants, children, adolescents, and
persons with special health care needs and are the primary
contributors to professional education programs and publica-
tions on pediatric oral health.
The AAPD, in accordance with its vision and mission,
advocates optimal oral health for all children. It is the leading
national advocate dedicated exclusively to children’s oral health.
Advocacy activities take place within the broader health care
community and with the public at local, regional, and national
levels. The Reference Manual of Pediatric Dentistry (https://
www.aapd.org/research/oral-health-policies--recommendations/) is
one of the components of the AAPD’s advocacy activities.
INTRODUCTION: OVERVIEW
How to Cite: American Academy of Pediatric Dentistry. Overview.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:7-9.
Intent of The Reference Manual of Pediatric
Dentistry
The Reference Manual of Pediatric Dentistry is intended to en-
courage a diverse audience to provide the highest possible level
of care to children. This audience includes, but is not limited to:
• pediatric dentists.
• general dental practitioners and other dental specialists.
• physicians and other health care providers.
• government agencies and health care policy makers.
• individuals interested in the oral health of children.
The Reference Manual of Pediatric Dentistry is divided into
five sections: (1) Definitions, (2) Oral Health Policies, (3)
Recommendations, (4) Endorsements, and (5) Resources. Oral
health policies are statements relating to AAPD positions on
various public health issues. Recommendations are developed
to assist the dental provider in making decisions concerning
patient care. This section has two subcategories, Clinical
Practice Guidelines and Best Practices, distinguished by the
methodology employed to develop the recommendations. Ad-
herence to the recommendations increases the probability of
a favorable practice outcome and decreases the likelihood of
an unfavorable practice outcome. The endorsements section
includes clinical recommendations relevant to the practice of
pediatric dentistry that have been developed by organizations
with recognized expertise and adopted by the AAPD.
Resources contains 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.
Proper utilization of The Reference Manual of Pediatric
Dentistry necessitates recognizing the distinction between
standards and recommendations. Although there are certain
instances within the recommendations where a specific action
is mandatory, The Reference Manual of Pediatric Dentistry is
not intended nor should it be construed to be either a stan-
dard of care or a scope of practice document. The Reference
Manual of Pediatric Dentistry contains recommendations for
care that could be modified to fit individual patient needs
based on the patient, the practitioner, the health care setting,
and other factors.
Definition and Scope of Pediatric Dentistry
For the purpose of this document, the following definitions
shall apply:
Standards: Any definite rule, principle, or measure established
by authority. Standards say what must be done. They are
intended to be applied rigidly and carry the expectation that
they are applied in all cases and any deviation from them
would be difficult to justify. The courts define legal standards
of care.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 7
INTRODUCTION: OVERVIEW
Clinical practice guidelines (CPG): “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.”3
CPG are intended to be more flexible than standards. They
should be followed in most cases, but they recognize that
treatment can and should be tailored to fit individual needs,
depending on the patient, practitioner, health care setting, and
other factors. Deviations could be fairly common and could
be justified by differences in individual circumstances. CPG
originate in an organization with recognized professional ex-
pertise and stature. They are designed to produce optimal
outcomes, not minimal standards of practice.
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.”4 Like CPG, best practices are more flexible than
standards and originate in an organization with recognized
professional expertise and stature. Although they may be un-
solicited, they usually are developed following a stated request
or perceived need for clinical advice or instruction.
Must or shall: Indicates an imperative need and/or duty; an
essential or indispensable item; mandatory.
Should: Indicates the recommended need and/or duty; highly
desirable.
May or could: Indicates freedom or liberty to follow a sug-
gested alternative.
Parent: Unless otherwise indicated, the term parent as used in
these oral health policies and recommendations has a broad
meaning encompassing:
1. a natural/biological or adoptive father or mother of a
child with full parental legal rights,
2. a person recognized by state statute to have full
parental legal rights,
3. a parent who in the case of divorce has been awarded
legal custody of a child,
4. a person appointed by a court to be the legal guardian
of a minor child,
5. a person appointed by a court to be the guardian for
an incapacitated adult,
6. a person appointed by a court to have limited, legal
rights to make health care decisions for a ward,
7. 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).
8 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Development of oral health policies, best practices, and
clinical practice guidelines
The oral health policies, best practices, and clinical practice
guidelines of the AAPD are developed under the direction
of the Board of Trustees (BOT), utilizing the resources and
expertise of its membership operating through the Council
on Clinical Affairs (CCA), the Council on Scientific Affairs
(CSA), and the Evidence-based Dentistry Committee (EBDC)
of the AAPD Pediatric Oral Health Research and Policy
Center. CCA and CSA are composed of individuals repre-
senting the five geographical (trustee) districts of the AAPD,
along with additional consultants confirmed by the BOT.
The EBDC is comprised of two members from each of these
councils as well as the AAPD’s editor-in-chief. Council/
committee members and consultants derive no financial
compensation from the AAPD for their participation in
development of oral health policies, best practices, and
clinical practice guidelines, and they are asked to disclose
potential conflicts of interest. The AAPD has neither solicited
nor accepted any commercial involvement in the development
of the content of this publication.
Proposals to develop or modify oral health policies and
best practices may originate from four sources:
• the officers or trustees acting at any meeting of the
BOT.
• a council, committee, or task force in its report to
the BOT.
• any member of the AAPD who submits a written
request to the BOT as per the AAPD Administrative
Policy and Procedure Manual, Section 9 (the full
text of this manual is available on the Members’
Only page of the AAPD website).
• officers, trustees, council and committee chairs, or
other participants at the AAPD’s annual strategic
planning session.
Regardless of the source, proposals for oral health policies
and best practices are considered carefully, and those deemed
sufficiently meritorious by a majority vote of the BOT are
referred to the CCA for development or review/revision. The
CCA members are instructed to follow the specified process
and format for the development of a policy. Oral health
policies and best practices utilize two sources of evidence:
the scientific literature and experts in the field. The CCA, in
collaboration with the CSA, performs a literature review for
each document. When scientific data do not appear conclusive
or supplemental expertise is deemed beneficial, authorities
from other organizations or institutions may be consulted.
The CCA meets on an interim basis to discuss proposed
oral health policies and best practices. Each new or reviewed/
revised document is deliberated, amended if necessary, and
confirmed by the entire council. Once developed by the
CCA, the proposed document is submitted for the consider-
ation of the BOT. While the Board may request revision, in

which case it is returned to the council for modification,
once accepted by majority vote of the Board, it is referred
for Reference Committee hearing at the next Annual
Session. The Reference Committee Hearing is an open forum
for the membership to provide comment or suggestion for
alteration of the document. The CCA carefully considers all
remarks presented at the Reference Committee Hearing prior
to submitting its final document for ratification by a majority
vote of the membership present and voting at the General
Assembly. If accepted by the General Assembly, either as
proposed or as amended by that body, the document then
becomes the official AAPD oral health policy or best practice
for publication in The Reference Manual of Pediatric
Dentistry and on the AAPD’s website (https://www.aapd.org/
research/oral-health-policies--recommendations/).
The EBDC provides oversight and management of the
CPG development process. The topic for each guideline is
recommended by the EBDC and approved by the BOT.
Once a topic has been affirmed, the process begins with
searches for an existing CPG from another organization with
recognized expertise and for related systematic reviews. The
EBDC will evaluate available publications and recommend
either endorsement of an existing guideline or development
of a new CPG. If a CPG is to be developed, the EBDC
recommends to the BOT individuals for the guideline work-
group. Workgroup members are respected clinicians (end
users), authors of peer reviewed publications in the topic under
review, and methodology experts. All workgroup members
should be capable of knowledgeably assessing a body of
evidence using criteria approved by the EBDC. The duties of
each workgroup may include:
• develop a research protocol.
• develop the PICO (Patient, Intervention, Comparison,
Outcome) question for each guideline.
• select studies for full-text retrieval and extraction, and
extract for each study selected.
• perform evidence synthesis: meta-analysis or narrative
synthesis.
• grade evidence (based on GRADE criteria5).
• write a systematic review.
• review and edit a guideline.
• modify a guideline according to external review recom-
mendations.
AAPD may choose to develop CPG in collaboration with
other organizations of recognized expertise and stature. Such
joint guidelines would undergo a similar development process
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
INTRODUCTION: OVERVIEW
Manual of Pediatric Dentistry, and posting on the AAPD’s
website (https://www.aapd.org/research/oral-health-policies--
recommendations/).
Review of oral health policies and clinical
recommendations
Each AAPD oral health policy, best practice, and clinical
practice guideline is reviewed for accuracy, relevance, and
currency every five years, and more often if directed by the
BOT. After completing a new literature search, reviewers may
recommend reaffirmation, revision, or retirement of the docu-
ment. Policies and recommendations of other organizations
that have been endorsed by the AAPD are reviewed annually
to determine currency as well as appropriateness for the
AAPD’s continued endorsement.
References
1. National Commission on Recognition of Dental Special-
ties and Certifying Boards. Specialty Definitions. Pediatric
Dentistry. Adopted May, 2018. Available at: “https://ncr
dscb.ada.org/en/dental-specialties/specialty-definitions”.
Accessed October 5, 2022.
2. Commission on Dental Accreditation. Accreditation
Standards for Advanced Dental Education Programs in
Pediatric Dentistry. Chicago, Ill.; 2022. Available at:
“https://coda.ada.org/~/media/CODA/Files/Pediatric_
Dentistry_Standards.pdf?la=en”. Accessed October 5,
2022.
3. Institute of Medicine. Introduction. In: Clinical Practice
Guidelines We Can Trust. 2011. Washington, D.C.: The
National Academies Press; 2022:25-6. Available at:
“https://www.ncbi.nlm.nih.gov/books/NBK209539/pdf/
Bookshelf_NBK209539.pdf ”. Accessed October 5, 2022.
4. Centers for Disease Control and Prevention. Acronyms,
glossary, and reference terms. Available at: “https://www.
cdc.gov/nphpsp/PDF/Glossary.pdf ”. Accessed October 5,
2022.
5. Schünemann H, Brożek J, Guyatt G, Oxman A. GRADE
Handbook: Handbook for grading the quality of evidence
and the strength of recommendations using the GRADE
approach. Update October 2013. The GRADE Working
Group. Available at: “https://gdt.gradepro.org/app/hand
book/handbook.html”. Accessed October 5, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 9
INTRODUCTION: STRATEGIC PLAN
The American Academy of Pediatric Dentistry
Strategic Plan
Reaffirmed
2022
Vision
Optimal oral health for all children.
Mission
To advance optimal oral health for all children by deliver-
ing outstanding service that meets and exceeds the needs and
expectations of our members, partners, and stakeholders.
AAPD Culture
Our members put children first in everything they do, and at
the highest standards of ethics and patient safety. As such,
the American Academy of Pediatric Dentistry is THE leading
national advocate dedicated exclusively to children’s oral
health. We are the embodiment of our members’ expertise as
the big authorities on little teeth.
Strategic Objectives
Clinical Expertise
We equip our members and all other providers with data,
knowledge, competencies, and skills to provide safe, high-
quality, evidence-based patient care in the context of a dental
home.
• Provide and promote continuing clinical education that
meets the changing needs of patients and their care-
givers.
• Use the authority and expertise of our members to
advocate for patient safety, improved outcomes, and
intelligent regulatory oversight.
• Invest in pre- and post-doctoral education by support-
ing training programs, advising accreditation boards,
and sponsoring programs to enhance success through-
out their career.
Patient Care and Access
We help members address barriers to care, such as parent oral
health literacy and affordability; reduce administrative burdens
for payment/reimbursement; and invest in community-based
initiatives providing care to underserved children.
• Support research that identifies the scope of dental need
in the U.S. and supports the best clinical practices for
patient care.
• Advocate for legislative reforms to reduce the admin-
istrative complexity of reimbursement for dental
treatment.
10 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. The American
Academy of Pediatric Dentistry strategic plan. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:10-1.
• Support and promote programs that provide care to
those in need.
Workforce and Practice Transformation
We support the pediatric dental workforce, expanding its
reach and to better address children’s oral health needs. We
develop practical tools and resources to help all members in
any practice setting build and sustain high-functioning dental
care practices to the benefit of their patients and their com-
munities.
• Support research to examine the distribution and pro-
files of providers, to help members make informed
decisions about their practices.
• Develop and provide tools that enable our members
in all practice settings to provide optimal care.
• Offer education courses in non-clinical areas of dental
practice.
• Assist members in achieving a healthy work-life bal-
ance so they can enjoy a sustained career in pediatric
dentistry.
• Provide opportunities to develop leadership skills that
will help our members in their practice as well as in
volunteer positions in the AAPD.
• Sponsor programs to manage student debt.
Advocacy
We take a solutions-based approach to educating the broader
dental profession, local, state, and national policy makers, and
consumers/parents about critical issues affecting child oral
health in the United States.
• Advise and influence public policy through direct ad-
vocacy as well as by training members to be advocates
in their practices and their communities.
• Educate the public on key children’s oral health topics
through public service messages, media interviews by
AAPD-trained spokespersons, contributions to parent
blogs, and other communication opportunities as they
occur.
• Help members to exchange information on legislative
issues.
• Exchange information with other healthcare and chil-
dren’s organizations.

Operations
We maintain organizational effectiveness by meeting and
exceeding accepted professional association management
standards.
• Nurture an efficient and effective governance struc-
ture that incorporates a variety of experiences so that
all viewpoints are represented. The structure creates a
network of experts so that AAPD can quickly respond
to emerging issues.
INTRODUCTION: STRATEGIC PLAN
• Help volunteer leadership concentrate on issues by
providing full administrative support and strategic
advice.
• Coordinate marketing and public relations for a con-
sistent message to members and the public.
• Select and develop the best talent.
• Provide solid financial analysis and direction for all
activities of the AAPD.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 11
INTRODUCTION: RESEARCH AGENDA
The American Academy of Pediatric Dentistry
Research Agenda
Latest Revision
2022
The American Academy of Pediatric Dentistry (AAPD) recognizes
that high-quality evidence is the foundation of the science and
practice of pediatric dentistry. Clinical care should be based
on evidence-based dentistry (EBD) principles. Where there is
insufficient evidence, relevant research should be conducted to
help fill scientific gaps and better inform clinical practice. The
AAPD Council on Scientific Affairs is charged with updating
and affirming the AAPD Research Agenda.
The AAPD Research Agenda highlights strategic research
topics relevant to the mission of pediatric dentistry. To help im-
prove individual patient and population oral health outcomes,
the AAPD urges academic, state, federal, philanthropic, and cor-
porate 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, addressing,
and eliminating oral health disparities to promote oral
health (e.g., basic behavioral and social determinants of
12 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. The American
Academy of Pediatric Dentistry research agenda. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:12.
health, basic science of craniofacial development, micro-
biology and microbiome research, development of
evidence-based public health interventions, clinical trials
focusing on children and vulnerable populations, integration
of dentistry into the broader health care delivery system,
bioinformatics, quality of care, models of interprofessional
collaboration, big data, data mining and sharing, inter-
disciplinary care teams, and telehealth/teledentistry).
• Translational research: Moving scientific knowledge into
practice and policy (e.g., dissemination and implementa-
tion of evidence-based care principles into clinical practice,
barriers to dissemination and implementation, policy and
practice partnerships).
• Operational safety and environmental impact research:
Increasing understanding of health and safety issues
within the established and remote practice of dentistry
and the protection of pediatric patients and dental/
healthcare professionals from risks of infection transmis-
sion (e.g., infection control, personal protective equip-
ment, waterline disinfection, sterilization techniques,
environmental impact to/from dentistry).
Definitions
Dental Home
Dental Neglect
Medically-Necessary Care
Special Health Care Needs

Definition of Dental Home
Latest Revision
2018
The dental home is the ongoing relationship between the
dentist and the patient, inclusive of all aspects of oral health
care delivered in a comprehensive, continuously accessible, co-
ordinated, and family-centered way. The dental home should
be established no later than 12 months of age to help children
and their families institute a lifetime of good oral health. A
DEFINITIONS: DENTAL HOME
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; 2022:15.
dental home addresses anticipatory guidance and preventive,
acute, and comprehensive oral health care and includes referral
to dental specialists when appropriate.
This definition was developed by the Council on Clinical
Affairs and adopted in 2006. This document is an update of
the previous version, revised in 2015.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 15
DEFINITIONS: DENTAL NEGLECT

Definition of Dental Neglect

Latest Reaffirmation How to Cite: American Academy of Pediatric Dentistry. Definition of
2020 dental neglect. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:16.

Dental caries, periodontal diseases, and other oral conditions,
if left untreated, can lead to pain, infection, and loss of func-
tion. These undesirable outcomes can adversely affect learning,
communication, nutrition, and other activities necessary for
normal growth and development.
Dental neglect is willful failure of parent or guardian to
seek and follow through with treatment necessary to ensure
a level of oral heath essential for adequate function and
freedom from pain and infection.
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.

16 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

DEFINITIONS: MEDICALLY-NECESSARY CARE
Definition of Medically-Necessary Care
Latest Reaffirmation
2019
Medically-necessary care (MNC) is the reasonable and essen-
tial diagnostic, preventive, and treatment services (including
supplies, appliances, and devices) and follow-up care as
determined by qualified health care providers in treating any
condition, disease, injury, or congenital or developmental
malformation to promote optimal health, growth, and devel-
opment. MNC includes all supportive health care services
that, in the judgment of the attending dentist, are necessary
for the provision of optimal quality therapeutic and preventive
oral care. These services include, but are not limited to,
sedation, general anesthesia, and utilization of surgical facilities.
DEFINITIONS: MEDICALLY-NECESSARY CARE
How to Cite: American Academy of Pediatric Dentistry. Definition of
medically-necessary care. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:17.
MNC must take into account the patient’s age, developmental
status, and psychosocial well-being, in addition to the setting
appropriate to meet the needs of the patient and family.
Dental care is medically-necessary to prevent and eliminate
orofacial disease, infection, and pain, to restore the form and
function of the dentition, and to correct facial disfiguration or
dysfunction.
This definition was developed by the Clinical Affairs
Committee on and adopted in 1997. This document is a
reaffirmation of the previous version, revised in 2015.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 17
DEFINITIONS: SPECIAL HEALTH CARE NEEDS
Definition of Special Health Care Needs
Latest Reaffirmation
2020
Special health care needs include any physical, developmental,
mental, sensory, behavioral, cognitive, or emotional impair-
ment or limiting condition that requires medical management,
health care intervention, and/or use of specialized services or
programs. The condition may be congenital, developmental, or
acquired through disease, trauma, or environmental cause and
may impose limitations in performing daily self-maintenance
activities or substantial limitations in a major life activity.
18 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Definition of
special health care needs. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:18.
Health care for individuals with special needs requires special-
ized knowledge, as well as increased awareness and attention,
adaptation, and accommodative measures beyond what are
considered routine.
This definition was developed by the Council on Clinical
Affairs and adopted in 2004. This document is a reaffirmation
of the previous version, revised in 2016.
 
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Oral health policies
Oral health policies represent
the American Academy of
Pediatric Dentistry’s positions
on various public health issues

Policy on the Dental Home
Latest Revision
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD)
supports the concept of a dental home for all infants, children,
adolescents, and persons with special health care needs. The
dental home is inclusive of all aspects of oral health that result
from the interaction of the patient, parents, dentists, dental
professionals, and nondental professionals. Establishment of
the dental home is initiated by the identification and interac-
tion of these individuals, resulting in a heightened awareness
of all issues impacting the patient’s oral health.1 This concept
is derived from the American Academy of Pediatrics’ (AAP)
definition of a medical home which is an approach to provid-
ing comprehensive and high quality primary care and not a
location or physical structure.2
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2001. This document is an update from the
last revision in 2015. This policy is based on a review of the
current dental and medical literature related to the establish-
ment of a dental home. An electronic search was conducted
using the terms: dental home, medical home in pediatrics, and
infant oral health care; fields: all fields; limit: within the last
10 years, humans, English. Papers for review were chosen from
this list and from references within selected articles. Expert
opinions and best current practices were relied upon when
clinical evidence was not available.
Background
The AAP issued a policy statement defining the medical home
in 1992.3 Since that time, it has been shown that health care
provided to patients in a medical home environment is more
effective and less costly in comparison to emergency care
facilities or hospitals.3-5 Strong clinical evidence exists for the
efficacy of early professional dental care complemented with
caries-risk and periodontal-risk assessment, anticipatory
guidance, and periodic supervision.6 The establishment of
a dental home follows the medical home model as a cost-
effective measure to reduce the financial burden and decrease
the number of dental treatment procedures experienced by
young children.7,8 It also serves as a higher quality health care
alternative in orofacial emergency care situations.9
Children who have a dental home are more likely to receive
appropriate preventive and routine oral health care, thereby
improving families’ oral health knowledge and practices,
especially in children at high risk for early childhood caries.6
ORAL HEALTH POLICIES: DENTAL HOME
How to Cite: American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:21-2.
Referral by the primary care physician or health provider has
been recommended, based on risk assessment, as early as six
months of age and no later than 12 months of age.10-12 Fur-
thermore, subsequent periodicity of reappointment is based
upon risk assessment. This provides time-critical opportunities
to implement preventive health practices and reduce the child’s
risk of preventable dental/oral disease.13
Policy statement
The AAPD encourages parents and other care providers to
help every child establish a dental home by 12 months of
age. The AAPD recognizes a dental home should provide:
• comprehensive, continuous, accessible, family-
centered, coordinated, compassionate, and culturally-
effective care for children, as modeled by the
AAP.1,14
• comprehensive evidence-base oral health care
including acute care and preventive services in
accordance with AAPD periodicity schedules.1,15
• comprehensive assessment for oral diseases and
conditions.
• individualized preventive dental health program based
upon a caries-risk assessment 16 and a periodontal
disease risk assessment12.
• anticipatory guidance regarding growth and dev-
elopment.15
• management of acute/chronic oral pain and infection.
• management of and long-term follow-up for acute
dental trauma.17-19
• information about proper care of the child’s teeth
and gingivae, and other oral structures. This would
include the prevention, diagnosis, and treatment
of disease of the supporting and surrounding tissues
and the maintenance of health, function, and
esthetics of those structures and tissues.20
• dietary counseling.21
• referrals to dental specialists when care cannot
directly be provided within the dental home.
• education regarding future referral to a dentist knowl-
edgeable and comfortable with adult oral health
issues for continuing oral health care.
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
Pediatric Dentistry.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 21
ORAL HEALTH POLICIES: DENTAL HOME
• recommendations and coordination of uninterrupted
comprehensive oral health care during the transition
from adolescence to adulthood.14,22
• referral, at an age determined by patient, parent, and
pediatric dentist, to a dentist knowledgeable and
comfortable with managing adult oral health care
needs.
The AAPD advocates interaction with early intervention
programs, schools, early childhood education and child care
programs, members of the medical and dental communities,
and other public and private community agencies to ensure
awareness of age-specific oral health issues.23
References
1. American Academy of Pediatric Dentistry. Definition of
dental home. Pediatr Dent 2018;40(6):12.
2. American Academy of Pediatrics. The medical home.
Pediatrics 2002;110(1Pt1):184-6.
3. American Academy of Pediatrics Ad Hoc Task Force on
the Definition of the Medical Home. The medical home.
Pediatrics 1992;90(5):774.
4. American Academy of Pediatrics Council on Children
with Disabilities. Care coordination: Integrating health
and related systems of care for children with special
health care needs. Pediatrics 2005;116(5):1238-44.
5. Klitzner TS, Rabbitt LA, Chang RK. Benefits of care
coordination for children with complex disease: A pilot
medical home project in a resident teaching clinic. J
Pediatr 2010;156(6):1006-10.
6. Thompson CL, McCann AL, Schneiderman ED. Does
the Texas First Dental Home program improve parental
oral care knowledge and practices? Pediatr Dent 2017;39
(2):124-9.
7. Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do
early dental visits reduce treatment and treatment costs
for children? Pediatr Dent 2014;36(7):489-93.
8. Kolstad C, Zavras A, Yoon R. Cost-benefit analysis of
the age one dental visit for the privately insured. Pediatr
Dent 2015;37(4):376-80.
9. Allareddy V, Nalliah RP, Haque M, Johnson H, Tech
SRB, Lee MK. Hospital-based emergency department
visits with dental conditions among children in the
United States: Nationwide epidemiological data. Pediatr
Dent 2014;36(5):393-9.
10. Nowak AJ, Casamassimo PS. The dental home: A pri-
mary oral health concept. J Am Dent Assoc 2002;133
(1):93-8.
11. Casamassimo P, Holt K, eds. Bright Futures in Practice:
Oral Health. Pocket Guide, 2nd ed. Washington, D.C.:
National Maternal and Child Oral Health Resource
Center; 2014.
12. American Academy of Periodontology. Periodontal
diseases of children and adolescents. J Periodontol 2003;
74(11):1696-704.
22 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
13. U.S. Department of Health and Human Services.
Healthy People 2020: Oral health of children and ado-
lescents. Available at: “http://www.healthypeople.gov/
2020/topics-objectives/topic/oral-health/objectives”.
Accessed March 16, 2018.
14. American Academy of Pediatrics. Preamble to patient-
centered medical home joint principles 2007. Available
at: “https://www.aap.org/en-us/professional-resources/
quality-improvement/_layouts/15/WopiFrame.aspx?
sourcedoc=/en-us/professional-resources/quality-
improvement/Documents/Preamble-Patient-Centered-
Principles.doc&action=default”. Accessed March 1, 2018.
15. American Academy of Pediatric Dentistry. Periodicity
of examination, preventive dental services, anticipatory
guidance/counseling, and oral treatment for infants,
children, and adolescents. Pediatr Dent 2018;40(6):
194-204.
16. American Academy of Pediatric Dentistry. Caries-risk
assessment and management for infants, children, and
adolescents. Pediatr Dent 2018;40(6):205-12.
17. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. In-
ternational Association of Dental Traumatology guide-
lines for the management of traumatic dental injuries:
1. Fractures and luxations of permanent teeth. Dent
Traumatol 2012;28(1):2-12. Erratum in Dent Traumatol
2012;28(6):499.
18. Andersson L, Andreasen JO, Day P, et al. International
Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 2. Avulsion of
permanent teeth. Dent Traumatol 2012;28(2):88-96.
19. Malmgren B, Andreasen JO, Flores MT, et al. Interna-
tional Association of Dental Traumatology guidelines
for the management of traumatic dental injuries: 3.
Injuries in the primary dentition. Dent Traumatol 2012;
28(3):174-82.
20. American Academy of Pediatric Dentistry. Policy on early
childhood caries: Classifications, consequences and
preventive strategies. Pediatr Dent 2018;40(6):60-2.
21. American Academy of Pediatric Dentistry. Policy on
dietary recommendations for infants, children and
adolescents. Pediatr Dent 2018;40(6):65-67.
22. American Academy of Pediatric Dentistry. Policy on
transitioning from a pediatric-centered to an adult-
centered dental home for individuals with special health
care needs. Pediatr Dent 2018;40(6):131-4.
23. American Academy of Pediatric Dentistry. Dental home
resource center. Available at: “http://www.aapd.org/
advocacy/dentalhome/”. Accessed March 16, 2018.

Policy on Medically-Necessary Care
Latest Revision
2019
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that dental care is medically-necessary for the
purpose of preventing and eliminating orofacial disease, in-
fection, and pain, restoring the form and function of the
dentition, and correcting facial disfiguration or dysfunction.
Methods
This document was developed by the Council on Clinical
Affairs and adopted in 2007. This document is an update
of the last revision from 2015. It includes an electronic
® ®
search with Scopus and PubMed /MEDLINE using the
terms: medically-necessary care, systemic disease AND oral
disease, dentistry as medically-necessary care, periodontal
disease AND cardiovascular disease, oral health AND
pregnancy, oral health AND respiratory illness, oral health
AND quality of life, pediatric dentistry, general anesthesia,
and nutritional deficiency cognitive development; fields:
all; limits: within the last 15 years, human, English. The
reviewers agreed upon the inclusion of 76 articles that met
the defined criteria.
Background
The AAPD defines medically-necessary care (MNC) as “the
reasonable and essential diagnostic, preventive, and treatment
services (including supplies, appliances, and devices) and
follow-up care as determined by qualified health care pro-
viders in treating any condition, disease, injury, or congenital
or developmental malformation to promote optimal health,
growth, and development. MNC includes all supportive
health care services that, in the judgment of the attending
dentist, are necessary for the provision of optimal quality
therapeutic and preventive oral care. These services include,
but are not limited to, sedation, general anesthesia, and utili-
zation of surgical facilities. MNC must take into account
the patient’s age, developmental status, and psychosocial
well-being, in addition to the clinical setting appropriate to
meet the needs of the patient and family.”1
MNC is based upon current preventive and therapeutic
practice guidelines formulated by professional organizations
with recognized clinical expertise. Such recommendations
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
risks. MNC increases the probability of good health and
well-being and decreases the likelihood of an unfavorable
outcome. Value of services is an important consideration,
ORAL HEALTH POLICIES: MEDICALLY-NECESSARY CARE
How to Cite: American Academy of Pediatric Dentistry. Policy on
medically-necessary care. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:23-8.
and all stakeholders should recognize that cost-effective care
is not necessarily the least expensive treatment.2
Dental care is medically necessary to prevent and eliminate
orofacial disease, infection, and pain, to restore the form and
function of the dentition, and to correct facial disfiguration or
dysfunction. Following the United States Surgeon General’s
report3 emphasizing that oral health is integral to general health,
the United States Department of Health and Human Services
recommended changing perceptions of the public, policy
makers, and healthcare providers so that oral health becomes
an accepted component of general health.4,5 Oral diseases can
have a direct and devastating impact on overall health, especially
for those with certain systemic health problems or conditions.
Caries is the most common chronic disease of childhood.3
Approximately 60 percent of children experience caries in
their primary teeth by age five. 6 Between 1988-1994 and
1999-2004, prevalence of caries in primary teeth increased
for youths aged two to 11 years, with a significant increase
noted for those in the two to five year age range.7 By 17
years of age, 78 percent of children in the United States have
experienced caries. 5 As much as 90 percent of all caries in
school-aged children occurs in pits and fissures. Caries,
periodontal diseases, and other oral conditions, if left un-
treated, can lead to pain, infection, and loss of function.
These undesirable outcomes can adversely affect learning,
communication, nutrition, and other activities necessary for
normal growth and development. 8 Rampant caries is asso-
ciated with insufficient development in children who have
no other medical problems.9 Children with early childhood
caries (ECC) may be severely underweight because of the
associated pain and disinclination to eat. Nutritional deficien-
cies during childhood can impact cognitive development.10,11
Other oral conditions also can impact general health and
well-being. Gingivitis is nearly universal in children and
adolescents, and children can develop severe forms of
periodontitis.12 A relationship may exist between periodontal
disease and cardiovascular disease13-15 as well as periodontal
disease and adverse pregnancy outcomes, 16,17 including
pregnancy hypertension.18 An association between oral health
and respiratory diseases has been recognized. 18,19 Oral
health, oral microflora, and bacterial pneumonia, especially
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CC: Chronic condi-
tion. ECC: Early childhood caries. MNC: Medically-necessary care.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 23
ORAL HEALTH POLICIES: MEDICALLY-NECESSARY CARE
in populations at high risk for respiratory disease, have been
linked. The mouth can harbor respiratory pathogens that may
be aspirated, resulting in airway infections.20 Furthermore,
dental plaque may serve as a reservoir for respiratory pathogens
in patients who are undergoing mechanical ventilation.21
Problems of esthetics, form, and function can affect the
developing psyche of children, with life-long consequences
in social, educational, and occupational environments.22,23
Self-image, self-esteem, and self-confidence are unavoidable
issues in society, and an acceptable orofacial presentation is
a necessary component of these psychological concepts.24,25
Congenital or acquired orofacial anomalies (e.g., ectoder-
mal dysplasia, cleft defects, cysts, tumors) and malformed
or missing teeth can have significant negative functional,
esthetic, and psychological effects on individuals and their
families.26,27 Patients with craniofacial anomalies often require
specialized oral health care as a direct result of their cranio-
facial condition. These services are an integral part of the
rehabilitative process.26 Young children benefit from esthetic
and functional restorative or surgical techniques and readily
adapt to appliances that replace missing teeth and improve
function, appearance, and self-image. During the period of
facial and oral growth, appliances require frequent adjustment
and must be remade as the individual grows.
Professional care is necessary to maintain oral health,3,4 and
risk assessment is an integral element of contemporary pre-
ventive care for infants, children, adolescents, and persons
with special health care needs. 28 The goal of caries-risk
assessment is to prevent disease by identifying and mini-
mizing causative factors (e.g., microbial burden, dietary habits,
dental morphology) and optimizing protective factors (e.g.,
fluoride exposure, personal oral hygiene, sealants).29,30 Ideally,
risk assessment and implementation of preventive strategies
would occur before the disease process has been initiated.
Infants and young children have unique caries-risk factors
such as ongoing establishment of oral flora and host defense
systems, susceptibility of newly erupted teeth, and develop-
ment of dietary habits and childhood food preferences.
Children are most likely to develop caries if Mutans strepto-
cocci is acquired at an early age.31-33 High-risk dietary practices
are multi-factorial.34 Food preferences appear to be established
early (probably by 12 months of age) and are maintained
throughout early childhood. 35-36 Adolescence can be a time
of heightened caries activity and periodontal disease due
to an increased intake of cariogenic substances and inattention
to oral hygiene procedures.37-39
An analysis of caries risk includes determination of
protective factors, such as fluoride exposure. More than one-
third of the United States population does not benefit from
community water fluoridation.3 Fluoride contributes to the
prevention, inhibition, and reversal of caries. 40 Therefore,
early determination of a child’s systemic and topical fluoride
exposure is important. Children experiencing caries as infants
and toddlers have a much greater probability of subsequent
caries in both the primary and permanent dentitions.10 An
24 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
individualized preventive plan based on a caries-risk assess-
ment is the key component of caries prevention. Because
any risk assessment tool may fail to identify all infants at risk
for developing ECC, early establishment of the dental home
is the ideal approach for disease prevention.41 Early diagnosis
and timely intervention, including necessary referrals, can
prevent the need for more extensive and expensive care often
required when problems have gone unrecognized and/or
untreated.42-44
When very young children have not been the beneficiaries
of adequate preventive care and subsequently develop ECC,
therapeutic intervention should be provided by a practitioner
with the training, experience, and expertise to manage both
the child and the disease process. Because of the aggressive
nature of ECC, restorative treatment should be definitive yet
specific for each individual patient. Conventional restorative
approaches may not arrest the disease.45 Areas of demineral-
ization and hypoplasia can cavitate rapidly. The placement of
stainless steel crowns may be necessary to decrease the number
of tooth surfaces at risk for new or secondary caries. Stainless
steel crowns are less likely than other restorations to require
retreatment. 45,46 Low levels of compliance with follow-up
care and a high recidivism rate of children requiring additional
treatment also can influence a practitioner’s decisions for
management of ECC47 and may decrease success of a disease
management approach to ECC.48
Sealants are particularly effective in preventing pit and
fissure caries and providing cost savings if placed on the teeth
of patients during periods of greatest risk. 49 Children with
multiple risk factors and tooth morphology predisposed to
plaque retention (i.e., developmental defects, pits and fis-
sures) benefit from having such teeth sealed prophylactically.
A child who receives sealants is 72 percent less likely to
receive restorative services over the next three years than
children who do not.50 Sealants placement on primary molars
in young children is a cost-effective strategy for children at
risk for caries, including those insured by state Medicaid
programs. 51,52 Although sealant retention rates initially are
high, sealant loss does occur.53 It is in the patient’s interest to
receive periodic evaluation of sealants. With follow-up care,
the success rate of sealants may be 80 to 90 percent, even
after a decade.53
Sealants are safe and effective, yet their use continues to
be low. 53-55 Initial insurance coverage for sealants often is
denied, and insurance coverage for repair and/or replacement
may be limited.55,56 While all Medicaid programs reimburse
dentists for placement of sealants on permanent teeth, only
one in three reimburses for primary molar sealants. 57 While
some third-party carriers restrict reimbursement for sealants
to patients of certain ages, it is important to consider that
timing of dental eruption can vary widely. Furthermore, car-
ies risk may increase at any time during a patient’s life due
to changes in habits (e.g., dietary, home care), oral micro-
flora, or physical condition, and previously unsealed teeth
subsequently might benefit from sealant application.53,58

The extent of the disease process, as well as the patient’s
developmental level and comprehension skills, affect the
practitioner’s behavior guidance approaches. The success of
restorations may be influenced by the child’s response to the
chosen behavior guidance technique. To perform treatment
safely, effectively, and efficiently, the practitioner caring for
a pediatric patient may employ advanced behavior guidance
techniques such as protective stabilization and/or sedation or
general anesthesia.59,60 The patient’s age, dental needs, disabil-
ities, medical conditions, and/or acute situational anxiety
may preclude the patient’s being treated safely in a traditional
outpatient setting.61,62 For some infants, children, adolescents,
and persons with special health care needs, treatment under
sedation or general anesthesia in a hospital, outpatient facility,
or dental office or clinic represents the only appropriate method
to deliver necessary oral health care.59,63 Failure by insurance
companies to cover general anesthesia costs, hospital fees, and/
or sedation costs can expose the patient to multiple ineffective,
potentially unsafe, and/or psychologically traumatic in-office
experiences. The impact of chronic conditions (CC) status and
CC severity increases the odds of receiving dental treatment
under general anesthesia.64 Although general anesthesia may
provide optimal conditions to perform restorative procedures,
it can add significantly to the cost of care.65 General anesthesia
may be required in the hospital setting due to the extent of
treatment, the need to deliver timely care, or the patient’s
medical history/CC (e.g., cardiac defects, severe bleeding dis-
orders, limited opening due to orofacial anomalies). General
anesthesia, under certain circumstances, may offer a cost-saving
alternative to sedation for children with ECC.66.67
Reimbursement issues defined by the concept of MNC
have been a complicated topic for dentistry. Pediatric den-
tal patients may be denied access to oral health care when
insurance companies refuse to provide reimbursement for
sedation/general anesthesia and related facility services. Most
denials cite the procedure as “not medically-necessary”.68 This
determination appears to be based on arbitrary and inconsis-
tent criteria.69-74 For instance, medical policies often provide
reimbursement for sedation/general anesthesia or facility fees
related to myringotomy for a three-year-old child, but deny
these benefits when related to treatment of dental disease
and/or dental infection for the same patient. American Den-
tal Association Resolution 1989-546 states that insurance
companies should not deny benefits that would otherwise
be payable “solely on the basis of the professional degree and
licensure of the dentist or physician providing treatment, if
that treatment is provided by a legally qualified dentist or
physician operating within the scope of his or her training
and licensure.”74
Patients with craniofacial anomalies often are denied third-
party coverage for initial appliance construction and, more
frequently, replacement of appliances as the child grows.
The distinction between congenital anomalies involving the
orofacial complex and those involving other parts of the
body is often arbitrary and unfair. Often, medical insurance
ORAL HEALTH POLICIES: MEDICALLY-NECESSARY CARE
companies interpret dental appliance construction to be solely
esthetic, without taking into consideration the restorative
function. For instance, health care policies may provide re-
imbursement for the prosthesis required for a congenitally
missing extremity and its replacement as the individual grows
but deny benefits for the initial prosthesis and necessary
periodic replacement for congenitally missing teeth. Third-
party payors frequently will refuse to pay for oral health care
services even when they clearly are associated with the complete
rehabilitation of the craniofacial condition.75,76
Policy statement
Dental care is medically necessary to prevent and eliminate
orofacial disease, infection, and pain, to restore the form and
function of the dentition, and to correct facial disfiguration
or dysfunction. MNC is based upon current preventive and
therapeutic practice guidelines formulated by professional
organizations with recognized clinical expertise. Expected
benefits of MNC outweigh potential risks of treatment or no
treatment. Early detection and management of oral condi-
tions can improve a child’s oral health, general health and
well-being, school readiness, and self-esteem. Early recognition,
prevention, and intervention could result in savings of health
care dollars for individuals, community health care programs,
and third-party payors. Because a child’s risk for developing
dental disease can change over time, continual professional
reevaluation and preventive maintenance are essential for good
oral health. Value of services is an important consideration,
and all stakeholders should recognize that cost-effective care
is not necessarily the least expensive treatment.
The AAPD encourages:
1. oral health care to be included in the design and pro-
vision of individual and community-based health care
programs to achieve comprehensive health care.
2. establishment of a dental home for all children by 12
months of age in order to institute an individualized
preventive oral health program based upon each pa-
tient’s unique caries risk assessment.
3. healthcare providers who diagnose oral disease to either
provide therapy or refer the patient to a primary care
dentist or dental/medical specialist as dictated by the
nature and complexity of the condition. Immediate
intervention is necessary to prevent further dental de-
struction, as well as more widespread health problems.
4. evaluation and care provided for an infant, child, or
adolescent by a cleft lip/palate, orofacial, or craniofacial
deformities team as the optimal way to coordinate and
deliver such complex services.
5. the dentist providing oral health care for a patient to
determine the medical indication and justification for
treatment. The dental care provider must assess the
patient’s developmental level and comprehension skills,
as well as the extent of the disease process, to determine
the need for advanced behavior guidance techniques
such as sedation or general anesthesia.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 25
ORAL HEALTH POLICIES: MEDICALLY-NECESSARY CARE
Furthermore, the AAPD encourages third-party payors to:
1. recognize malformed and missing teeth are resultant
anomalies of facial development seen in orofacial anom-
alies and may be from congenital defects. Just as the
congenital absence of other body parts requires care
over the lifetime of the patient, so will these.
2. include oral health care services related to these facial
and dental anomalies as benefits of health insurance
without discrimination between the medical and dental
nature of the congenital defect. These services, optimally
provided by the craniofacial team, include, but are not
limited to, initial appliance construction, periodic exam-
inations, and replacement of appliances.
3. end arbitrary and unfair refusal of compensation for
oral health care services related to orofacial and dental
anomalies.
4. recognize the oral health benefits of dental sealants
and not base coverage for sealants on permanent and
primary teeth on a patient’s age.
5. ensure that all children have access to the full range of
oral health delivery systems. If sedation or general anes-
thesia and related facility fees are payable benefits of a
health care plan, these same benefits shall apply for the
delivery of oral health services.
6. regularly consult the AAPD with respect to the devel-
opment of benefit plans that best serve the oral health
interests of infants, children, adolescents, and persons
with special health care needs, especially those with
craniofacial or acquired orofacial anomalies.
References
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24. Zhang M, McGrath C, Hägg U. Impact of malocclusion
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27. National Foundation for Ectodermal Dysplasias. Param-
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OfOralHealthCare.pdf.” Accessed August 10, 2019.
28. American Academy of Pediatric Dentistry. Caries-risk
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29. Fontana M, Zero DT. Assessing patients’ caries risk. J Am
Dent Assoc 2006;37(9):1231-9.
30. Milgrom P, Chi DL. Prevention-centered caries manage-
ment strategies during critical periods in early childhood.
J Calif Dent Assoc 2011;39(10):735-41.
31. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors
for dental caries in young children: A systematic review of
the literature. Community Dent Health 2004;21(suppl 1):
71-85.
32. Douglass JM, Douglass AB, Silk HJ. A practical guide
to infant oral health. Am Fam Physician 2004;70(11):
2113-22.
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33. Douglass JM, Li Y, Tinanoff N. Association of mutans
streptococci between caregivers and their children. Ped
Dent 2008;30(5):375-87.
34. Mobley D, Marshall TA, Milgrom P, Coldwell SE. The
contribution of dietary factors to dental caries and dis-
parities in caries. Acad Pediatr 2009;9(6):410-4.
35. Douglass JM. Response to Tinanoff and Palmer: Dietary
determinants of dental caries and dietary recommenda-
tions for preschool children. J Public Health Dent 2000;
60(3):207-9.
36. Nicklaus S, Boggio V, Chabanet C, Issanchou S. A prospec-
tive study of food variety seeking in childhood, adolescence
and early adult life. Appetite 2005;44(3):289-97.
37. American Psychological Association. Developing adoles-
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“https://www.apa.org/pi/families/resources/develop.pdf ”.
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38. Kawamura M, Takase N, Sasahara H, Okada M. Teenagers
oral health attitudes and behavior in Japan: Comparison
by sex and age group. J Oral Science 2008;50(2):167-74.
39. Källestål C, Dahlgren L, Stenlund H. Oral health behavior
and self-esteem in Swedish adolescents over four years.
J Adolesc Health 2006;38(5):583-90.
40. Centers for Disease Control and Prevention. Recommen-
dations for using fluoride to prevent and control dental
caries in the United States. MMWR Recomm Rep 2001;
50(RR14):1-42.
41. American Academy of Pediatric Dentistry. Perinatal and
infant oral health care. Pediatr Dent 2018;40(6):216-20.
42. American Academy of Pediatric Dentistry Pediatric Oral
Health Research and Policy Center. Early preventive
dental visits. April, 2014. Available at: “http://www.aapd.
org/assets/1/7/Early_Preventive_Dental_Visits_Tech_Brief
_2014.pdf ”. Accessed August 10, 2019.
43. Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining
the cost-effectiveness of early dental visits. Pediatr Dent
2006;28(2):102-5, discussion 192-8.
44. Ladewig NM, Camargo LB, Tedesco TK, et al. Manage-
ment of dental caries among children: A look at cost-
effectiveness. Expert Rev Pharmacoecon Outcomes Res
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45. Foster T, Perinpanayagam H, Pfaffenbach A, Certo M.
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treatment with general anesthesia and follow-up. J Dent
Child 2006;73(1):25-30.
46. Eidelman E, Faibis S, Peretz B. A comparison of restora-
tions for children with early childhood caries treated
under general anesthesia or conscious sedation. Pediatr
Dent 2000;22(1):33-7.
47. Almeida AG, Roseman MM, Sheff M, Huntington N,
Hughes CV. Future caries susceptibility in children with
early childhood caries following treatment under general
anesthesia. Pediatr Dent 2000;22(4):302-6.
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 27
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48. Samnaliev M, Wijeratne R, Kown EG, Ohiomoba H, Ng
MW. Cost-effectiveness of a disease management program
for early childhood caries. J Pub Health Dent 2015;75(1):
24-33.
49. Weintraub JA. Pit and fissure sealants in high-caries risk
individuals. J Dent Educ 2001;65(10):1084-90.
50. Anderson M. Risk assessment and epidemiology of dental
caries: Review of the literature. Pediatr Dent 2002;24(5):
377-85.
51. Chi DL, van der Goes D, Ney JP. Cost-effectiveness of
pit-and-fissure sealants on primary molars in Medicaid-
enrolled children. Am J Public Health 2014;104(3):
555-61.
52. Griffin SO, Naavaal S, Scherrer C, Patel M, Chattopadhyay
S, Community Services Task Force. Evaluation of school-
based dental sealant programs: An updated community
guide systematic economic review. Am J Prev Med 2017;
52(3):407-15.
53. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent
2002;24(5):415-22.
54. Tellez M, Gray SL, Gray A, Lim S, Ismail AI. Sealants
and dental caries: Dentists’ perspectives on evidence-
based recommendations. J Am Dent Assoc 2011;142(9):
1033-40.
55. Wright JT, Crall JJ, Fontana M, et al. Evidence-based
clinical practice guideline for the use of pit-and-fissure
sealants. American Academy of Pediatric Dentistry,
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56. American Dental Association. Statement on preventive
coverage in dental benefits plans (1992:602; 1994:656;
2013:306). In: ADA Current Policies, Adopted 1954-
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org/~/media/ADA/Member%20Center/Members/current
_policies.pdf?la=en”. Accessed November 8, 2018.
57. Chi DL, Singh J. Reimbursement rates and policies for
primary molar pit-and-fissure sealants across state Medi-
caid programs. J Am Dent Assoc 2013;144(11):1272-8.
Erratum in J Am Dent Assoc 2014;145(1):121.
58. Quiñonez RB, Downs SM, Shugars D, Christensen J, Vann
WF Jr. Assessing cost-effectiveness of sealant placement
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60. Adair SM, Rockman RA, Schafer TE, Waller JL. Survey
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61. American Academy of Pediatric Dentistry. Behavior guid-
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62. Coté CJ, Wilson S, American Academy of Pediatric
Dentistry, American Academy of Pediatrics. Guidelines for
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during, and after sedation for diagnostic and therapeutic
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Policy on Social Determinants of Children’s Oral
Health and Health Disparities
Revised
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD) rec-
ognizes the influence of social factors on children’s oral health
including access to care, dental disease, behaviors, and oral
health inequalities. The AAPD encourages oral health profes-
sionals and policymakers to formally acknowledge the role
social determinants of health (SDH) have in producing and
perpetuating poor oral health and oral health inequalities in
children. Moreover, AAPD encourages the implementation of
oral health promotion strategies that account for SDH and
appropriate clinical management protocols informed by and
sensitive to SDH. All relevant stakeholders (e.g., health profes-
sionals, researchers, educators, policy makers) are encouraged
to develop strategies that incorporate SDH-related knowledge
to improve oral health, prevent dental disease, and address oral
health inequalities in children.
Methods
This policy, developed by the Council on Clinical Affairs and
adopted in 20171, is based on a review of the current literature,
®
including a search of PubMed /MEDLINE database using
the terms: social determinants AND dental; fields: all; limits:
English, birth-18 years. A total of 1485 articles matched
these criteria. Articles for review were selected from this list,
the references within selected articles, and other articles from
the literature.
Background
The World Health Organization defines social determinants
of health as “the conditions in which people are born, grow,
work, live, and age, and the wider set of forces and systems
shaping the conditions of daily life”.2 Life circumstances are
heavily influenced by social behaviors, cultural practices, gov-
ernment policies, and economic and political systems.3 The
term SDH implies that improving social conditions is a
necessary to optimize health outcomes for vulnerable popula-
tions, narrow inequalities, and achieve health equity and social
justice. Health equity may be defined as the “fair and just op-
portunity to be as healthy as possible”4, a concept that requires
elimination of those societal factors (e.g., poverty, discrimi-
nation, lack of access to healthcare) that unfairly result in
poorer health for at-risk social groups. Social groups can be
identified by many characteristics including ethnicity, religion,
ORAL HEALTH POLICIES: SOCIAL DETERMINANTS OF ORAL HEALTH
How to Cite: American Academy of Pediatric Dentistry. Policy on so-
cial determinants of children’s oral health and health disparities. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy
of Pediatric Dentistry; 2022:29-33.
socioeconomic status, gender identity, age, disability status,
sexual orientation, or geographic location. 5,6 From a social
justice perspective, addressing SDH is essential to achieving
improved oral health outcomes and reducing inequalities for
children from historically disadvantaged groups.5 One strategy
is to prioritize interventions, programs, and policies that
properly acknowledge and account for SDH.
Past work has demonstrated gradients in oral health out-
comes based on socioeconomic position. 3,7,8 Measures of
socioeconomic position include income, educational attainment,
occupation, and race/ethnicity. 9-11 SDH are influenced by
socioeconomic position and more broadly embody the social
environment and context in which individuals live and make
health-related decisions over the life course.3,12 Various con-
ceptual models from dentistry include SDH as upstream
factors that influence oral health behaviors, dental disease rates,
and oral health outcomes.13-18 In 2013, the American Academy
of Pediatrics published a policy statement that acknowledged
the influence of SDH on chronic diseases including dental
caries.19 Since then, the body of scientific research addressing
SDH and oral health has grown substantially. Findings from
the social determinants of children’s oral health literature can
be organized into categories that provide guidance on how
dentists, other health professionals, researchers, educators, and
policy makers can account for SDH to improve children’s
health outcomes. Examples are provided of past efforts and
future opportunities to address children’s oral health inequali-
ties through SDH-based interventions, programs, and policies.
SDH commonly are measured at the caregiver or household
level. The same SDH that affect a caregiver’s oral health out-
comes also affect his children’s oral health directly and indi-
rectly.20 Caregiver level of education influences both material
and non-material components of a child’s oral health, including
access to and utilization of preventive services, dental knowl-
edge, and oral health behaviors.12,21-23 Socioeconomic status
was found to mediate the influence of maternal psychological
factors (e.g., depression, external locus of control, self-efficacy)
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. SDH: Social
determinants of health.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 29
ORAL HEALTH POLICIES: SOCIAL DETERMINANTS OF ORAL HEALTH
on oral health in offspring.23-27 Examples of SDH at the house-
hold level include food insecurity (defined as reduced quality,
variety, or desirability of diet, and disrupted eating patterns
with or without reduced food intake28) and overcrowding.29,30
These factors can make it difficult for families to afford non-
cariogenic food and preventive oral hygiene products or to
have designated spaces in the home for important routines like
toothbrushing.3,31,32 Children living in settings with multiple
social risks are at substantially greater risk for caries.33 SDH
may be reflected by a heavy allostatic load (biological markers
of chronic stress) among household members, with implica-
tions for poor oral health behaviors and higher caries rates.34
This is particularly worrisome from a life course perspective.35
A small cross-sectional study suggests associations between the
adverse effects of socioenvironmental stressors, neuroendocrine
factors, and levels of intraoral cariogenic bacteria in children,36
findings that need to be validated with additional studies.
Examples of ways in which chronic stress associated with
socioeconomic status leads to negative physiologic effects on
oral health include pro-inflammatory, endocrine, and micro-
biological responses.37 Furthermore, poverty and stress could
influence child temperament 38, which in turn may affect
behaviors in dental settings39, including the ability to cooperate
for dental procedures40,41.
SDH are also measured within neighborhoods and commu-
nities. Neighborhood income is positively associated with oral
health-related behaviors like improved oral hygiene practices
and lower dental disease levels for children.21,42-45 In addition,
higher levels of income inequality within a community are
associated with poorer oral health outcomes.46
Social capital, a term that encompasses social support, social
networks, and social cohesion, is an important SDH that
affects both individuals and communities.47 Social support is
tied to emotional development in adolescents, including self-
efficacy, trust, and avoidance of detrimental oral health behav-
iors.48 Weak social ties and social networks are associated with
poor oral health outcomes.21,49-51 Social capital may manifest as
neighborhood resources such as community centers that benefit
the oral health of members.52 Studies generally have reported
positive health outcomes associated with greater levels of social
capital53-56, but at least one study57 found negative outcomes.
These findings suggest that enhancing social capital is bene-
ficial, but that social norms can influence the way in which
resources are deployed, which can lead to suboptimal oral
health behaviors and poor outcomes.
Structural determinants of health are formed by the econo-
mic, political, and social policies that modulate SDH. 6
Economic policies affect employment to population ratios,
standard of living, and individual cost of living, which in
turn influence access to health insurance or ability to pay for
healthcare expenses. Policies that have expanded Medicaid
access, reduced influences of neighborhood poverty, and in-
vested in education quality have demonstrated long-term posi-
tive health outcomes for youth.58 The determination of public
insurance coverage for specific procedures, including the cost
30 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
of general anesthesia during dental treatment, is at the dis-
cretion of individual states rather than the federal government.
Depending on individual state Medicaid policies, out-of-pocket
costs may be prohibitive and divert patients toward less ideal
treatment options for behavior management.59 Inability to pay
for services may preclude some children from receiving treat-
ment at all. Sociolegal policies that regulate insurance coverage,
including those related to preauthorization and informed
consent, have been shown to delay or prevent adolescents from
obtaining health services.60
Translational science has led to the development of pedi-
atric oral health interventions that address SDH. For example,
Baby Smiles was a community-based randomized trial that
implemented motivational interviewing in conjunction with
age one dental visits for those with Medicaid.61 The program
focused on improving the health of the mothers as well as on
prevention for their at-risk children. Other initiatives, such as
school-based sealant programs, have developed strategies to
overcome socioenvironmental barriers to oral healthcare and
reach at-risk children.62 A recent evaluation found that school-
based sealant programs resulted in benefits that outweighed
costs, including reduced rates of dental caries, untreated decay,
and school absenteeism. 63 It is imperative that future oral
health interventions account for SDH and aim to achieve
greater health equity for all children.
Systematic policies and environmental changes that improve
living conditions and alleviate poverty are necessary to address
SDH. Examples include universal housing programs, emer-
gency rental assistance, public health insurance programs like
Medicare, Medicaid, and Children’s Health Insurance Program
(CHIP), and programs that mediate food insecurity such as
Supplemental Nutrition Assistance Program (SNAP) and the
National School Lunch Program (NSLP). Broader policies are
likely to have the long-term impact needed to improve the
conditions in which vulnerable families and children live.
Policy Statement
Recognizing the importance of the social determinants of oral
health for children, the AAPD:
• supports broader policies and programs that help to
alleviate poverty and social inequalities.
• encourages dentists and the oral health care team to
collect a social history from patients, provide antici-
patory guidance that is sensitive to SDH, and connect
patients with helpful resources (e.g., social service
organizations, food banks) when needed.
• supports inter-professional educational approaches to
train students as well as practicing dentists and health
professionals on the social determinants of health.64-67
• endorses interdisciplinary approaches to improve oral
health that account for social determinants of chronic
diseases.68,69
• supports additional research to understand mechanisms
underlying the social determinants of oral health.70

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30. Paula JS, Ambrosano GM, Mialhe FL. The impact of
social determinants on schoolchildren’s oral health in
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31. Angelopoulou MV, Shanti SD, Gonzalez CD, Love A,
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hood caries. J Public Health Dent 2019;79(2):102-8.
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32. Hill, B. Evaluating the association between food insecu-
rity and dental caries in US children 1-19 years: Results
from the National Health and Nutrition Examination
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33. Yang AJ, Gromoske AN, Olson MA, Chaffin JG. Single
and cumulative relations of social risk factors with chil-
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of the United States. Matern Child Health J 2016;20(3):
495-506.
34. Masterson EE, Sabbah W. Maternal allostatic load, care-
taking behaviors, and child dental caries experience: A
cross-sectional evaluation of linked mother-child data
from the Third National Health and Nutrition Examina-
tion Survey. Am J Public Health 2015;105(11):2306-11.
35. Boyce WT. The lifelong effects of early childhood adver-
sity and toxic stress. Pediatr Dent 2014;36(2):102-8.
36. Boyce WT, Den Besten PK, Stamperdahl J, et al. Social
inequalities in childhood dental caries: The convergent
roles of stress, bacteria and disadvantage. Soc Sci Med
2010;71(9):1644-52.
37. Gomaa N, Glogauer M, Tenenbaum H, et al. Social-
biological interactions in oral disease: A ‘cells to society’
view. PLoS One 2016;11(1):e0146218.
38. Strickhouser JE, Sutin AR. Family and neighborhood so-
cioeconomic status and temperament development from
childhood to adolescence. J Pers 2020;99(3):515-29.
39. Quiñonez RB, Santos RG, Eckert GJ, et al. Influence of
temperament as a risk indicator for early childhood caries.
Pediatr Dent 2020;42(6):470-5.
40. da Fonseca MA. Eat or heat? The effects of poverty on
children’s behavior. Pediatr Dent 2014;36(2):132-7.
41. Fisher-Owens S. Broadening perspectives on pediatric
oral health care provision: Social determinants of health
and behavioral management. Pediatr Dent 2014;36(2):
115-20.
42. Martens L, Vanobbergen J, Willems S, et al. Determinants
of early childhood caries in a group of inner-city children.
Quintessence Int 2006;37(7):527-36.
43. Mathur MR, Tsakos G, Millett C, et al. Socioeconomic
inequalities in dental caries and their determinants in
adolescents in New Delhi, India. BMJ Open 2014;4
(12):e006391.
44. Mathur MR, Tsakos G, Parmar P, et al. Socioeconomic
inequalities and determinants of oral hygiene status
among Urban Indian adolescents. Community Dent Oral
Epidemiol 2016;44(3):248-54.
45. Priesnitz MC, Celeste RK, Pereira MJ, et al. Neighbour-
hood determinants of caries experience in preschool
children: A multilevel study. Caries Res 2016;50(5):
455-61.
46. Moeller J, Starkel R, Quinonez C, Vujicic M. Income
inequality in the United States and its potential effect on
oral health. J Am Dent Assoc 2017;148(6):361-8.
32 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
47. Duh-Leong C, Dreyer BP, Huang TT, et al. Social capital
as a positive social determinant of health: A narrative
review. Acad Pediatr 2021;21(4):594-9.
48. Fontanini H, Marshman Z, Vettore M. Social support
and social network as intermediary social determinants
of dental caries in adolescents. Community Dent Oral
Epidemiol 2015;43(2):172-82.
49. Zini A, Sgan-Cohen HD, Marcenes W. Religiosity, spiri-
tuality, social support, health behaviour and dental caries
among 35- to 44-year-old Jerusalem adults: A proposed
conceptual model. Caries Res 2012;46(4):368-75.
50. Vettore MV, Faerstein E, Baker SR. Social position, social
ties and adult’s oral health: 13 year cohort study. J Dent
2016;44:50-6.
51. Vettore MV, Ahmad SFH, Machuca C, Fontanini H.
Socio-economic status, social support, social network,
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escents. Eur J Oral Sci 2019;127(2):139-46.
52. Guedes RS, Piovesan C, Antunes JL, et al. Assessing
individual and neighborhood social factors in child oral
health-related quality of life: A multilevel analysis. Qual
Life Res 2014;23(9):2521-30.
53. Iida H, Rozier RG. Mother-perceived social capital and
children’s oral health and use of dental care in the United
States. Am J Public Health 2013;103(3):480-7.
54. Santiago BM, Valença AM, Vettore MV. Social capi-
tal and dental pain in Brazilian northeast: A multilevel
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55. Reynolds, JC, Damiano PC, Glanville JL, et al. Neigh-
borhood and family social capital and parent-reported
oral health of children of Iowa. Community Dent Oral
Epidemiol 2015;43(6):569-77.
56. Knorst JK, Menegazzo GR, Emmanuelli B, et al. Effect
of neighborhood and individual social capital in early
childhood on oral health-related quality of life: A 7-year
cohort study. Qual Life Res 2019;28(7):1773-82.
57. Chi DL, Carpiano RM. Neighborhood social capital,
neighborhood attachment, and dental care use for Los
Angeles Family and Neighborhood Survey adults. Am J
Public Health 2013;103(4):e88-95.
58. Venkataramani AS, O’Brien R, Whitehorn GL, Tsai AC.
Economic influences on population health in the United
States: Toward policymaking driven by data and evidence.
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59. Edelstein BL. Insurers’ policies on coverage for behavior
management services and the impact of the Affordable
Care Act. Pediatr Dent 2014;36(2):145-51.
60. Garney W, Wilson K, Ajayi KV, et al. Social-ecological
barriers to access to healthcare for adolescents: A scoping
review. Int J Environ Res Public Health 2021;18(8):4138.
61. Milgrom P, Riedy CA, Weinstein P, et al. Design of a
community-based intergenerational oral health study:
“Baby Smiles”. BMC Oral Health 2013;13:38.

62. Siegal MD, Detty AM. Do school-based dental sealant
programs reach higher risk children? J Public Health
Dent 2010;70(3):181-7.
63. Griffin SO, Naavaal S, Scherrer C, et al. Community Pre-
ventive Services Task Force. Evaluation of school-based
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407-15.
64. Lapidos A, Gwozdek A. An interprofessional approach to
exploring the social determinants of health with dental
hygiene students. J Allied Health 2016;45(3):e43-7.
65. Lévesque MC, Levine A, Bedos C. Ideological roadblocks
to humanizing dentistry, an evaluative case study of a
continuing education course on social determinants of
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66. Lévesque M, Levine A, Bedos C. Humanizing oral health
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ORAL HEALTH POLICIES: SOCIAL DETERMINANTS OF ORAL HEALTH
67. Foster Page LA, Chen V, Gibson B, McMillan J. Over-
coming structural inequalities in oral health: The role of
dental curricula. Community Dent Health 2016;33(2):
168-72.
68. Newton JT. Interdisciplinary health promotion: A call
for theory-based interventions drawing on the skills of
multiple disciplines. Community Dent Oral Epidemiol
2012;40(Suppl 2):49-54.
69. Watt RG, Sheiham A. Integrating the common risk factor
approach into a social determinants framework. Commu-
nity Dent Oral Epidemiol 2012;40(4):289-96.
70. Newton JT, Bower EJ. The social determinants of oral
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Epidemiol 2005;33(1):25-34.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 33
ORAL HEALTH POLICIES: CARE FOR VULNERABLE POPULATIONS
Policy on Care for Vulnerable Populations
in a Dental Setting
Adopted
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD) is
committed to the improvement of healthcare for all children
and adolescents, regardless of their race, ethnicity, religion,
sexual or gender identity, medical status, family structure, or
financial circumstances. Additionally, the AAPD is committed
to increased access to dental services and improved oral health
for all children and adolescents, including those from vulner-
able and underserved communities. The intent of this docu-
ment is to increase awareness of the challenges that vulnerable
populations face in achieving optimal oral health, to educate
providers regarding the importance of culturally-sensitive care,
and to encourage oral health professionals to advocate for
improved access to dental services for vulnerable communities.
Methods
This policy was developed by the Council on Clinical Affairs.
This document is based on a review of current dental and
®
medical literature, including search of the PubMed and Google
Scholar databases combining the word dental with the follow-
ing terms: vulnerable populations; special health care needs
(SHCN); lesbian; gay; bisexual; transgender; lesbian, gay,
bisexual, transgender, questioning (LGBTQ); homosexuality;
sexual minority; gender diverse; homeless children; foster
children; military-connected AND children; immigrant;
incarcerated youth; mental health; fields: all; limits: within
the last 10 years, human, English. Data from 67 articles met
these criteria. Papers for review were chosen from this list
and from references within selected articles. Expert opinions
and best current practices were relied upon when clinical
evidence was not available.
Background
Vulnerable populations are communities that have limited
access to healthcare for many reasons including geography,
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
the state and federal levels. Negative health sequelae of limited
access to care among vulnerable populations include dispro-
portionately poor oral and systemic health status and lower
utilization rates of preventive services.1-3
34 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on care
for vulnerable populations in a dental setting. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:34-40.
While the negative oral health consequences for some vul-
nerable populations have been established, there are additional
groups that typically have been emphasized less in studies of
oral health. This document allows for a broader concept of
vulnerability and lends additional information to providers
regarding support for such communities. These groups extend
beyond the better understood vulnerabilities of poverty and
special health care needs and include LGBTQ youth, military-
connected families, families without consistent housing, youth
with mental illness, and immigrants. While by no means
comprehensive in its list of vulnerable groups, this document
discusses barriers to care that may be applicable to additional
populations.
Many pediatric dentists take active roles in their communi-
ties as advocates for children’s health beyond the responsibilities
of providing healthcare. It is important that dentists maintain
an awareness of the various social determinants of oral health4
and approach care for their patients with cultural sensitivity.
Dentists should be aware of the particular vulnerabilities of
their patients when it comes to their health and are encouraged
to advocate for and seek out resources that would benefit their
patients as individuals and as a community.
Youth in the juvenile justice system
Adolescents who have passed through the juvenile justice
system constitute a vulnerable population due to higher rates
of health risky behaviors, limited access to healthcare, and
sociodemographic factors. Over 850,000 arrests of youth
younger than 18 were made in 2016.5 The number of youth
in residential placement varies, but recent census data reports
more than 40,000 juveniles may be assigned to residential
placement on any given day.6 Lack of housing stability, dis-
ruptions in education, and other sequelae of poverty correlate
with higher rates of arrests among youth from low socio-
economic backgrounds.7 Incarcerated youth have higher rates
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ADHD: Attention
deficit hyperactivity disorder. LGBT: Lesbian, gay, bisexual, or trans-
gender. LGBTQ: Lesbian, gay, bisexual, transgender, questioning.
SHCN: Special health care needs. TGD: Transgender or gender
diverse.

of health risky behaviors, particularly in the realm of mental
and sexual health.8,9 Nationwide, it was found that two-thirds
of juvenile detention facilities hold youth without criminal
charges who are awaiting community mental health services.10
The oral health of youth in juvenile detention centers may
be compromised by a lack of comprehensive treatment and
continuity of care and concomitant health risky behaviors.
There is a dearth of current studies on the oral health of in-
carcerated youth. One study of a detention center in Texas
found significantly higher rates of untreated decay and low
rates of preventive measures among its residents compared to
non-incarcerated youth.11 Urgent dental problems including
infection, tooth and jaw fractures, and severe periodontal di-
sease were found in over six percent of the subjects included
in the study.11 Juvenile detention and confinement facilities are
required to provide a dental examination by a licensed dentist
within 60 days of admission.12 Beyond the examination, how-
ever, youth in detention facilities may have dental needs that
are addressed only on an emergency basis, without access to
routine care and without family, school, or community
resources to facilitate management of their dental needs.
Dental providers offering care within detention facilities
may have explicit biases toward youth in custody, and they
may doubt the truthfulness of symptoms reported by these pa-
tients. Biases and doubts may cause a delay in diagnoses or
treatment.13 Additional challenges in caring for youth in de-
tention facilities include scheduling appointments, security
concerns, transportation considerations, lack of legal guardian
presence, and availability of providers.14 Once released from
detention facilities, juveniles may face hardships establishing
care and preventive services due to lack of family involvement
and external support, difficulties adjusting to their previous
environment, problems accessing previous medical records,
and challenges in obtaining insurance coverage.7
Dental providers should be aware of these challenges when
treating incarcerated youth. Ideally, efforts to establish a
dental home and to reinstate insurance coverage should be
made prior to release from the facility. Providers are encour-
aged to connect with social services in their communities to
facilitate ongoing care for previously incarcerated youth.
Incarcerated youth should be provided with the same standard
of care as non-incarcerated individuals and should receive
comprehensive dental examinations within a defined amount
of time in detention. Efforts should be made by dental
providers to connect patients to other healthcare services
within the facility, particularly when oral manifestations of
systemic diseases are recognized in youth who have not yet
been evaluated by a physician.8
Youth with mental health conditions or behavioral
disorders
One out of every five children in the United States has been
diagnosed with a mental health disorder. 14 Mental health
conditions vary in terms of cause, incidence, and severity. The
most commonly diagnosed mental health conditions in
ORAL HEALTH POLICIES: CARE FOR VULNERABLE POPULATIONS
children are attention deficit hyperactivity disorder (ADHD),
behavior problems, anxiety, and depression. 15 According to
recent data, over six million children under the age of 18 have
been diagnosed with ADHD, 4.4 million with anxiety, and
1.9 million with depression.15 Unfortunately, only about 20
percent of those children diagnosed with a mental health con-
dition receive treatment for their disorder.16 Worldwide, people
with mental health disorders may be subject to social stigma-
tization and discrimination, higher rates of physical and sexual
violence, and limitations to their participation in civic life and
public affairs. Their ability to access essential health care and
social services, including emergency services, may be challenging.17
People with behavioral or mental health conditions are
susceptible to worsened oral health. Those with depressive
disorders may experience fatigue and lack of motivation for
self-care that impedes proper home oral hygiene. Anxiety or
depression can lead to lower self-esteem and dental fears that
make one less likely to seek professional dental care.18 Such
risk factors may cause increased rates of dental decay and tooth
loss, which in turn exacerbate mental health conditions by
contributing to social withdrawal, low self-esteem, and diffi-
culty with functions such as eating and speaking.19 Children
and adolescents with ADHD may be prone to dental injuries
and bruxism habits.20-22 Xerostomia is a known side effect of
multiple psychotropic medications.19 Those patients at risk for
xerostomia should be educated on proper fluoride use and in-
creased frequency of water intake. Eating disorders may start
in childhood and more commonly in adolescence and have
the highest rate of mortality of any mental health condition.23
Eating disorders can result in detrimental oral health behaviors
with consequences including severe erosion of enamel and
increased risk of dental caries.24 Dentists should be aware of
intraoral signs of eating disorders and be prepared to discuss
concerns with their patients and families.
Dentists should consider the mental health of their patients
and inquire about their psychiatric management, including
behavior modification strategies 25, medications, and home
hygiene practices. They are encouraged to connect with men-
tal health provider networks and refer patients for counseling
for concerns that have not yet been addressed by a mental
health professional.
Individuals with special health care needs
Individuals with SHCN are among the many vulnerable
populations who suffer profound health disparities.26-31 Those
who treat individuals with SHCN need specialized knowledge,
training, awareness, and willingness to accommodate
patients beyond routine measures.32 Although children with
SHCN utilize preventive dental care at equal or higher rates
when compared to children without SHCN, dental care
continues to be the most common unmet healthcare need
among this population. 26-29 In fact, low-income children
with the most severe healthcare conditions are more likely
to have unmet dental needs. 26,27 Individuals with SHCN
face many barriers to obtaining adequate oral health care
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 35
ORAL HEALTH POLICIES: CARE FOR VULNERABLE POPULATIONS
including competing medical priorities, difficulties finding a
knowledgeable and willing provider, residing in rural locations,
transportation issues, inadequate insurance, and caregivers
factors such as depression, low levels of functioning, and fi-
nancial burdens of caring for an individual with SHCN.26-30
An integral part of the specialty of pediatric dentistry is to
provide comprehensive preventive and therapeutic oral health
care to individuals with SHCN.33 Failure to accommodate
patients with SHCN could be considered discrimination and a
violation of federal and/or state law.34 Therefore, when the
needs of an individual with SHCN are beyond the skills of
the dentist, the patient should be referred to a practitioner
who is comfortable, knowledgeable, and appropriately trained
to manage the patient’s individual oral health care needs.
LGBTQ youth
LGBTQ is an initialism that is used to describe those
individuals who identify as lesbian, gay, bisexual, transgender,
or questioning.35 TGD also may be used to describe individ-
uals that identify as transgender or gender diverse.35 LGBTQ
and TGD individuals and their families may face disparities
stemming from inequitable laws and policies, encounter so-
cietal discrimination, and lack access to quality health care.35
Individuals identified as lesbian, gay, bisexual, or transgender
(LGBT) present to dental providers with unique oral health
needs36 and are at greater risk for poor health conditions.37 It
is, therefore, imperative that dental offices be willing and
prepared to treat individuals of all backgrounds, including
those who identify as LGBTQ or TGD.
Many LGBTQ or TGD individuals face stigma and dis-
crimination35 and experience stress and anxiety in healthcare
settings.37 Dental fear among transgender individuals has been
associated with prior experiences and fears of discrimination.38
For these reason, some patients may not feel comfortable dis-
closing their sexual orientation, gender identity, or expression.39,40
Providers are encouraged to create a welcoming office environ-
ment for patients who identify as LGBTQ or TGD. Examples
include using gender neutral terms39,40 and placing a rainbow
decal or button that is easily seen by patients. Intake forms
can be modified to include questions about the patient’s
preferred pronoun, sex at birth, preferred gender, and legal and
preferred names 39 and should ask for parent rather than
mother/father information. These efforts demonstrate
inclusion of parents and legal guardians who are in same-sex
relationships and indicate that the office is open and
welcoming to individuals of diverse sexual orientation, gender
identity, or expression.40
Professional education regarding oral health and oral health
disparities of individuals identified as LGBTQ is lacking. In
a 2016 survey of United States and Canadian dental schools,
29 percent of responding schools did not offer any LGBT
content, and 12 percent did not know if content was covered.39
Proper training of health care providers to take care of these
individuals 35,41 and more evidence-based research regarding
LGBT health and health disparities are needed.42
36 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Immigrant youth and families
Immigrant children and families present unique needs and
can encounter barriers to oral health as a vulnerable population.
In 2017, 18.2 million children in the United States lived with
one immigrant parent.43 Children who grow up in a multicul-
tural setting can experience differences in their oral health if
there is a difference between parental or cultural views and the
mainstream culture.44 Children who have recently immigrated
are at an increased risk for caries.44,45 Language barriers, insur-
ance coverage, available providers, as well as cultural views can
create barriers in accessing oral health care.44 Acceptance of
health interventions as well as responses to health information
can be affected by an individual’s or family’s culture.43 It is im-
portant that providers understand and consider these factors
when treating immigrant children and families.
Oral health messages can be developed with special con-
sideration to a community’s cultural beliefs, motivation, and
knowledge. Acceptance of oral health care recommendations
and treatment may be improved by training community
members to participate in the delivery of care to families.44
Involvement of a greater network or community members in
the delivery of care can foster trust in the dental provider. De-
livering oral health information that considers a gain-framed
or loss-framed approach based on cultural background and
acculturation can improve responsiveness.43 Immigrant families
with greater exposure to the mainstream culture may respond
more positively to gain-framed messaging. An example of a
gain-framed message would be if one brushes twice daily, the
individual will have better oral health. 46 Immigrant families
with less exposure to the mainstream culture may respond
better to loss-framed messaging.46 An example of a loss-framed
message would be if one does not brush twice daily, the
individual risks having poor gingival health and caries. Den-
tal providers should make efforts to understand the cultural
backgrounds of immigrant patients and families and utilize
many approaches to improve their delivery of care.
Military-connected youth
Military-connected youth face challenges and vulnerabilities
caused by the unique requirements of military life. Providing
care to military-connected youth requires appropriate knowl-
edge, understanding, and appreciation of military culture.47
The armed services represent a culturally and ethnically diverse
population with 31 percent of the force represented by racial
minorities,48 and 16.4 percent of service members are females.48
In 2018, over 1.5 million dependent children were reported to
be living in active duty, guard, and reserve families. 48 Along
with the approximately two million children of veterans, the
total number of military-connected children in the United States is
nearly four million.48
Military-connected children may grow up without the
physical presence of a parent due to frequent deployments,
missions, training exercises, and school.47 Deployment and its
dangers can threaten a child’s sense of security and can result
in complex psychosocial burdens. 47-51 Military-connected

families experience frequent relocations involving the changing
of schools and social networks. Some evidence suggests that
military-connected children cope well with relocation and
experience lower risk behaviors when compared to civilian
counterparts.50 Conversely, other resources point to more risk
behaviors and depressed mood as a result of parental military
service.52 Some military-connected children may experience
marginalization and victimization52 while others face problems
in communities where there is a lack of sensitivity to or prepa-
ration for dealing with military-connected difficulties.51 Child
maltreatment and neglect are concerns for military-connected
children.53 Some studies demonstrated an elevated risk while
others show risk comparable to civilian populations.53-56
Reestablishing medical and dental homes is a common
challenge military-connected families face. Although military
families have health insurance coverage, a recent study found
military-connected children are more likely to have special
health care needs and behavioral health needs when compared
with civilian peers.57 Furthermore, frequent relocations may
interfere with continuity of care and leave some medical or
dental problems unresolved. A study on dental care in military
children found socioeconomic status of the service member
influenced care seeking behavior.58 Frequent changes in military
insurance plans may deter some dental offices from accepting
or continuing care after changes in coverage.
Military-connected children may have an increased risk for
caries due to deficiencies in protective and biological factors.
A consistent dental home with regular dental care may be
lacking, and fluoride exposure may be suboptimal. Sporadic
dental care may be more common because of frequent reloca-
tions. Inconsistent fluoride exposure may be expected if
children have a history of residing in international or non-
fluoridated communities. Children in single parent or dual
military families also may be at an increased risk for caries.
During work, training, or deployments, military-connected
children may be enrolled in extensive childcare and after
school programs or be cared for by extended family where they
have more frequent exposure to cariogenic foods. Dentists
caring for military families are encouraged to be thorough in
their discussion of dietary choices and to help connect families
to other dentists upon relocation.
Foster care and homeless youth
Youth who are homeless or in foster care present unique needs
and can encounter significant barriers to oral health care as a
vulnerable population. Approximately 415,000 children are in
foster care in the United States, and some remain in foster care
until adulthood.59 Abuse, neglect, and family disruption are the
most common reasons why youth are placed in foster care.59
Foster parents are often unable to locate dentists who accept
Medicaid, and studies have found that foster children suffer
from relatively poor health, unresolved or worsening health
conditions, and lack of access to medical and dental care.60,61
Foster caretakers’ own knowledge, attitudes, and experiences
influence dental management and behaviors of the foster child.
ORAL HEALTH POLICIES: CARE FOR VULNERABLE POPULATIONS
Foster caretakers often are challenged with the inability to
consent for needed dental care and rely on social services to
assist with obtaining consent from legal authorities.60-62 A
recent study found that youth in foster care were more likely
to experience caries in both the primary and permanent den-
tition than other children who were enrolled in Medicaid.60
Every year, more than 2.5 million children will experience
a period of homelessness in the United States.63 Approximately
40 percent of homeless in the United States are under the age
of 18.64 The main cause of youth homelessness is physical,
sexual, and/or emotional abuse from parents or guardians.63 As
many as 20,000 homeless youth are forced into prostitution by
human trafficking.65 Approximately half of youths who age out
of foster care or the juvenile justice system will be homeless
within six months.63 Youth who are homeless face challenges
in obtaining dental care including transportation, consent for
treatment, and general dental knowledge.66 A homeless minor
may be able to provide consent for treatment based on indi-
vidual state laws. The 2018 Federal Runaway and Homeless
Youth Act allows for some youth to have legal rights for treat-
ment decisions.67 Homeless youth have a higher caries rate
than those who have Medicaid.63 Provision of dental services
for youth in foster care or who are homeless should be made
available whenever possible. This usually requires additional
measures on behalf of the dental health professional in order to
provide appropriate dental procedures in a safe and empathetic
environment.
Policy statement
Recognizing of the challenges faced by vulnerable populations
in achieving optimal oral health status, the AAPD supports:
• advocacy for programs and policies that support vul-
nerable populations in obtaining improved access to
healthcare services.
• pre- and postdoctoral programs as well as continuing
education courses that include training dentists in cul-
tural sensitivity and social concerns for vulnerable
populations.
• inter-professional networks that will aid vulnerable
populations in accessing important healthcare resources.
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T, Schwartz SB. “I just want to be treated like a normal
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41. Haffeez H, Zeshan M, Tahir MA, Jahan N, Naveed S.
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system. Pediatr Dent 2019;15;41(1):48-51. • Autism Speaks
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40 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Policy on Diversity, Equity, and Inclusion
Adopted
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
advocates for the health and well-being of all infants, children,
and adolescents, regardless of their race, ethnicity, religion,
sexual or gender identity, medical status, family structure, or
financial circumstances1 and supports efforts to increase health
equity among youth. Diversity, equity, and inclusion (DEI) are
critical to achieve the AAPD’S vision of optimal oral health
for all children.2 The intent of this policy is to review the pub-
lished literature on how race, ethnicity, and other identifiers
are related to children’s oral health and health inequities, to
identify barriers to DEI within the dental profession, and to
encourage clinicians, educators, researchers, and policy makers
to advance DEI within the specialty of pediatric dentistry.
Methods
This policy was developed by the Council on Clinical Affairs.
A review of current dental and medical literature and sources
of recognized professional expertise related to diversity, equity,
and inclusion was completed. The literature search of the
®
PubMed /MEDLINE database was conducted using the
terms: diversity, equity, inclusion; fields: all; limits: within the
last 10 years, English. Papers for review were chosen from this
list and from the references within selected articles. Expert
and/or consensus opinion by experienced researchers and
clinicians was also considered.
Definitions
Diversity: constitutes “a broad range of individual, population,
and social characteristics, including but not limited to age;
sex; race; ethnicity; sexual orientation; gender identity; family
structures; geographic locations; national origin; immigrants
and refugees; language; physical, functional, and learning abil-
ities; religious beliefs; and socioeconomic status”.3 In addition,
other characteristics of diversity include body/size image,
veteran status, housing status, and mental health status.4
Equity: is defined as “the state, quality or ideal of being just,
impartial and fair.”5 The concept of equity is synonymous
with fairness and justice. To be achieved and sustained, equity
needs to be thought of as a structural and systemic concept.5
Moreover, health equity is described as the “attainment of the
highest level of health for all people. Achieving health equity
requires valuing everyone equally with focused and ongoing
societal efforts to address avoidable inequalities, historical and
ORAL HEALTH POLICIES: DIVERSITY, EQUITY, INCLUSION
How to Cite: American Academy of Pediatric Dentistry. Policy on
diversity, equity, and inclusion. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:
41-4.
contemporary injustices, and the elimination of health and
health care disparities”.6
Inclusion: “is a dynamic state of operating in which diversity
is leveraged to create a fair, healthy, and high-performing or-
ganization or community. An inclusive environment ensures
equitable access to resources and opportunities for all. It also
enables individuals and groups to feel safe, respected, engaged,
motivated, and valued, for who they are and for their con-
tributions toward organizational and societal goals.”7
Background
Marked oral health disparities exist by race and ethnicity for
children and adolescents in the United States.8-11 Children of
American Indian and/or Alaska Native descent and Native
Hawaiian children have the highest documented prevalence
of early childhood caries, and a significantly higher percentage
of non-Hispanic Black and Mexican American children have
dental caries, compared to non-Hispanic White children.12-15
Reasons such as consumption of more added sugars and less
utilization of preventive dental care have been used to explain
the higher caries risk assigned to racial and ethnic minor-
ities.16,17 While behavior modification strategies are important
to improve oral health, the overarching role of social determi-
nants of health must be addressed if oral heath disparities are
to be reduced in a long-lasting and meaningful way.18,19
Structural racism (i.e., processes that are embedded in laws,
policies, and institutions20,21) impacts social determinants of
oral health.22,23 Discriminatory policies such as unfair lending
practices, employment standards, and workplace policies
heavily influence factors such as income level, insurance cover-
age, quality of education, food security, housing, chronic stress,
and neighborhood resources that lead to poorer oral health
outcomes for marginalized populations. 9,10,18,24,25 Access to
dental services, nutritious food, and safe and fluoridated drink-
ing water 10,25 are significantly hindered by barriers such as
housing instability, food deserts, inflexible work schedules,
lack of transportation, and high costs of care that dispropor-
tionately affect non-Caucasian families.26-29 Recognition of the
influence of discrimination on the social determinants of oral
health is necessary to advocate for greater health equity.25,30
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. DEI: Diversity, equity,
and inclusion.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 41
ORAL HEALTH POLICIES: DIVERSITY, EQUITY, INCLUSION
Available literature has discussed more direct effects of
bias on oral health. Racial minorities often receive lower
quality health care than their White counterparts even when
accounting for factors related to access, socioeconomic status,
and education.10,31 Negative effects on self-perceptions of oral
health status31,32, diminished oral health-related self-efficacy33,
and avoidance of dental appointments due to fear of maltreat-
ment10,34 have been reported. Caregivers of minority children
have expressed unmet dental needs and inattentiveness from
dental providers.10
Heightened awareness of oral health inequities and related
social injustices have inspired professional efforts to enhance
diversity and inclusion in the pediatric dental workforce and
to combat discrimination that leads to oral health inequi-
ties. Dental schools and professional organizations have
created strategies to increase diversity among their students,
members, and leadership. 36,37 The increased presence of
underrepresented populations among healthcare profes-
sionals is important for building trust between providers
and marginalized families.10,19 AAPD legislative priorities
align with aims to increase professional diversity and health
equity through the support of provider training programs,
recommended Medicaid reform, and expansion of the
dental workforce.38,39
Both intentional and non-intentional provider biases affect
the health care that children receive. The National Institutes of
Health report Oral Health in America: Advances and Challenges
calls for a new framework in dental education that emphasizes
the social determinants of health, inequities, and population
diversity.19 Improved cultural competency training in practices,
residency programs, dental schools, universities, and other
institutions relevant to the practice of dentistry is necessary
to address discriminatory assumptions and behaviors among
dental providers. 35,40-43 Relevant training may encourage
providers to be mindful of the ways in which personal and
professional biases influence practice settings, treatment deci-
sions, office policies, and patient relationships22 and motivate
them to create an inclusive and respectful environment for
all children in their care. Barriers to implementation of DEI
principles, including lack of social supports to help manage
children’s needs, have been reported.44,45
Policy statement
The AAPD acknowledges and celebrates the increasing diver-
sity of children, including their racial and ethnic backgrounds,
national origin and citizenship, languages spoken, religious
beliefs, abilities, gender and sexual identities, and cultural
norms. Additionally, the AAPD welcomes greater diversity
within the profession and appreciates the personal experiences,
skills, and knowledge possessed by each of its individual mem-
bers. The AAPD supports broader inclusivity in leadership,
membership, education, and practice and deeper engagement
with communities to promote necessary collaboration, respect,
and dignity for all children and families. Programs, initiatives,
and policies that address and overcome social barriers, including
42 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
racism and other forms of discrimination, are necessary to
achieve greater health equity and the AAPD’s vision of optimal
oral health for children.
Recognizing the importance of DEI to pediatric dentistry,
the AAPD:
• supports social and economic policies, research, and
initiatives to address social determinants of oral health
that result in racial and ethnic oral inequities.
• encourages providers to implement diversity, equity,
and inclusion training within the dental office.
• urges dental educators to implement strategies to miti-
gate bias in applicant and trainee evaluation processes
and to enhance institutional DEI curricula.
References
1. American Academy of Pediatric Dentistry. Policy on
care for vulnerable populations in a dental setting. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:34-40.
2. American Academy of Pediatric Dentistry. Strategic Plan.
The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:
10-1.
3. American Association of Colleges of Nursing. Diversity,
Inclusion, and Equity in Academic Nursing: AACN
Position Statement. Boston, Mass.; 2017. Available at:
“https://www.aacnnursing.org/Portals/42/News/Position-
Statements/Diversity-Inclusion.pdf ”. Accessed July 26,
2022.
4. Buchanan DT, O’Connor MR. Integrating diversity,
equity, and inclusion into a simulation program. Clin
Simul Nurs 2020;49(C):58-65.
5. Annie E. Casey Foundation. Race Equity and Inclusion
Action Guide. Baltimore, Md.; 2015 Available at: “https:
//www.aecf.org/resources/race-equity-and-inclusion-
action-guide”. Accessed July 26, 2022.
6. Office of Disease Control and Prevention. Disparities.
Foundation Health Measures. Healthy People 2020. U.S.
Department of Health and Human Services. Decem-
ber, 2010. Available at: “https://www.healthypeople.gov/
2020/about/foundation-health-measures/Disparities”.
Accessed June 22, 2022.
7. The Centre for Global Inclusion. Diversity, Equity, and
Inclusion Policy. Available at: “https://centreforglobal
inclusion.org/resources/dei-policy.html”. Accessed August
15, 2022.
8. Lau M, Lin H, Flores G. Racial/ethnic disparities in
health and health care among U.S. adolescents. Health
Serv Res 2012;47(5):2031-59.
9. McLaren L, McNeil DA, Potestio M, et al. Equity in
children’s dental caries before and after cessation of
community water fluoridation: Differential impact by
dental insurance status and geographic material depri-
vation. Int J Equity Health 2016;15:24.

10. Como DH, Stein Duker LI, Polido JC, Cermak SA. The
persistence of oral health disparities for African Ameri-
can children: A scoping review. Int J Environ Res Public
Health 2019;16(5):710.
11. Centers for Disease Control and Prevention. Oral Health:
Disparities in Oral Health. February 5, 2021. Available at:
“https://www.cdc.gov/oralhealth/oral_health_disparities/
index.htm”. Accessed May 31, 2022.
12. Edelstein BL, Chinn CH. Update on disparities in oral
health and access to dental care for America’s children.
Acad Pediatr 2009;9(6):415-9.
13. Deguchi M, Valente T, Efird J, Oropeza M, Niederman
R, Nigg CR. Hawai’i’s silent epidemic: Children’s caries
(dental decay). Hawaii J Med Public Health 2013;72(6):
204-8.
14. Matsuo G, Rozier RG, Kranz AM. Dental caries: Racial
and ethnic disparities among North communities.
Paediatr Child Health 2021;26(4):255-8.
15. Holve S, Braun P, Irvine JD, Nadeau K, Schroth RJ.
Early childhood caries in Indigenous communities.
Paediatr Child Health 2021;26(4):255-8.
16. Chi DL, Hopkins S, O’Brien D, Mancl L, Orr E, Lenaker
D. Association between added sugar intake and dental
caries in Yup’ik children using a novel hair biomarker.
BMC Oral Health 2015;15(1):121.
17. Choi YY, Andreyeva T, Fleming-Milici F, Harris JL. U.S.
households’ children’s drink purchases: 2006-2017 trends
and associations with marketing. Am J Prev Med 2022;
62(1):9-17.
18. American Academy of Pediatric Dentistry. Policy on
social determinants of children’s oral health and health
disparities. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:29-33.
19. National Institutes of Health. Oral Health in America:
Advances and Challenges. Bethesda, Md.: U.S. Depart-
ment of Health and Human Services, National Institutes
of Health, National Institute of Dental and Craniofacial
Research; 2021. Available at: “https://www.nidcr.nih.
gov/sites/default/files/2021-12/Oral-Health-in-America-
Advances-and-Challenges.pdf ”. Accessed August 15, 2022.
20. Williams DR, Lawrence JA, Davis BA. Racism and health:
Evidence and needed research. Ann Rev Public Health
2019;40:105-25.
21. National Academies of Sciences, Engineering, and
Medicine. Addressing Diversity, Equity, Inclusion, and
Anti-Racism in 21st Century STEMM Organizations:
Proceedings of a Workshop-in Brief. Washington, D.C.;
2021. The National Academies Press. Available at: “https:
//doi.org/10.17226/26294”. Accessed July 26, 2022.
22. Jamieson L, Peres MA, Guarnizo-Herreño CC, Bastos
JL. Racism and oral health inequities; An overview.
EClinicalMedicine 2021;34:100827. Available at: “https:
//www.ncbi.nlm.nih.gov/pmc/articles/PMC8027540/”.
Accessed August 15, 2022.
ORAL HEALTH POLICIES: DIVERSITY, EQUITY, INCLUSION
23. Bastos JL, Constante HM, Jamieson LM. Making science
and doing justice: The need to reframe research on racial
inequities in oral health. Community Dent Health 2021;
38(2):132-7.
24. Lee JY, Divaris K. The ethical imperative of addressing
oral health disparities: A unifying framework. J Dent Res
2014;93(3):224-30.
25. Braveman P, Gottlieb L. The social determinants of
health: It’s time to consider the causes of the causes.
Public Health Rep 2014;129(Suppl 2):19-31.
26. Cao S, Gentili M, Griffin PM, Griffin SO, Serban N.
Disparities in preventive dental care among children in
Georgia. Prev Chronic Dis 2017;14:E104.
27. da Fonseca MA, Avenetti D. Social determinants of
pediatric oral health. Dent Clin North Am 2017;61(3):
519-32.
28. Chi DL. Oral health for US children with special health
care needs. Pediatr Clin North Am 2018;65(5):981-93.
29. Vujicic M, Fosse C. Time for dental care to be consid-
ered essential in US health care policy. AMA J Ethics
2022;24(1):E57-63.
30. Evans, CA, Smith, P. Effects of racism on oral health in
the United States. Community Dent Health 2021;38(2):
138-41.
31. Smith WR, Betancourt JR, Wynia MK, et al. Recom-
mendations for teaching about racial and ethnic disparities
in health and health care. Ann Intern Med 2007;147(9):
654-65.
32. Schwartz SB, Sanders AE, Lee JY, Divaris K. Sexual
orientation-related oral health disparities in the United
States. J Public Health Dent 2019;79(1):18-24.
33. Gibson LB, Blake M, Baker S. Inequalities in oral health:
The role of sociology. Community Dent Health 2016;
33(2):156-60.
34. Schwartz SB. L.G.B.T: Let’s go beyond teeth. Pediatr
Dent 2017;39(2):90-2.
35. American Dental Education Association. Access, Diversity
and Inclusion Strategic Framework 1-1; 2018. Available
at: “https://www.adea.org/diversity/framework/”. Accessed
June 22, 2022.
36. American Dental Education Association. 2019-2020 Key
ADEA Access, Diversity and Inclusion Initiatives and
Activities. Chicago, Ill.; 2018. Available at: “https://www.
adea.org/uploadedFiles/ADEA/Content_Conversion_
Final/policy_advocacy/diversity_equity/Documents/
2019-20_Key-ADEA-ADI-Intiatives.pdf ”. Accessed July
26, 2022.
37. American Dental Association. 2020-2025 Diversity and
Inclusion Plan. Advancing Inclusion while Growing
Membership Diversity. Chicago, Ill.; 2020. Available at
“https://www.ada.org/-/media/project/ada-organization/
ada/ada-org/files/about/ada_diversity_inclusion_plan.pdf?
rev=7c532219f8ad4c308bc15d6011af7c73&hash=CF41B
5AACADDDD99122AA15C1054876C”. Accessed June
22, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 43
ORAL HEALTH POLICIES: DIVERSITY, EQUITY, INCLUSION
38. American Academy of Pediatric Dentistry. Legislative
Priorities. Available at: “https://www.aapd.org/global
assets/2022-legislative-priorities-for-website.pdf ”. Accessed
March 12, 2022.
39. American Academy of Pediatric Dentistry. Policy on
workforce issues and delivery of oral health care services
in a dental home. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:45-9.
40. Goodman XY, Nugent RL. Teaching cultural competence
and cultural humility in dental medicine. Med Ref Serv
Q 2020;39(4):309-22.
41. Forsyth C, Short S, Gilroy J, Tennant M, Irving M. An
Indigenous cultural competence model for dentistry
education. Br Dent J 2020;228(9):719-25.
42. Noushi N, Enriquez N, Esfandiari S. A scoping review
on social justice education in current undergraduate
dental curricula. J Dent Educ 2020;84(5):593-606.
44 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
43. American Dental Association. Commission on Dental
Accreditation. Accreditation Standards for Dental Edu-
cation Programs. Revised August 5, 2021. Available at:
“https://coda.ada.org/~/media/CODA/Files/predoc_
standards.pdf?la=en”. Accessed July 26, 2022.
44. United States Department of Health and Human
Services. HHS Action Plan to Reduce Racial and Ethnic
Disparities. A Nation Free of Disparities in Health and
Health Care. U.S. Department of Health and Human
Services. Office of Minority Health. Rockville, Md.;
2013. Available at: “https://www.minorityhealth.hhs.
gov/assets/pdf/hhs/HHS_Plan_complete.pdf ”. Accessed
July 26, 2022.
45. Olzmann JA. Diversity through equity and inclusion:
The responsibility belongs to all of us. Mol Biol Cell
2020;31(25):2757-60.

Policy on Workforce Issues and Delivery of Oral
Health Care Services in a Dental Home
Latest Revision
2019
Purpose
The American Academy of Pediatric Dentistry (AAPD)
advocates optimal oral health and health care services for all
children, including those with special health care needs. Strate-
gies for improving access to dental care, the most prevalent
unmet health care need for disadvantaged United States (U.S.)
children, and increasing utilization of available services should
include, but not be limited to, workforce considerations. This
policy will address workforce issues with an emphasis on the
benefits of oral health care services delivered within a dentist-
directed dental home.
Methods
In 2008, the AAPD created a Task Force on Workforce Issues
(TFWI) which was charged, in part, with investigating the
problem of access to oral health care services by children in
the U.S. and analyzing the different auxiliary delivery sys-
tems available. The TFWI’s findings and recommendations
were summarized in a report1 presented to the AAPD Board
of Trustees in 2009. That report served as the basis for the
original version of this policy, developed by the Council on
Clinical Affairs and initially adopted in 2011. This document
is an update of the 2014 revision. It includes an electronic
®
search with PubMed /MEDLINE using the terms: pediatric
dentistry workforce, access to oral health care, disparities in
oral health care, nondentist provider model, dental therapy
model, expanded function dental assistants/auxiliaries, dental
care delivery, dental workforce, oral health inequalities, access
to dental care, and dental therapists.
Background
Access to oral health care for children is an important concern
that has received considerable attention since publication of
Oral Health in America: A Report of the Surgeon General in
2000. 2 The report identified “profound and consequential
disparities in the oral health of our citizens” and that dental
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
is a “silent epidemic” of dental disease.2 This report identified
dental caries as the most common chronic disease of children
in the U.S., noting that 80 percent of tooth decay is found
in 20 to 25 percent of children, large portions of whom live
ORAL HEALTH POLICIES: WORKFORCE ISSUES AND DELIVERY OF SERVICES
How to Cite: American Academy of Pediatric Dentistry. Policy on work-
force issues and delivery of oral health care services in a dental home.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:45-9.
in poverty or low-income households and lack access to an
on-going source of quality dental care.2 Research on the topic
has shown that the distribution of these disparities may vary
by age group.3
The mission of the AAPD is “to advance optimal oral
health for all children by delivering outstanding service that
meets and exceeds the needs and expectations of our mem-
bers, partners, and stakeholders.”4 The AAPD has long focused
its efforts on addressing the disparities between children
who are at risk of having high rates of dental caries and the
millions of U.S. children who enjoy access to quality oral
health care and unprecedented levels of oral health. The
AAPD’s advocacy activities take place within the broader
health care community and with the public at local, regional,
and national levels.
Access to care issues extend beyond a shortage or mal-
distribution of dentists or, more specifically, dentists who
treat Medicaid or State Children’s Health Insurance Program
(CHIP) recipients. Health care professionals often elect to not
participate as providers in these programs due to low reim-
bursement rates, administrative burdens, and the frequency of
failed appointments by patients whose treatment is publicly
funded.5-8 Nevertheless, American Dental Association (ADA)
survey data reveals that pediatric dentists report the highest
percentage of patients insured through public assistance among
all dentists.9 Medicaid-enrolled children living in areas with
more pediatric dentists are more likely to utilize preventive
dental care.10 However, when considering the disincentives of
participating as Medicaid/CHIP providers, more dentists and/
or nondentist oral health care providers cannot be considered
the panacea for oral health disparities.
Inequities in oral health can result from underutilization
of services. Lack of health literacy, limited English proficiency,
and cultural and societal barriers can lead to difficulties in
utilizing available services. Financial circumstances, as well as
geographical and transportational considerations, also can
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy of
Pediatric Dentistry. ADA: American Dental Association. CHIP: Chil-
dren’s Health Insurance Program. TFWI: Task Force on Workforce
Issues. U.S.: United States.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 45
ORAL HEALTH POLICIES: WORKFORCE ISSUES AND DELIVERY OF SERVICES
impede access to care. Eliminating such barriers will require a
collaborative, multifaceted approach.11,12 Systematic policy
and environmental changes that improve living conditions
and alleviate poverty are needed to directly address the social
determinants of health. 13 All the while, stakeholders must
promote education and primary prevention so that disease
levels and the need for therapeutic services decrease.
All AAPD advocacy efforts are based upon the organiza-
tion’s strategic objectives.4 A major component of AAPD’s
advocacy efforts is development of oral health policies, best
practices, and evidence-based clinical practice guidelines 14
that promote access to and delivery of safe, high-quality com-
prehensive oral health care for all children, including those
with special health care needs, within a dental home. A dental
home is the ongoing relationship between the dentist and the
patient, inclusive of all aspects of oral health care delivery, in
a comprehensive, continuously accessible, coordinated, and
family-centered way.15 Such care takes into consideration the
patient’s age, developmental status, and psychosocial well-
being and is appropriate to the needs of the child and family.
This concept of a dental home was detailed in a 2001 AAPD
oral health policy16 and is derived from the American Academy
of Pediatrics’ (AAP) model of a medical home.17,18 The AAPD,
AAP, ADA, and Academy of General Dentistry support the
establishment of a dental home as early as six months of age
and no later than 12 months of age.14,18-20 This provides time-
critical opportunities to provide education on preventive
health practices and reduce a child’s risk of preventable dental/
oral disease when delivered within the context of an ongoing
relationship. Prevention can be customized to an individual
child’s and/or family’s risk factors. Growing evidence supports
the effectiveness of early dental visits in reducing dental
caries.21-23 Each child’s dental home should include the capacity
to refer to other dentists or medical care providers when all
medically-necessary care cannot be provided within the dental
home. The AAPD strongly believes a dental home is essential
for ensuring optimal oral health for all children.24
Central to the dental home model is dentist-directed
care. The dentist performs the examination, diagnoses oral
conditions, and establishes a treatment plan that includes
preventive services, and all services are carried out under the
dentist’s supervision. The dental home delivery model implies
direct supervision (i.e., physical presence during the provision
of care) of allied dental personnel by the dentist. The allied
dental personnel (e.g., dental hygienist, expanded function
dental assistant/auxiliary, dental assistant) work under direct
supervision of the dentist to increase productivity and efficiency
while preserving quality of care. This model also allows for
provision of preventive oral health education and preventive
oral health services by allied dental personnel under general
supervision (i.e., without the presence of the supervising
dentist in the treatment facility) following the examination,
diagnosis, and treatment plan by the licensed, supervising
dentist. Furthermore, the dental team can be expanded to
include auxiliaries who go into the community to provide
46 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
education and coordination of oral health services. Utilizing
allied personnel to improve oral health literacy could decrease
individuals’ risk for oral diseases and mitigate a later need for
more extensive and expensive therapeutic services.
In addition, advancing optimal oral health for all children
through its policies, best practices, and clinical practice
guidelines, AAPD advocacy efforts, in part, include:
1. working closely with legislators, professional associations
and health care professionals to implement research op-
portunities in pediatric oral health and educate pediatric
dentists, health care providers, and the public regarding
pediatric oral health.
2. convening an annual Advocacy Conference in Washington,
D.C. to advocate for funding for pediatric and general
dentistry residency programs and faculty loan repayment.
3. working with the ADA to identify nonfinancial barriers
to oral health care and develop recommendations to
improve access to care for Medicaid recipients.25,26
4. partnering with federally-funded agencies to develop
strategies to improve children’s oral health.27
5. examining the various nondentist (also known as mid-
level) provider models that exist and/or are being
proposed to address the access to care issues.28
The AAPD TFWI reported that a number of provider
models to improve access to care for disadvantaged children
have been proposed and, in some cases, implemented follow-
ing the Surgeon General’s report. 1 At the heart of the issue
with each nondentist provider proposal is ensuring ongoing
access to dental care for the underserved. Therefore, practice
location and retention of independent nondentist providers
are important considerations. When providers are government
employees (e.g., Indian Health Services, National Health
Services Corps), they are assigned to high-need areas. The
dental therapy model has been shown to improve use of
dental care services in Alaska.29,30 However, the current U.S.
proposed models are private practice/nongovernment em-
ployee models, providing no assurances that independent
providers will locate in underserved areas. Recent case studies
of private practices in Minnesota describe the impact of dental
therapists on production. Their findings suggest that while a
therapist joining a dentist in a located practice may increase
that dentist’s efficiency, it does not expand geographic access
to dental care characteristic of the Alaska initiative or of the
international model of therapists. 31-33 Moreover, evidence
from several developed countries that have initiated mid-level
provider programs suggests that, when afforded an opportu-
nity, those practitioners often gravitate toward private practice
settings in less-remote areas, thereby diminishing the impact
on care for the underserved.34
In all existing and proposed nondentist provider models,
the clinician receives abbreviated levels of education compared
to the educational requirements of a dentist. For example, the
dental health aid therapist model in Alaska is a two-year certi-
ficate program with a pre-requisite high school education.35,36

The level of educational training varies from state to state,37-39
and none of the current programs is approved by the Com-
mission on Dental Accreditation. In contrast, building on
their college education, dental students generally spend four
years learning the biological principles, diagnostic skills, and
clinical techniques to distinguish between health and disease
and to manage oral conditions while taking into consideration a
patient’s general health and well-being. The clinical care they
provide during their doctoral education is under direct super-
vision. Those who specialize in pediatric dentistry must spend
an additional 24 or more months in a full-time post-doctoral
program that provides advanced didactic and clinical experi-
ences.40 The skills that pediatric dentists develop are applied
to the needs of children through their ever-changing stages
of dental, physical, and psychosocial development, treating
conditions and diseases unique to growing individuals.
While most pediatric dental patients can be managed effec-
tively using communicative behavioral guidance techniques,
many of the disadvantaged children who exhibit the greatest
levels of dental disease require advanced techniques (e.g.,
sedation, general anesthesia).41,42 Successful behavior guidance
enables the oral health team to perform quality treatment safely
and efficiently and to nurture a positive dental attitude in the
pediatric patient.43 Accurate diagnosis of behavior and safe
and effective implementation of advanced behavior guidance
techniques necessitate specialized knowledge and experience.
Studies addressing the technical quality of restorative pro-
cedures performed by nondentist providers have found, in
general, that within the scope of services and circumstances
to which their practices are limited, the technical quality is
comparable to that produced by dentists.44,45 There is, how-
ever, no evidence to suggest that they deliver any expertise
comparable to a dentist in the fields of diagnosis, pathology,
trauma care, pharmacology, behavioral guidance, treatment
plan development, and care of patients with special health care
needs. It is essential that policy makers recognize that evalua-
tions which demonstrate comparable levels of technical quality
merely indicate that individuals know how to provide certain
limited services, not that those providers have the knowledge
and experience necessary to determine whether and when
various procedures should be performed or to manage
individuals’ comprehensive oral health care, especially with
concurrent conditions that may complicate treatment or have
implications for overall health. Technical competence cannot
be equated with long-term outcomes.
The AAPD continues to work diligently to ensure that the
dental home is recognized as the foundation for delivering
oral health care of the highest quality to infants, children, and
adolescents, including those with special health care needs.
The AAPD envisions that many new and varied delivery models
will be proposed to meet increasing demands on the infra-
structure of existing oral health care services in the U.S. New
Zealand, known for utilizing dental therapists since the 1920’s
and frequently referenced as a workforce model for consid-
eration in the U.S., makes dental care available at no cost
ORAL HEALTH POLICIES: WORKFORCE ISSUES AND DELIVERY OF SERVICES
for children up to 18 years of age, with most public primary
schools having a dental clinic and many regions operating
mobile clinics.46 In New Zealand’s most recent nationwide
oral health status survey, overall, one in two children aged
two-17 years was caries-free. The caries rate for five-year-olds
and eight-year-olds in 2009 was 44.4 percent and 47.9 per-
cent respectively.47 These caries rates, which are higher than
the U.S., United Kingdom, and Australia, help refute a pre-
sumption that utilization of nondentist providers will
overcome the disparities.
As technology continues to improve, proposed models may
suggest dentist supervision of services outside the primary
practice location via electronic communicative means to be
comparable in safety and effectiveness to services provided
under direct supervision by a dentist. Health care already has
witnessed benefits of electronic communications in diagnostic
radiology and other consultative services. The AAPD encour-
ages exploration of new models of dentist-directed health
care services that will increase access to care for underserved
populations. But as witnessed through the New Zealand oral
health survey, a multifaceted approach will be necessary to
improve the oral health status of our nation’s children.
Policy statement
The American Academy of Pediatric Dentistry remains com-
mitted in its vision and mission to address the disparities
between children who lack access to quality oral health care
and those who benefit from such services. The AAPD believes
that all infants, children, and adolescents, including those with
special health care needs, deserve access to high quality com-
prehensive preventive and therapeutic oral health care services
provided through a dentist-directed dental home. In the delivery
of all dental care, patient safety must be of paramount concern.
The AAPD encourages the greater use of expanded function
dental assistants/auxiliaries and dental hygienists under direct
supervision by a dentist to help increase volume of services
provided within a dental home, based upon their proven
effectiveness and efficiency in a wide range of settings.45-51 The
AAPD also supports provision of preventive oral health services
by a dental hygienist under general supervision (i.e., without
the presence of the supervising dentist in the treatment facility)
following the examination, diagnosis, and treatment plan by
the licensed, supervising dentist. Similarly, partnering with
other health providers, especially those who most often see
children during the first years of life (e.g., pediatricians, family
physicians, pediatric nurses), will expand efforts for improving
children’s oral health.
The AAPD strongly believes there should not be a two-
tiered standard of care, with our nation’s most vulnerable
children receiving services by providers with less education and
experience. The AAPD will continue its efforts to:
1. educate families, health care providers, academicians,
community leaders, and partnered governmental agen-
cies on the benefits of early establishment of a dental
home.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 47
ORAL HEALTH POLICIES: WORKFORCE ISSUES AND DELIVERY OF SERVICES
2. forge alliances with legislative leaders that will advance
the dental home concept and improve funding for
delivery of oral health care services and dental education.
3. expand public-private partnerships to improve the oral
health of children who suffer disproportionately from
oral diseases.
4. encourage recruitment of qualified students from rural
areas and underrepresented minorities into the dental
profession.
5. partner with other dental and medical organizations to
study barriers to care and underutilization of available
services.
6. support scientific research on safe, efficacious, and sus-
tainable models of delivery of dentist-directed pediatric
oral health care that is consistent with the AAPD’s
oral health policies and clinical practice guidelines.
Furthermore, the AAPD encourages researchers and policy
makers to consult with the AAPD and its state units in the
development of pilot programs and policies that have potential
for significant impact in the delivery of oral health care
services for our nation’s children.
References
1. Hinson HP, Berlocher WC, Berg JH, et al. Report of the
American Academy of Pediatric Dentistry’s Task Force
on Workforce Issues. Chicago, Ill.: American Academy
of Pediatric Dentistry; 2009.
2. U.S. Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General.
Rockville, Md.: U.S. Department of Health and Human
Services. National Institute of Dental and Craniofacial
Research, National Institutes of Health; 2000.
3. Macek MD, Heller KE, Selwitz RH, Manz MC. Is 75
percent of dental caries found in 25 percent of the
population? J Public Health Dent 2004;61(1):20-5.
4. American Academy of Pediatric Dentistry. Strategic Plan
2020. Pediatr Dent 2018;40(6):8-9.
5. Damiano PC, Brown ER, Johnson JD, Scheetz JP. Factors
affecting dentist participation in a state Medicaid
program. J Dent Educ 1990;54(11):638-43.
6. Morris PJ, Freed JR, Nguyen A, Duperon DE, Freed BA,
Dickmeyer J. Pediatric dentists’ participation in the
California Medicaid program. Pediatr Dent 2004;26(1):
79-86.
7. Hughes RJ, Damiano PC, Kanellis MJ, Kuthy R, Slayton
R. Dentists’ participation and children’s use of services in
the Indiana dental Medicaid program and SCHIP:
Assessing the impact of increased fees and administrative
changes. J Am Dent Assoc 2005;136(4):517-23.
8. Berman S, Dolins J, Tang S, Yudkowsky B. Factors that
influence the willingness of private primary care pedi-
atricians to accept more Medicaid patients. Pediatrics
2002;110(2):239-48.
48 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
9. American Dental Association. 2009 Survey of Dental
Fees. Chicago, Ill.: American Dental Association;
September, 2009.
10. Heidenreich JF, Kim AS, Scott JM, Chi DL. Pediatric
dentistry and preventive care utilization for Medicaid
children. Pediatr Dent 2015;37(4):371-5.
11. American Dental Association. Breaking down barriers to
oral health for all Americans: The role of workforce. A
statement from the American Dental Association.
February 22, 2011. Available at: “http://www.ada.org/en/
~/media/ADA/Advocacy/Files/ada_workforce_statement”.
Accessed October 11, 2017.
12. Academy of General Dentistry. White paper on increas-
ing access to and utilization of oral health care services.
Available at: “https://www.agd.org/docs/default-source/
advocacy-papers/agd-white-paper-increasing-access-to
-and-utilization-of-oral-health-care-services.pdf?sfvrsn
=2”. Accessed July 13, 2019.
13. American Academy of Pediatric Dentistry. Policy on
social determinants of children’s oral health and health
disparities. Pediatr Dent 2018;40(6):23-6.
14. American Academy of Pediatric Dentistry. American
Academy of Pediatric Dentistry Oral Health Policies and
Recommendations. Available at: “https://www.aapd.org/
research/oral-health-policies--recommendations/”. Accessed
July 13, 2019.
15. American Academy of Pediatric Dentistry. Definition of
dental home. Pediatr Dent 2018;40(6):12.
16. American Academy of Pediatric Dentistry. Policy on
dental home. Pediatr Dent 2018;40(6):29-30.
17. American Academy of Pediatrics Ad Hoc Task Force on
the Definition of the Medical Home. The medical home.
Pediatrics 1992;90(5):774.
18. American Academy of Pediatrics. Preventive oral health
intervention for pediatricians. Pediatrics 2008;122(6):
1387-94.
19. American Dental Association. ADA Statement on Early
Childhood Caries. 2000:454. Available at: “http://www.
ada.org/en/about-the-ada/ada-positions-policies-and-
statements/statement-on-early-childhood-caries”. Accessed
July 13, 2019.
20. Academy of General Dentistry. When should my child
first see a dentist? Available at: “http://www.knowyour
teeth.com/infobites/abc/article/?abc=c&iid=296&aid=
1186”. Accessed July 13, 2019.
21. Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early pre-
ventive dental visits: Effects on subsequent utilization
and costs. Pediatrics 2004;114(4):e418-23.
22. Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining
the cost-effectiveness of early dental visits. Pediatr Dent
2006;28(2):102-5; discussion 192-8.
23. Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do
early dental visits reduce treatment and treatment costs
for children? Pediatr Dent 2014;36(7):489-93.

24. Damiano P, Reynolds J, Herndon JB, McKernan S, Kuthy
R. The patient-centered dental home: A standardized
definition for quality assessment, improvement, and
integration. Health Serv Res 2019;54(2):446-54.
25. American Dental Association Council on Access, Preven-
tion, and Interprofessional Relations. Report on the June
23, 2008 Medicaid Provider Symposium. Chicago, Ill.
Available at: “http://www.medicaiddental.org/files/
Resource%20Documents/MedicaidSymposiumFinal
Report.pdf ”. Accessed July 13, 2019.
26. American Dental Association. Proceedings of the March
23-25, 2009 Access to Dental Care Summit. Chicago, Ill.
Available at: “http://www.ada.org/~/media/ADA/Public%
20Programs/Files/access_dental_care_summit.pdf?la=en”.
Accessed July 13, 2019.
27. Office of Management and Budget. Providing Dental
Homes for Head Start and Early Head Start Children.
Reference #HHSP23320072912YC. Office of Manage-
ment and Budget No. 0990-0115. Effective Date:
September 30, 2007.
28. Wright JT, Graham F, Hayes C, et al. A systematic review
of oral health outcomes produced by dental teams incor-
porating midlevel providers. J Am Dent Assoc 2013;144
(1):75-91.
29. Chi DL, Lenaker D, Mancl L, Dunbar M, Babb M. Dental
therapists linked to improved dental outcomes for Alaska
Native communities in the Yukon-Kuskokwim Delta. J
Public Health Dent 2018;78(2):175-82.
30. Senturia K, Fiset L, Hort K, et al. Dental health aides
in Alaska: A qualitative assessment to improve paediatric
oral health in remote rural villages. Community Dent
Oral Epidemiol 2018;46(4):416-24.
31. Nash DA, Mathu-Muju KR, Friedman JW. The dental
therapist movement in the United States: A critique of
current trends. J Public Health Dent 2018;78(2):127-33.
32. Pew Charitable Trusts. Expanding the dental team:
Studies of two private practices. February 2014. Available
at: “http://www.pewtrusts.org/~/media/legacy/uploaded
files/pcs_assets/2014/expandingdentalteamreportpdf.pdf ”.
Accessed May 24, 2019.
33. Delta Dental of Minnesota. Grand Marais family dentis-
try: Dental therapist case study. Minneapolis (MN): Delta
Dental of Minnesota; May 2017. Available at: “http://
www.wilder.org/Wilder-Research/Publications/Studies/
Delta%20Dental%20of%20Minnesota/Grand%20Marais
%20Family%20Dentistry%20-%20Dental%20Therapist
%20Case%20Study.pdf ”. Accessed May 24, 2019.
34. Satur J, Gussy M, Mariño R, Martini T. Patterns of dental
therapists’ scope of practice and employment in Victoria,
Australia. J Dent Educ 2009;73(3):416-25.
35. University of Alaska Anchorage Alaska Center for Rural
Health and Health Workforce. Dental health aide. Avail-
able at: “https://www.uaa.alaska.edu/academics/college
-of-health/departments/acrhhw/healthcareerresources/
careersdescriptions/_documents/DentalHealthAide.pdf ”.
Accessed July 13, 2019.
36. Bader JD, Lee JY, Shugars DA, Burrus BB, Weterhall S.
Clinical technical performance of dental therapists in
Alaska. J Am Dent Assoc 2011;142(3):322-6.
37. State of Minnesota. Revised Statutes, 150A.105, 150A.106.
St. Paul: State of Minnesota; 2017. Available at: “https:
//www.revisor.mn.gov/statutes/?id=150A.106”. Accessed
July 13, 2019.
ORAL HEALTH POLICIES: WORKFORCE ISSUES AND DELIVERY OF SERVICES
38. Vermont 2016 S.20. An act relating to the regulation of
dental therapists as passed by House and Senate. Avail-
able at: “http://legislature.vermont.gov/assets/Documents
/2016/Docs/BILLS/S-0020/S0020%20As%20Passed%20
by%20Both% 20House%20and%20Senate%20Unofficial.
pdf ”. Accessed May 24, 2019.
39. State of Maine. An Act to Improve Access to Oral Health-
Care. Sec. 1.32 MRSA c. 16, sub-c. 3-C. Augusta, Maine:
State of Maine; 2014. Available at: “http://www.maine
legislature.org/legis/bills/bills_126th/billtexts/HP087001.
asp”. Accessed May 24, 2019.
40. American Dental Association Commission on Dental Ac-
creditation. Accreditation Standards for Advanced Spe-
cialty Education Programs in Pediatric Dentistry. 2013.
Revised 2018. Available at: “https://www.ada.org/~/media
/CODA/Files/ped.pdf?la=en”. Accessed July 13, 2019.
41. Vargas CM, Ronzio CR. Disparities in early childhood
caries. BMC Oral Health 2006;(6 Suppl)1:S3.
42. Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E.
Beyond the dmft: The human and economic cost of early
childhood caries. J Am Dent Assoc 2009;140(6):650-7.
43. American Academy of Pediatric Dentistry. Behavior
guidance for the pediatric dental patient. Pediatr Dent
2018;40(6):254-67.
44. Ryge G, Snyder M. Evaluating the quality of dental
restorations. J Am Dent Assoc 1973;87(2):369-77.
45. Scott Wetterhall S, Bader JD, Burrus BB, Lee JY, Shugars
DA. Evaluation of the Dental Health Aide Therapist
Workforce Model in Alaska – Final Report. 2010. Avail-
able at: “https://www.communitycatalyst.org/initiatives
-and-issues/initiatives/dental-access-project/RTI-Program
Evaluation-of-DHAT-Workforce-Model-in-AK-Executive
-Summary-1.pdf ”. Accessed July 13, 2019.
46. Gillies A. NZ children’s dental health still among worst.
The New Zealand Herald. March 6, 2011. Available at:
“http://www.nzherald.co.nz/nz/news/article.cfm?c_id
=1&objectid=10710408”. Accessed July 13, 2019.
47. New Zealand Ministry of Health. Age 5 and year 8 oral
health. In: Our Oral Health: Key findings of the 2009
New Zealand Oral Health Survey. New Zealand, 2010.
Available at: “http://www.health.govt.nz/system/files/
documents/publications/our-oral-health-2010.pdf ”.
Accessed July 13, 2019.
48. Luciano JW, Rothfuss LG, Von Gonten AS. The expanded
function dental assistant training program. U.S. Army
Med Dep J 2006;Jan-Mar:16-20. Available at: “http://
www.cs.amedd.army.mil/AMEDDJournal/2006jan
mar.pdf ”. Accessed July 13, 2019.
49. Beazoglou T, Brown LJ, Ray S, Chen L, Lazar V. An Eco-
nomic Study of Expanded Duties of Dental Auxiliaries
in Colorado. Chicago, Ill.: American Dental Association,
Health Policy Resources Center; 2009. Available at: “http:
//www.aapd.org/assets/1/7/EFDAeconomic2009.pdf ”.
Accessed July 13, 2019.
50. Brearley Lj, Rosenblum FN. Two-year evaluation of
auxiliaries trained in expanded duties. J Am Dent Assoc
1972;84(3):600-10.
51. Lotzkar S, Johnson DW, Thompson MB. Experimental
program in expanded functions for dental assistants:
Phase 3 experiment with dental teams. J Am Dent Assoc
1971;82(5):1067-81.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 49
ORAL HEALTH POLICIES: TELEDENTISTRY
Policy on Teledentistry
Adopted
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the need for improved access to services for infants,
children, adolescents, and individuals with special health care
needs when circumstances create barriers to care. The AAPD
advocates for teledentistry as a valuable tool to improve access
to care for pediatric patients.
Methods
This policy was developed by the Council on Clinical Affairs. A
®
PubMed /MEDLINE search was performed using the terms:
telehealth, teledentistry; fields: all; limits: within the last 10
years, humans, English, birth through age 18. Additionally,
websites for the American Dental Association, AAPD, American
Academy of Pediatrics, and American Telemedicine Association
were reviewed. Expert opinions and best current practices were
relied upon when clinical evidence was not available.
Background
Telehealth broadens healthcare delivery for patients in remote
and underserved communities.1-4 Teledentistry involves the
use of telehealth modalities to deliver dental care. Teledentistry
has many benefits in improving access to oral healthcare for
infants, children, adolescents, and individuals with special
healthcare needs in a cost-effective manner.3 Additionally,
telehealth and teledentistry are useful in time-sensitive injuries
such as trauma or when unexpected circumstances result in
difficulties accessing care.
Telehealth, including teledentistry, occurs in numerous
formats, including asynchronous (also known as store and
forward) or synchronous (live video) modalities, mobile
healthcare utilizing mobile technology, and remote patient
monitoring.4-6 Asynchronous modalities in telehealth utilize
the transmission of health records, including photographs,
videos, and radiographs, to a practitioner so that he may assess
the patient.3-5 Asynchronous modalities do not occur in real-
time. Synchronous telehealth modalities include a real-time
two-way visual interaction between a practitioner and patient.4,5
Mobile healthcare utilizes mobile technology such as cellular
telephones to promote oral health behaviors and monitor oral
health.4,5 Remote patient monitoring is the electronic trans-
mission of health and medical data from individuals outside
a hospital or clinic to providers in an alternate location to
facilitate monitoring and surveillance of diseases.7
Teledentistry has many benefits and reduces barriers to
accessing oral healthcare. 3,5 Virtual appointments via
50 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
teledentistry. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:50-1.
teledentistry can result in improved access to specialty care for
patients in rural communities.3 Using teledentistry allows pro-
viders to collaborate for multidisciplinary care, such as a cleft
team. Teledentistry heightens continuity of care as well as aug-
ments oral health instruction, diet counseling, and nutrition
education.3 Also, teledentistry is widely accepted by patients,
their families, and dental providers through utilization of
technology that is economical and already part of daily life
for many.3
Studies find teledentistry to be as reliable as visual clinical
examinations for screenings, orthognathic evaluations, indica-
tions for oral surgery, and managing odontogenic infections.3,8
Examinations conducted via teledentistry result in valid
treatment decisions by dental providers. 8 Consultations via
teledentistry for pediatric patients increase access to dental
specialists.1,2 While teledentistry has acceptable value in the
detection of caries, more well-designed research is needed to
investigate its effectiveness instead of its efficacy.9
Statutes and case law of individual states govern the practice
of dentistry, including teledentistry. Some states may require
dentists to be licensed in the state in which their patient is
receiving service.5 As with traditional delivery of dental services,
consent for and documentation of teledentistry in accordance
with state guidelines are essential. Documentation of a tele-
dentistry visit would be similar to that of an in-person visit,
encompassing a thorough description of the encounter. Secu-
rity measures and privacy of protected patient information are
necessary to ensure compliance with state and federal laws.5,6,10
Review of applicable regulations can help practitioners deter-
mine their compliance regarding licensure, documentation,
and electronic security for teledentistry. The care delivered
through teledentistry is an adjunct to in-person care and
expected to conform to evidence-based dentistry.5
Policy statement
The AAPD encourages the use of teledentistry as an adjunct
to in-person clinical care to improve access to care for infants,
children, adolescents, and individuals with special health care
needs. The AAPD advocates that teledentistry services:
• gain recognition as a subset of telehealth.
• complement but do not serve as a substitute for the
establishment of a dental home.
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

• serve as a useful tool for the timely assessment and
triage of traumatic injuries.
• provide an important adjunct when access to providers
is limited including, but not limited to, local unfore-
seen circumstances, patients in remote locations,
and patients with special health care needs who may
not be able to engage in traditional services.
• be consistent with evidence-based guidelines and
recommendations promulgated by organizations or
agencies with recognized expertise and stature.
• be included as an essential component of health care
benefits plans with reimbursement rates on par with
in-person delivery of care.
The AAPD recognizes that teledentistry is an expanding
and increasingly beneficial technology. Further research
and development of teledentistry policy and technology are
needed on a state and national level to facilitate widespread
implementation.
References
1. Kopycka-Kedzierawski DT, Billings RJ. Comparative
effectiveness study to assess two examination modalities
used to detect dental caries in preschool urban children.
Telemed J E Health 2013;19(11):834-40.
2. McLaren SW, Kopycka-Kedzierawski DT, Nordfelt J.
Accuracy of teledentistry examinations at predicting
actual treatment modality in a pediatric dentistry clinic.
J Telemed Telecare 2017;23(8):710-5.
3. Irving M, Stewart R, Spallek H, Blinkhorn A. Using
teledentistry in clinical practice as an enabler to improve
access to clinical care: A qualitative systematic review. J
Telemed Telecare 2018;24(3):129-46.
ORAL HEALTH POLICIES: TELEDENTISTRY
4. Kopycka-Kedzierawski DT, McLaren SW, Billings RJ.
Advancement of teledentistry at the University of Roch-
ester’s Eastman Institute for Oral Health. Health Affairs
2018;37(12):1960-6.
5. American Dental Association. ADA Policy on Teleden-
tistry. Chicago, Ill.: American Dental Association, 2020.
Available at: “https://www.ada.org/en/about-the-ada/
ada-positions-policies-and-statements/statement-on-
teledentistry”. Accessed June 16, 2021.
6. Burke BL Jr, Hall RW, Section on Telehealth Care. Tele-
medicine: Pediatric applications. Pediatrics 2015;136(1):
e293-e308.
7. American Telemedicine Association. Telehealth: Defining
21st Century Care. Arlington, Va.: American Telemedi-
cine Association; 2020. Available at: “https://f.hubspot
usercontent30.net/hubfs/5096139/Files/Resources/
ATA_Telehealth_Taxonomy_9-11-20.pdf ”. Accessed June
16, 2021.
8. Alabdullah JH, Daniel SJ. A systematic review on the
validity of teledentistry. Telemed J E Health 2018;24(8):
639-48.
9. Estai M, Bunt S, Kanagasingam Y, Kurger E, Tennant M.
Diagnostic accuracy of teledentistry in the detection of
dental caries: A systematic review. J Evid Base Dent Pract
2016;16(3):161-72.
10. American Telemedicine Association. Operating Procedures
for Pediatric Telehealth. Arlington, Va.: American Tele-
medicine Association; 2017:1-23. Available at: “https://
www.aap.org/en-us/Documents/ATA_Pediatric_Telehealth.
pdf ”. Accessed June 16, 2021.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 51
ORAL HEALTH POLICIES: CHILD ID PROGRAMS
Policy on Child Identification Programs
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD),
recognizing the role that dental records play in forensic identi-
fication, encourages dental practitioners and administrators of
child identification programs to implement simple practices
that can aid in identification of unknown infants, children,
and adolescents. The AAPD recommends that parents establish
a dental home, where clinical data is gathered, stored, and
updated routinely and can be made available to assist in
identification of missing and abducted persons.
Methods
This document was developed by the Council on Clinical
Affairs, adopted in 20031, and last revised in 20172. This policy
revision included a new literature search of the PubMed / ® Masons. This program gathers a physical description
MEDLINE electronic database using the terms: child, forensic,
dental, and identification; fields: all; limits: within the last
10 years, English. One hundred twelve articles matched these
criteria. Papers for review were chosen from this list and from
references within selected articles. When information from
these articles did not appear sufficient or was inconclusive,
policies were based upon expert and/or consensus opinion by
experienced researchers and clinicians.
Background
Nearly 350,000 reports of missing children and approximately
900 unidentified person records were submitted to the Federal
Bureau of Investigation’s National Crime Information Center
in 2021.3 Since the passage of the Missing Children Act in
1982 and the creation of the National Crime Information
Center, the dental profession has provided much of the infor-
mation used to compare missing persons with unidentified
individuals.4,5 The Manual of Forensic Odontology, produced by
the American Society of Forensic Odontology, demonstrates
the vital role of dentistry in identification of missing and un-
known persons.5 Numerous cases have been published in
which law enforcement agencies called upon dentistry to
provide information that proved vital to the identification
process.6,7 Dental records used for identification purposes
have included dental radiographs8, facial photographs, study
casts, bite registrations, dental examinations documenting
teeth present and distinguishing features of oral structures, and
histories documenting appliances (prosthetic and orthodontic)
in place, orthodontic treatment, and restored surfaces with
materials used.9-11
52 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on child
identification programs. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:52-3.
Nondental sources of distinguishing information currently
include fingerprints, photographs, physical descriptions, and
DNA from blood, saliva, and other tissue.12 Some nondental
sources have practical limitations. Few children have finger-
print records. DNA sampling, while being state of the art, can
be difficult to access as well as protracted and costly.13 While
not routinely collected, saliva may be a useful tool in profiling
age and gender determination for forensic experts.14 Dentists
may provide many non-invasive tools that help in the identi-
fication and tracking of children.15
Many programs have been developed and sponsored by
community groups that use various child identification meth-
ods. Examples are:
• Child Identification Program (CHIP), sponsored by the
and features fingerprinting, several still photos of various
profiles, a video recording or mannerisms with voice
interview, and various DNA samples collected on dental
impressions and/or cheek swabs.16
• New England Kids Identification System (KIDS) spon-
sored by the Massachusetts Free Masons and the Mas-
sachusetts Dental Society, which incorporates dental bite
impression and cheek swabs to gather DNA material into
the CHIP events.16-18
• The National Child Identification Program, sponsored by
the American Football Coaches Association. They provide
an identification kit which includes an inkless finger-
printing card with a DNA collection site.19
• The Federal Bureau of Investigation (FBI) has a free
mobile telephone application (app) “FBI Child ID”20.
This application provides an easily accessible means to
electronically store photos and vital information about
children. Additionally, there is a special tab on the app
that allows quick and easily access to e-mail to send
information to authorities, if necessary.
Policy statement
The AAPD recognizes the importance of dentistry’s role in
the provision of data for identification of missing or deceased
children and encourages dental professionals to assist in
identifying such individuals through dental records and other
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CHIP: Child
Identification Program. FBI: Federal Bureau of Investigation.

mechanisms. The AAPD also encourages community identifi-
cation programs to include a dental component documenting
the child’s dental home21 and encouraging consistent dental
visits. A dental home should be established for every child
by 12 months of age.21,22 A detailed dental record, updated
at recall appointments, economically establishes an excellent
database of confidential, state-of-the-art child identification
information that can be retrieved easily, stored safely, and up-
dated periodically. The dental record may contain a thorough
description of the oral cavity documenting all anomalies, a
record of restorative care delivered including materials used,
appropriate dental radiographs23, photographs, study casts, and
bite registration.
References
1. American Academy of Pediatric Dentistry. Policy on child
identification programs. Pediatr Dent 2003;25(7):13.
2. American Academy of Pediatric Dentistry. Policy on child
identification programs. The Reference Manual of Pediatric
Dentistry. Chicago Ill.: American Academy of Pediatric
Dentistry; 2017:53-4.
3. Federal Bureau of Investigation National Crime Information
Center. 2021 National Crime Information Center (NCIC)
Missing Person and Unidentified Person Statistics Pur-
suant to the Requirements of the Crime Control Act of
1990, Pub. L. No. 101-647, 104 Stat. 4789. February
2, 2022. Pages 5,10. Available at: “https://www.fbi.gov/
file-repository/2021-ncic-missing-person-and-unidentified-
person-statistics.pdf ”. Accessed March 26, 2022.
4. Sperber N. Identification of children and adults through
federal and state identification systems: Recognition of
human bite marks. Forensic Sci Int 1986;30(2-3):187-93.
5. Kavanaugh SA, Filippi JE. Missing and unidentified
persons. In: Senn DR, Weems RA, eds. Manual of Forensic
Odontology. 5th ed. Boca Raton, Fla.: CRC Press; 2013:
195.
6. Chen H, Jain AK. Automatic forensic dental identifica-
tion. In: Jain AK, Flynn P, Ross AA, eds. Handbook of
Biometrics. New York, NY: Springer Science+Business
Media, LLC; 2008:231-51.
7. Debnath N, Gupta R, Nongthombam RS, Chandran P.
Forensic odontology. J Med Soc 2016;30(1):20-3.
8. Du H, Li M, Li G, Lyu T, Tian X. Specific oral and
maxillofacial identifiers in panoramic radiographs used for
human identification. J Forensic Sci 2021;66(3):910-8.
9. Cardoza AR, Wood JD. Atypical forensic dental identifi-
cations. J Calif Dent Assoc 2015;43(6):303-8.
10. Berman GM, Bush MA, Bush PI, Freeman AJ, et al. Den-
tal identification. In: Senn DR, Weems RA, eds. Manual
of Forensic Odontology. 5th ed. Boca Raton, Fla.: CRC
Press; 2013:75-127.
11. Shanbhag VK. Significance of dental records in personal
identification in forensic sciences. J Forensic Sci Med
2016;2(1):39-43.
ORAL HEALTH POLICIES: CHILD ID PROGRAMS
12. Conceição L, da Silveira IA, Lund RG. Forensic dentistry:
An overview of the human identification’s techniques of
this dental specialty. J Forensic Res 2015;6(1):1.
13. Aidar M, Line SR. A simple and cost-effective protocol
for DNA isolation from buccal epithelial cells. Braz Dent
J 2007;18(2):148-52.
14. Bhuptani D, Kumar S, Vats M, Sagav R. Age and gender
related changes in salivary total protein levels for forensic
application. J Forensic Odontostomatol 2018;36(1):
26-33.
15. Vij N, Kochhar GK, Chachra S, Kaur T. Dentistry to the
rescue of missing children. A review. J Forensic Dent Sci
2016:8(1):7-12.
16. Masonic Youth Child Identification Program. MYCHIP.
Grand Lodge of Massachusetts Child ID Program. Avail-
able at: “http://www.mychip.org”. Accessed July 26,
2022.
17. Ellis MA, Song F, Parks ET, Eckert GJ, Dean JA, Windsor
LJ. An evaluation of DNA yield, DNA quality and bite
registration from a dental impression wafer. J Am Dent
Assoc 2007;138(9):1234-40.
18. Tesini DA, Harte DB. Anatomy of a properly taken tooth
print thermoplastic bite impression. J Mass Dent Soc
2005;54(2):22.
19. National Child Identification Program. The ID Kit. Avail-
able at: “http://www.childidprogram.com/the-id-kit”.
Accessed July 22, 2022.
20. Federal Bureau of Investigation. The FBI’s Child ID app
putting safety in your hands. Available at “https://www.
fbi.gov/file-repository/child-id-app-full-content.pdf ”.
Accessed July 26, 2022.
21. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Den-
tistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:21-2.
22. American Academy of Pediatric Dentistry. Perinatal and
infant oral health care. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:277-81.
23. American Dental Association, U.S. Department of Health
and Human Services. Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting
Radiation Exposure. Rockville, Md.: Food and Drug Ad-
ministration; 2012. Available at: “https://www.fda.gov/
media/84818/download”. Accessed July 26, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 53
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
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the importance of education, prevention, diagnosis,
and treatment necessary to maintain the oral health of in-
fants, children, adolescents, and individuals with special health
care needs through preventive and restorative care. Compre-
hensive health care cannot be achieved unless oral care is
included in all health service programs.
Methods
This policy was developed by the Dental Care Programs
Committee and adopted in 1972.1 This document is an
update of the previous version, revised in 2016.2 This revision
is based upon a review of current publications and websites
of governmental agencies and health care organizations. A
®
PubMed /MEDLINE search was performed using the terms:
oral health policy, infant oral health policy, child oral health
policy, adolescent oral health policy; oral health for special
needs; fields: all; limits: within the last 10 years, humans,
English, birth through age 18. Six hundred thirty-six articles
matched these criteria. Papers for review were chosen from
this list and from references within selected articles.
Background
The United States Department of Health and Human Services
(HSS) reports that caries is the most prevalent chronic child-
hood disease in our nation’s children.3 Early childhood caries
affects children’s quality of life and their ability to learn and
concentrate in school.4-6 Although the AAPD7, the American
Academy of Pediatrics8, and the American Dental Association9
recommend establishment of a dental home by 12 months of
age, referral patterns by primary care providers are inconsi-
tent with this recommendation.10-13 Only nine percent of
Medicaid-enrolled children aged one to 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 prevalence of dental caries among chil-
dren in older age groups, the prevalence of caries in poor
United States (U.S.) children under the age of five is
increasing.16 Studies demonstrated caries prevalence within the
54 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on oral
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; 2022:
54-7.
two-to-five-year-old age group from higher-income families
was 18 percent while that of children from low-income families
was 42 percent.17,18 Disparities in caries prevalence exist within
specific population subgroups in the U.S.19-22 From 2011-2014,
12.4 million children below the age of 19 in the U.S. had
untreated caries.23 Socioeconomic and demographic differences
are cited as barriers for treatment.23
Researchers used the 2016-2017 National Survey of Chil-
dren’s Health to analyze a link between oral health status and
academic performance.24 Assessing data from more than 45,000
six- through 17-year-olds, they found poor oral health was
strongly linked to poor academic performance and missed
school days.24 This association was consistent across subpop-
ulations defined by age, gender, household income, and type
of health insurance coverage.24
New strategies are needed to meet the needs of children
and families and effectively address early childhood caries
(ECC).18 Primary care medical providers have frequent con-
tact with families, providing opportunities to incorporate oral
health promotion and prevention in nondental settings. They
can accomplish an oral screening, risk assessment, oral health
counseling, and application of fluoride varnish.18
Key findings from the National Health and Nutrition
Examination Survey (NHANES) include:
• “For 2015–2016, prevalence of total caries (untreated
and treated) was 45.8% and untreated caries was
13.0% among youth aged 2–19 years.
• Prevalence was lowest in youth aged 2–5 years
compared with those aged 6–11 and 12–19 for total
(21.4%, 50.5%, 53.8%) and untreated caries (8.8%,
15.3%, 13.4%).
• Hispanic youth had the highest prevalence of total
caries; non-Hispanic black youth had the highest
prevalence of untreated caries.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. AI: Alaskan Indian.
AN: Alaska native. HSS: United States Department of Health and
Human Services. IOM: Institute of Medicine. U.S.: United States.

• For both total and untreated caries, prevalence decreased
as family income level increased.
• Untreated caries prevalence increased from 2011–2012
(16.1%) to 2013–2014 (18.0%) and then decreased in
2015–2016 (13.0%).”25
Untreated caries among children two to eight years of age
was shown to be twice as high for Hispanic and non-Hispanic
African American children in comparison to non-Hispanic
White children.19 American Indian (AI) and Alaska Native
(AN) children demonstrated a higher rate of caries than other
population groups in the U.S., with approximately 40 percent
of AI/AN children aged three through five years exhibiting
untreated caries in contrast to only 11 percent of non-Hispanic
White children.21
HHS reports a perception that oral health is separate from
general health and, therefore, less important.3 By raising oral
health awareness, the prevention, early detection, and man-
agement of dental, oral, and craniofacial tissues can become
integrated into general health care, community-based pro-
grams, and social services.3 HHS recognizes that oral health
can have a significant impact on overall health and well-being.
Major themes of the Oral Health in America: A Report of the
Surgeon General 3 include:
• “Oral health means much more than healthy teeth.”
• “Oral health is integral to general health.”
Oral health integration into the broader health care system
is still viewed as a supplemental benefit, not a priority benefit.26
This separate view of oral health negatively impacts our na-
tion including the increasing use of emergency departments
at substantial cost to treat dental pain and related conditions.26
Accordingly, the HHS report National Call to Action to
Promote Oral Health 27 included a partnership of public and
private organizations that specified a vision, goals, and a series
of actions to promote oral health, prevent disease, and reduce
oral health disparities in vulnerable populations including the
disadvantaged poor, racial and ethnic groups, individuals living
in geographically isolated areas, and those with special oral
health care needs. These actions are necessary and define cer-
tain tasks to assure that all Americans of all ages and those
individuals who require specialized health care services, inter-
ventions, and programs achieve optimal oral health.
The five principal actions and implementation strategies
that constitute the Call to Action include:
• “Action 1–Change Perceptions of Oral Health-
Policymakers, community leaders, private industry,
health professionals, the media, and the public are called
upon to raise the level of awareness and understanding
of oral health, affirming that oral health is essential to
general health and well-being.
• Action 2–Overcome Barriers by Replicating Effective
Programs and Proven Efforts-Remove known barriers
between people and oral health services by implementing
ORAL HEALTH POLICIES: ORAL HEALTH CARE PROGRAMS
strategies to engage all groups to eliminate health dis-
parities through health promotion and health literacy,
improve access.
• Action 3–Build the Science Base and Accelerate Science
Transfer-Application of research findings to improve oral
health.
• Action 4–Increase Oral Health Workforce Diversity,
Capacity, and Flexibility-Ensure the adequacy of public
and private health personnel and resources to meet the
oral health needs of all Americans and enable the inte-
gration of oral health effectively with general health.
• Action 5–Increase Collaborations-Develop partnerships
and utilize resources from social services, education, health
care services at state and local levels, including commu-
nity groups, voluntary organizations and individuals.”27
The Call to Action urges that oral health promotion, dis-
ease prevention, and oral health care issues have a presence in
all health policy agendas and are discussed at local, state, and
national levels.27 Its success relies on shared knowledge and
its execution at all levels.27
As follow-up to Oral Health in America3, the HHS Oral
Health Initiative 2010 was developed.28 The key statement
from this initiative was, “Oral health is integral to overall
health”.28 Total health and wellness cannot exist without oral
health. Oral disease can have an impact on physical, psycho-
logical, social, and economic health and well-being through
pain, diminished function, and reduced quality of life.29
Through this initiative, programs were created, produced, and
financed to:
• emphasize oral health promotion and disease prevention.
• increase access to care.
• enhance oral health workforce.
• eliminate oral health disparities.28
The HHS created the U.S. Department of Health and
Human Services Oral Health Strategic Framework, 2014-2017
(known as the Framework) which reflects deliberations and
next steps proposed by HHS and other federal partners to
support the department’s oral health vision and eliminate oral
health disparities.30 The Framework has five goals:
“1. Integrate oral health and primary health care.
2. Prevent disease and promote oral health.
3. Increase access to oral health care and eliminate
disparities.
4. Increase the dissemination of oral health information
and improve health literacy.
5. Advance oral health in public policy and research.”30
Federal agencies currently collaborate and through commu-
nication processes ensure that comprehensive, updated,
evidence-based health information is disseminated.30 Govern-
ment agencies and providers continue to engage, develop and
implement solutions to improve overall health and well-being.30
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 55
ORAL HEALTH POLICIES: ORAL HEALTH CARE PROGRAMS
The Institute of Medicine (IOM) in 2009 evaluated the
oral health system for the entire U.S. population and provided
recommendations and strategic approaches to the HHS for a
potential oral health initiative.31 Reviewing important factors
such as care settings, workforce, financing, quality assessments,
access to care, and education, the IOM committee focused on
these areas and how these factors linked to current and future
HHS programs and policies.12 The committee report, Advanc-
ing Oral Health in America 32, provided recommendations/
organizing principles for a new oral health initiative:
• establish HHS high-level accountability in evaluating
the oral health initiative.
• focusing on disease prevention and oral health promotion.
• improving oral health literacy and cultural competence.
• reducing oral health disparities.
• enhancing the delivery of oral health care.
• enhance the role of non-dental health care professionals.
• expand oral health research and improve data collection.
• promote collaboration among private and public stake-
holders.
• measure progress toward short-term and long-term goals
and objectives.
• advance the goals and objectives of Healthy People
202013.
Policy statement
The AAPD advocates that oral health care must be included
in the design and provision of individual, community-based,
and national health care programs to achieve comprehensive
health care. This can be achieved through the recommenda-
tions of the HHS reports Oral Health Initiative 2010 28 and
U.S. Department of Health and Human Services Oral Health
Strategic Framework, 2014-2017 30.
References
1. American Academy of Pedodontics. Oral health care
programs for children and adolescents. Chicago, Ill.:
American Academy of Pedodontics; 1972.
2. American Academy of Pediatric Dentistry. Oral health
care programs for infants, children, and adolescents.
Pediatr Dent 2016;38(special issue):23-4.
3. U.S. Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General.
Rockville, Md.: U.S. Department of Health and Human
Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health; 2000.
4. Abanto J, Carvalho TS, Mendes FM, Wanderley MT,
Bonecker M, Raggio DP. Impact of oral diseases and
disorders on oral health-related quality of life of preschool
children. Community Dent Oral Epidemiol 2011;39(2):
105-14.
5. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY.
Impact of poor oral health on children’s school attend-
ance and performance. Am J Public Health 2011;101(10):
1900-6.
56 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
6. Martins-Júnior PA, Vieira-Ansdrade RG, Corrêa-Faria P,
Oliveira-Ferreira F, Marques LS, Ramos-Jorge ML. Impact
of early childhood caries on the oral health-related quality
of life of preschool children and their parents. Caries Res
2013;47(3):211-8.
7. American Academy of Pediatric Dentistry. Policy on den-
tal home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:43-4.
8. American Academy of Pediatrics Section on Oral Health.
Maintaining and improving the oral health of young
children. Pediatrics 2014;134(6):1224-9. Reaffirmed
January, 2019.
9. American Academy of Pediatric Dentistry Foundation,
Dental Trade Alliance Foundation, American Dental
Association. The Dental Home: It’s Never Too Early to
Start February, 2007. Available at: “https://www.aapd.
org/assets/1/7/DentalHomeNeverTooEarly.pdf ”. Accessed
August 16, 2020.
10. Brickhouse TH, Unkel JH, Kancitis I, Best AM, Davis
RD. Infant oral health care: A survey of general dentists,
pediatric dentists, and pediatricians in Virginia. Pediatr
Dent 2008;30(2):147-53.
11. Chay PL, Nair R, Tong HJ. Pediatricians’ self-efficacy
affects frequency of giving oral health advice, conducting
oral examination, and prescribing referrals. J Dent Child
2019;86(3):131-8.
12. Zhu Y, Close K, Zeldin L, Quiñonez RB, White BA,
Rozier RG. A clinical vignette-based study of physicians’
adherence to guidelines for dental referrals of young
children. Acad Pediatr 2019;19(2):195-202.
13. Zhu Y, Close K, Zeldin LP, White BA, Rozier RG. Imple-
mentation of oral health screening and referral guidelines
in primary health care. JDR Clin Trans Res 2019;4(2):
167-77.
14. Bouchery E. Utilization of dental services among
Medicaid-enrolled children. Medicare Medicaid Res Rev
2013;3(3):E1-E14. Available at: “https://www.cms.gov/
mmrr/Downloads/MMRR2013_003_03_b04.pdf ”.
Accessed September 9, 2020.
15. Pierce KM, Rozier RG, Vann WF Jr. Accuracy of pediatric
care providers’ screening and referral for early childhood
caries. Pediatrics 2002;109(5):E82-2.
16. Dye BA, Tan S, Smith V, et al. Trends in oral health
status: United States, 1988-1994 and 1999-2004. National
Center for Health Statistics, Centers for Disease Control
and Prevention, U.S. Department of Health and Human
Services. Vital Health Stat 2007;11(248):1-92.
17. Dye BA, Arevalo O, Vargas CM. Trends in paediatric
dental caries by poverty status in the United States, 1988-
1994 and 1999-2004. Int J Paediatr Dent 2010;20(2):
132-43.
18. Douglass JM, Clark MB. Integrating oral health into
overall health care to prevent early childhood caries: Need,
evidence, and solutions. Pediatr Dent 2015;37(3):266-74.

19. Dye BA, Hsu KL, Afful J. Prevalence and measurement
of dental caries in young children. Pediatr Dent 2015;37
(3):200-16.
20. Garcia R, Borrelli B, Vineet D, et al. Progress in early
childhood caries and opportunities in research, policy, and
clinical management. Pediatr Dent 2015;37(3):294-9.
21. Phipps KR, Ricks TL. The oral health of American
Indian and Alaska Native children aged 1-5 years: Results
of the 2014 IHS oral health survey. Indian Health Ser-
vice Data Brief. Rocksville, Md.: Indian Health Service;
2015. Available at: “http://www.ihs.gov/doh/ documents/
IHS_Data_Brief_1-5_Year-Old.pdf ”. Accessed August
16, 2020.
22. Ricks TL, Phipps KR, Bruerd B. The Indian Health
Service early childhood caries collaborative: A 5-year
summary. Pediatr Dent 2015;37(3):275-80.
23. Gupta N, Vujici M, Yarbrough C, Harrison B. Disparities
in untreated caries among children and adults in the
U.S., 2011-2014. BMC Oral Health 2018;18:30. Avail-
able at: “https://bmcoralhealth.biomedcentral.com/track
/pdf/10.1186/s12903-018-0493-7”. Accessed September
9, 2020.
24. Guarnizo-Herreño CC, Lyu W, Wehby GL. Children’s
oral health and academic performance: Evidence of a
persisting relationship over the last decade in the United
States. J Pediatr 2019;209:183-9.e2. Available at: “https://
www.jpeds.com/article/S0022-3476(19)30135-0/fulltext”.
Accessed September 9, 2020.
25. Fleming E, Afful J. Prevalence of total and untreated
dental caries among youth: United States, 2015-2016.
NCHS Data Brief, no 307. Hyattsville, Md.: National
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: ORAL HEALTH CARE PROGRAMS
27. Office of the Surgeon General (US). National Call To
Action To Promote Oral Health. Rockville, Md.: Na-
tional Institute of Dental and Craniofacial Research (US);
2003. Available at: “https://www.ncbi.nlm.nih.gov/books/
NBK47472/”. Accessed September 9, 2020.
28. U.S. Department of Health and Human Services. Oral
Health Initiative 2010. Rocksville, Md.: U.S. Department
of Health and Human Services, Health Resources and
Services Administration; 2010. Available at: “https://
www.hrsa.gov/sites/default/files/oralhealth/hhsinitiative.
pdf ”. Accessed August 16, 2019.
29. Murthy VH. Surgeon General’s Perspectives. Oral Health
in America, 2000 to Present: Progress made, but chal-
lenges remain. Public Health Rep 2016;131(2):224-5.
Available at: “https://journals.sagepub.com/doi/pdf/10.1
177/003335491613100202”. Accessed August 16, 2020.
30. U.S. Department of Health and Human Services Oral
Health Coordinating Committee. U.S. Department of
Health and Human Services Oral Health Strategic Frame-
work, 2014-2017. Public Health Rep 2016;131(2):242-
57. Available at: “https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC4765973/”. Accessed November 13, 2020.
31. Institute of Medicine. Informing the Future: Critical
Issues in Health. Fifth Edition. Washington, D.C.:
The National Academies Press; 2009. Available at:
“https://doi.org/10.17226/12709”. Accessed November
11, 2020.
32. Institute of Medicine. Advancing Oral Health in America.
Washington, D.C.: The National Academies Press; 2011.
Available at: “https://www.hrsa.gov/sites/default/files/
publichealth/clinical/oralhealth/advancingoralhealth.pdf ”.
Accessed November 11, 2020.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 57
ORAL HEALTH POLICIES: ORAL HEALTH IN CHILD CARE CENTERS
Policy on Oral Health in Child Care Centers
Latest Reaffirmation
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that one out of three preschool age children receives
care in a child care center.1 The expectation is that this policy
will provide guidance to the child care centers, pediatric
dentists, other health care professionals, legislators, and policy
makers regarding oral health activities and oral health pro-
motion in out-of-home child care settings.
Methods
This policy was developed by the Council of Clinical Affairs
and adopted in 2011. This document is a reaffirmation of the
updated version, revised in 2016. The revision was based upon
a review of current dental and medical literature, including a
®
search of the PubMed /MEDLINE database using the terms:
oral health care guidelines in child care centers, child daycare
centers and dental health, dental guidelines and daycare centers,
and dental care in child day care centers; fields: all; limits:
within the last 10 years, humans, English, birth through age
18. Twenty-two articles matched these criteria. Papers for
review were chosen from this list and from the references
within selected articles. When data did not appear sufficient
or were inconclusive, policies were based upon expert and/or
consensus opinion by experienced researchers and clinicians.
Documents of health care and public policy organizations,
state statutes, and regulations relating to the concept of oral
health in child care centers also were reviewed.
Background
In the United States (U.S.) in 2011, 61 percent of children
ages zero through five received some form of child care
arrangement on a regular basis from persons other than their
parents.1 Fifty-five to 65 percent of these children attended
center-based programs which include day care centers, pre-
kindergartens, nursery schools, Head Start programs, and
other early childhood education programs.2,3
Parents, directors of child care centers, and health profes-
sionals believe that enhancing health promotion education in
child care could improve child health.4 It is important that
the oral health needs of infants and young children be ad-
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
However, a majority of states’ oral health regulations in early
education and child care center programs do not provide
comprehensive oral health policies and practices.5 Forty-six
58 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on oral
health in child care centers. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:58-60.
states developed nutritional regulations on the frequency of
providing snacks and meals at child care centers.6 In con-
trast, oral health practices were not well addressed, as
demonstrated by limited regulations highlighting prevention
of early childhood caries (ECC).6 In one state, there were
found to be variations in some oral health practices between
centers serving children of lower socioeconomic status and
those providing care to higher socioeconomic status children.7
In comparison of state-funded and non-state-funded child
care centers, the researcher found non-state-funded centers
were more inclined to implement oral health practices.7 A
higher percentage of state-funded childcare centers reported
tooth brushing as a routine activity in the classroom, whereas
a higher percentage of non-state funded centers reported
having implemented numerous oral health practices as well
as an educational practice focusing on oral health.7 Many
organizations have requirements and recommendations that
apply to out-of-home child care. The American Academy of
Pediatrics, the American Public Health Association, the
National Association for the Education of Young Children
(NAEYC), and Head Start are some of the organizations that
address oral health in out-of-home child care.8-10 They are
valuable resources, as are many state publications.
Effective oral health care requires collaboration between
families, early care and educational professionals, and health
care professionals. Collaboration has the potential to improve
the breadth and effectiveness of health promotion education4
and enhance the opportunity for a child to have a lifetime
free from preventable oral disease. Establishment of a dental
home by 12 months of age ensures awareness of age-specific
oral health issues with long term positive effects for the chil-
dren.11 Caries is a significant public health problem affecting
preschool children.12 It is the most common chronic disease
of childhood, affecting 28 percent of children two to five
years of age, or over four million children nationwide.13 By
the time they begin kindergarten, 40 percent of children have
caries.14 Epidemiologic data from a 2011-2012 national survey
clearly indicates that ECC remains highly prevalent in poor
and near-poor U.S. preschool children.15 The prevalence of
caries within the two-to-five-year-old age group among
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ECC: Early childhood
caries. U.S.: United States.

higher-income families was 18 percent, while that of children
from low-income families was 42 percent.16,17 Low-income
children are affected disproportionately; 80 percent of tooth
decay is found in 20 to 25 percent of children, large portions
of whom live in poverty or low-income households.18 Dental
care is the greatest unmet need for children.19
Policy statement
The AAPD encourages child care centers, early education pro-
viders, and parents to implement preventive practices that
can decrease a child’s risk of developing ECC.12 The AAPD
recognizes that increasing health promotion in out-of-home
child care settings could improve the oral health of millions
of preschool-age children. Therefore, the AAPD encourages
child care centers to:
• utilize oral health consultation, preferably by a pediatric
dentist, at least once a year and as needed. The health
consultant should review and observe program practices
regarding oral health and make individualized recom-
mendations for each program.
• promote the concept of the dental home by educating
their personnel, as well as the parents, on the importance
of oral health and providing assistance with establishment
of a dental home no later than 12 months of age of the
child.
• maintain a dental record, starting at age 12 months with
yearly updates, as part of the child’s health report. It
should address the child’s oral health needs including
any special instructions given to the caregivers.
• have written, up-to-date, comprehensive procedures to
prepare for, report, and respond to medical and dental
emergencies. The source of urgent care should be known
to caregivers and acceptable to parents.
• sponsor on-site, age-appropriate oral health education
programs for the children that will promote good oral
hygiene and dietary practices, injury prevention, and the
importance of regularly scheduled dental visits.
• provide in-service training programs for personnel regard-
ing oral hygiene concepts, proper nutrition choices,
link between diet and tooth decay, prevention of ECC,
and children’s oral health issues including proper initial
response to traumatic injuries along with dental conse-
quences. Personnel with an understanding of these
concepts are at a great advantage in caring for children.
• encourage parents to be active partners in their children’s
health care process and provide an individualized educa-
tion plan, one that is sensitive to cultural values and
beliefs, to meet every family’s needs. Written material
should be available and, at a minimum, address oral
health promotion and disease prevention and the timing
of dental visits.
• familiarize parents with the use of and rationale for oral
health procedures administered through the program and
obtain advance parental authorization for such procedures.
ORAL HEALTH POLICIES: ORAL HEALTH IN CHILD CARE CENTERS
• incorporate an oral health assessment as part of the daily
health check of each child.
• promote supervised or assisted oral hygiene practices at
least once daily after a meal or a snack.
• provide well-balanced and nutrient-dense diets of low
caries-risk.20
• have clean, optimally-fluoridated drinking water available
for consumption throughout the day.21
• not permit infants and toddlers to have bottles/sippy cups
in the crib or to carry them while walking or crawling
while under the child care center’s supervision.
• minimize saliva-sharing activities (e.g., sharing utensils,
orally cleansing a pacifier) to help decrease an infant’s or
toddler’s acquisition of cariogenic microbes.22
• consider implementation of comprehensive oral health
practices when legislative regulations are limited or non-
existent.7
References
1. Laughlin L. Who’s minding the kids? Child care arrange-
ments: Spring 2011. Current Population Reports, P70-135,
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Accessed June 15, 2016.
2. The Federal Interagency Forum on Child and Family
Statistics (Forum), America’s Children in Brief: Key
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“http://www.childstats.gov/pdf/ac2010/ac_10.pdf ”.
Accessed June 15, 2016.
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Finkelstein JA. Opportunities for health promotion edu-
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5. Kranz AM, Rozier RG. Oral health content of early
education and child care regulations and standards. J
Public Health Dent 2011;71(2):81-90.
6. Kim J, Kaste LM, Fadavi S, Benjamin Neelon SE. Are state
child care regulations meeting national oral health and
nutritional standards? Pediatr Dent 2012;34(4):317-24.
7. Scheunemann D, Schwab M, Margaritis V. Oral health
practices of state and non-state funded licensed child care
centers in Wisconsin, USA. J Int Soc Prev Community
Dent 2015;5(4):296-301.
8. American Academy of Pediatrics, American Public Health
Association, and National Resource Center for Health and
Safety in Child Care and Early Education. 2011 Caring
for Our Children: National Health and Safety Performance
Standards; Guidelines for Early Care and Education Pro-
grams, 3rd ed. Elk Grove Village, Ill.: American Academy
of Pediatrics; Washington, D.C.: American Public Health
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CFOC3_updated_final.pdf ”. Accessed June 15, 2016.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 59
ORAL HEALTH POLICIES: ORAL HEALTH IN CHILD CARE CENTERS
9. National Association for the Education of Young
Children. NAEYC Early Childhood Program Standards
and Accreditation Criteria & Guidance for Assessment.
Washington, D.C.: National Association for the Edu-
cation of Young Children; 2015. Available at: “http://
www.naeyc.org/files/academy/file/AllCriteriaDocument.
pdf ”. Accessed June 30, 2016.
10. Office of Human Development, U.S. Department of
Health and Human Services. Head Start Program Per-
formance Standards & Other Regulations (45 CFR Parts
1301-1311). Available at: “http://eclkc.ohs.acf.hhs.gov/
hslc/standards/hspps/45-cfr-chapter-xiii/45-cfr-chap-xiii
-eng.pdf ”. Accessed June 15, 2016.
11. American Academy of Pediatric Dentistry. Policy on the
dental home. Pediatr Dent 2016;38(special issue):25-6.
12. American Academy of Pediatric Dentistry. Policy on early
childhood caries (ECC): Classifications, consequences,
and preventive strategies. Pediatr Dent 2016;38(special
issue):52-4.
13. Dye BA, Tan S, Smith V, Lewis BG, et al. Trends in oral
health status. United States, 1988-1994 and 1999-2004.
National Center for Health Statistics. Vital Health Stat
2007;11(248):1-92.
14. Pierce KM, Rozier RG, Vann WF. Accuracy of pediatric
primary care providers’ screening and referral for early
childhood caries. Pediatrics 2002;109(5):E82. Available
at: “http://pediatrics.aappublications.org/content/109/5/
e82.long”. Accessed June 15, 2016.
60 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
15. Dye BA, Hsu KL, Afful J. Prevalence and measurement
of dental caries in young children. Pediatr Dent 2015;
37(3):200-16.
16. Dye BA, Arevalo O, Vargas CM. Trends in paediatric
dental caries by poverty status in the United States,
1988-1994 and 1999-2004. Int J Paediatr Dent 2010;20
(2):132-43.
17. Douglass JM, Clark MB. Integrating oral health into
overall health care to prevent early childhood caries:
Need, evidence, and solutions. Pediatr Dent 2015;37(3):
266-74.
18. U.S. Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General.
Rockville, Md.: U.S. Department of Health and Human
Services. National Institute of Dental and Craniofacial
Research, National Institutes of Health; 2000.
19. Newacheck P, Hughes D, Hung Y, Wong S, Stoddard J.
The unmet health needs of America’s children. Pediatrics
2000;105(4):989-97.
20. American Academy of Pediatric Dentistry. Policy on
dietary recommendations for infants, children, and
adolescents. Pediatr Dent 2016;38(special issue):57-9.
21. American Academy of Pediatric Dentistry. Policy on use
of fluoride. Pediatr Dent 2016;38(special issue):45-6.
22. Berkowitz RJ. Mutans streptococci: Acquisition and
transmission. Pediatr Dent 2006;28(2):106-9.

Policy on School-Entrance Oral Health
Examinations
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
encourages policy makers, public health and education officials,
and medical and dental communities to recognize that unmet
oral health needs can impact a child’s ability to learn. An oral
health examination prior to matriculation into school may
improve school readiness by providing a timely opportunity
for prevention, diagnosis, and treatment of oral conditions.
Methods
This policy was developed by the Council on Clinical Affairs,
adopted in 20031, and last revised in 20172. This revision
included electronic database and hand searches of articles in
the medical and dental literature using the terms: oral health
examination, dental screening, dental examination, dental
assessment, school oral health examinations, dental certificates
AND school-entrance; fields: all; limits: within the last 10
years, humans, English, birth through age 18. Additionally,
reports on oral health in American3,4 and websites for the
American Academy of Pediatrics and the AAPD were reviewed.
Background
Professional care is necessary to maintain oral health.3,4 The
AAPD “emphasizes the importance of initiating professional
oral health intervention in infancy and continuing through
adolescence and beyond. The periodicity of professional oral
health intervention and services is based on a patient’s indivi-
dual needs and risk indicators.”5 The American Academy of
Pediatrics recommends that, beginning at age three, a child’s
comprehensive health assessment should include attention to
problems that might influence school achievement.6,7 Many
states mandate general health examinations prior to school
entrance. However, integration of general health and oral
health care programs remains deficient.8 While regulations
may not guarantee that every child will be examined by a
dentist, they do increase the likelihood of this happening.9
Caries is the most common chronic disease of childhood
in the United States (U.S.).3 Early childhood caries (ECC) is a
severe problem for young children nationwide, with approxi-
mately 23 percent of children aged two through five years
having experienced caries in the primary dentition, and 10
percent having untreated disease.10,11 By six to eight years of
age, the prevalence of dental caries increases to 56 percent.10,11
ORAL HEALTH POLICIES: SCHOOL-ENTRANCE ORAL HEALTH EXAMS
How to Cite: American Academy of Pediatric Dentistry. Policy on
school-entrance oral health examinations. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:61-3.
Poverty remains one of the most important indicators of early
childhood dental caries experience, with about one in three
preschoolers living in poverty having some form of ECC. 4
Dental care remains as one of the greatest unmet needs for
children. Untreated health conditions such as asthma, den-
tal pain, and vision and hearing deficits are leading causes of
chronic absence, and children with oral health problems are
three times more likely than their peers to miss school.10,12 Safe
and effective measures exist to prevent caries and periodontal
diseases; however, dissemination and awareness of such mea-
sures do not reach the population at large. 4 More than
one-fourth of the U.S. population does not benefit from
community water fluoridation.13 Because the use of fluoride
contributes to the prevention, inhibition, and reversal of
caries,13 early determination of a child’s systemic and topical
fluoride exposure is important. A dental home provides the
necessary diagnostic, preventive, and therapeutic practices, as
well as on-going risk assessment and education, to improve
and maintain the oral health of infants, children, and
adolescents. 14 To maximize effectiveness, the dental home
should be established within six months of eruption of a
child’s first tooth and no later than the child’s first birthday.14
The public’s lack of awareness of the importance of oral
health is a major barrier to dental care.3,4 Oral health is integral
to general health.3,4 Oral conditions can interfere with eating
and adequate nutritional intake, speaking, self-esteem, and
daily activities. 15 Children with untreated disease may be
severely underweight because of associated pain and the disin-
clination to eat. Nutritional deficiencies during childhood can
impact cognitive development.16 Rampant caries is one of the
factors causing insufficient development in children who have
no other medical problems.17 Unrecognized disease and post-
poned care result in exacerbated problems, which lead to more
extensive and costly treatment needs.
Health and education are closely related. 18 Children with
dental pain may be irritable, withdrawn, or unable to con-
centrate. Pain can affect test performance as well as school
attendance.15,16 Data from the North Carolina Child Health
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ECC: Early childhood
caries. U.S.: United States.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 61
ORAL HEALTH POLICIES: SCHOOL-ENTRANCE ORAL HEALTH EXAMS
Assessment and Monitoring Program showed that children
with poor oral health status were nearly three times more likely
to miss school as a result of dental pain than were their counter-
parts.19 In addition, absences caused by pain were associated
with poorer school performance.19 Further analysis demon-
strated that oral health status was associated with performance
independent of absence related to pain.18
Following a report by the U.S. Surgeon General, 3 the
Centers for Disease Control and Prevention launched the Oral
Health Program Strategic Plan for 2011-2014.20 This campaign
aimed to provide leadership to prevent and control oral
diseases at national level. The program helped individual states
strengthen their oral health promotion and disease prevention
programs. However, requirements for oral health examinations,
implementation/enforcement of regulations, and administrative
disposition of collected data vary both among and within
states.20 As of 2019, 14 states and the District of Columbia
had a dental screening law, and another state (Connecticut)
had legislation in process.9 Although dental screening laws
are used to help ensure that children’s oral health does not
impede their ability to learn, these laws also present an op-
portunity to connect children in need with a dental home.9
Policy statement
Early detection and management of oral conditions can im-
prove a child’s oral health, general health and well-being, and
school readiness. Recognizing the relationship between oral
health and education, the AAPD:
• advocates legislation requiring a comprehensive oral
health examination by a qualified dentist for every stu-
dent prior to matriculation into school. The examination
should be performed in sufficient detail to provide mean-
ingful information to a consulting dentist and/or public
health officials. This would include documentation of oral
health history, soft tissue health/pathologic conditions,
oral hygiene level, variations from a normal eruption/
exfoliation pattern, dental dysmorphology or discoloration,
dental caries (including noncavitated lesions), and existing
restorations. The examination also should provide an
educational experience for both the child and the parent.
The child/parent dyad should be made aware of age-related
caries-risk and caries-protective factors, as well as the
benefits of a dental home.
• recognizes that without requiring, tracking, and funding
appropriate follow-up care, requiring oral health exami-
nations is insufficient to ensure school readiness and,
therefore, advocates such legislation to include subsequent
comprehensive oral examinations at periodic intervals
throughout the educational process because a child’s risk
for developing dental disease changes and oral diseases
are cumulative and progressive.
• encourages local leaders to establish a referral system to
help parents obtain needed oral health care and establish
a dental home for their children.
62 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• encourages state and local public health and education
officials, along with other stakeholders such as health care
providers and dental/medical organizations, to document
oral health needs, to work toward improved oral health
and school readiness for all children, and to address re-
lated issues such as barriers to oral health care.
• opposes regulations that would prevent a child from
attending school due to noncompliance with required
examinations.
• encourages its members and the dental community at
large to volunteer in programs for school-entry dental
examinations to benefit the oral and general health of
the pediatric community.
References
1. American Academy of Pediatric Dentistry. Policy on
mandatory school-entrance oral health examinations.
Pediatr Dent 2003;25(suppl):15-6.
2. American Academy of Pediatric Dentistry. Policy on
mandatory school-entrance oral health examinations.
Pediatr Dent 2017;39(6):188-96.
3. U.S. Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General.
Rockville, Md.: U.S. Department of Health and Human
Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health; 2000.
4. National Institutes of Health. Oral Health in America:
Advances and Challenges. Bethesda, Md.: U.S. Depart-
ment of Health and Human Services, National Institutes
of Health, National Institute of Dental and Craniofacial
Research, 2021. Section 2A 1-97. Available at: “https://
www.nidcr.nih.gov/sites/default/files/2021-12/Oral
-Health-in-America-Advances-and-Challenges.pdf ”.
Accessed May 30, 2022.
5. American Academy of Pediatric Dentistry. Periodicity
of examination, preventive dental services, anticipatory
guidance, and oral treatment for children. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:253-65.
6. American Academy of Pediatrics. Committee on School
Health. School health assessment. Pediatrics 2000;105(4
Pt 1):875-7. Reaffirmed October 2011.
7. Ruff RR, Senthi S, Susser SR, Tsutsui A. Oral health,
academic performance, and school absenteeism in children
and adolescents: A systematic review and meta-analysis. J
Am Dent Assoc 2019;150(2):111-21.
8. Institute of Medicine, National Research Council. Im-
proving Access to Oral Health Care for Vulnerable and
Underserved Populations. Washington, D.C.: The National
Academies Press; 2011. Available at: “https://www.hrsa.
gov/publichealth/clinical/oralhealth/improvingaccess.
pdf ”. Accessed March 17, 2022.

9. Children’s Dental Health Project. State Dental Screening
Laws for Children: Examining the Trend and Impact. An
Update to the 2008 Report. January 2019. Available at:
“https://s3.amazonaws.com/cdhp/Matt+Jacob/Dental+Sc
reening+Law+Report+(Jan+2019).pdf ”. Accessed March
18, 2022.
10. Centers for Disease Control and Prevention. Oral Health
Surveillance Report, 2019. Available at: “https://www.cdc.
gov/oralhealth/publications/OHSR-2019-index.html”
Accessed March 17, 2022.
11. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental Caries
and Sealant Prevalence in Children and Adolescents in
the United States, 2011–2012. NCHS data brief, No. 191.
Hyattsville, Md.: National Center for Health Statistics.
2015. Available at: “https://www.cdc.gov/nchs/products/
databriefs/db191.htm”. Accessed March 17, 2022
12. National Association of State Boards of Education.
Examining chronic absence through a student health
lens. Policy Update 2019;6(1):1-2. Available at: “https://
nasbe.nyc3.digitaloceanspaces.com/2019/02/Blanco-et-al
_Chronic-Absence-Final.pdf ”. Accessed March 18, 2022.
13. Centers for Disease Control and Prevention. Water
Fluoridation Basics. October 1, 2021. Available at: “https://
www.cdc.gov/fluoridation/basics/index.htm”. Accessed
May 30, 2022.
14. American Academy of Pediatric Dentistry. Policy on
the dental home. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:21-2.
ORAL HEALTH POLICIES: SCHOOL-ENTRANCE ORAL HEALTH EXAMS
15. Moynihan P, Petersen PE. Diet, nutrition and the preven-
tion of dental diseases. Public Health Nutr 2004;7(1A):
201-26.
16. Nyaradi A, Li J, Hickling S, Foster J, Oddy WH. The role
of nutrition in children’s neurocognitive development,
from pregnancy through childhood. Front Hum Neurosci
2013;7:97. Available at: “https://doi.org/10.3389/fnhum.
2013.00097”. Accessed March 17, 2022.
17. Colak H, Dülgergil CT, Dalli M, Hamidi MM. Early
childhood caries update: A review of causes, diagnoses,
and treatments. J Nat Sci Biol Med 2013;4(1):29-38.
Available at: “https://doi.org/10.4103/0976-9668.1072
57”. Accessed March 18, 2022.
18. Centers for Disease Control and Prevention. Healthy
schools. Making the connection: Other health behaviors
2020. Available at : “https://www.cdc.gov/healthyschools/
health_and_academics/pdf/320889-C_FS_Other_Health
_Behaviors_508-tag.pdf ”. Accessed March 18, 2022.
19. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact
of poor oral health on children’s school attendance and
performance. Am J Public Health 2011;101(10):1900-6.
20. National Center for Chronic Disease Prevention and
Health Promotion, Division of Oral Health. Oral Health
Program: Strategic Plan 2011-2014. March 2011. Avail-
able at: “https://stacks.cdc.gov/view/cdc/11658”. Accessed
June 26, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 63
ORAL HEALTH POLICIES: SCHOOL ABSENCES
Policy on School Absences for Dental
Appointments
Latest Reaffirmation
2019
Purpose
The American Academy of Pediatric Dentistry recognizes
dental care is medically necessary and that poor oral health
can negatively affect a child’s ability to learn. This policy is
intended to assist public health and school education
administrators in developing enlightened policies on school
absence for dental appointments and support parents in
seeking medically necessary care for their children.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2010. This document is a reaffirmation of the
2015 version. An electronic database search was conducted
using the terms: school absences for dental appointments,
excused school absences, and department of education. Papers
for review were chosen from this list and from references
within selected articles. When data did not appear sufficient
or were inconclusive, statements were based on expert and/or
consensus opinion by experienced researchers and clinicians.
It is beyond the scope of this document to review every
state statute and regulation on absences from school for
dental appointments.
Background
Oral health is integral to general health. Many systemic dis-
eases and conditions have oral manifestations. These oral
manifestations may be the initial sign of clinical disease and
indicate the need for further assessment.1 Oral conditions can
interfere with eating and adequate nutritional intake, speaking,
self-esteem, daily activities, and quality of life.2 Dental care is
medically necessary to prevent and eliminate orofacial disease,
infection, and pain. It is also important to restore the form and
function of the dentition and correct facial disfiguration or
dysfunction.3 The public’s lack of awareness of the importance
of oral health is a major barrier to dental care.1 Unrecognized
disease and postponed care result in exacerbated problems,
which lead to more extensive and costly treatment needs.3
The National Association of State Boards of Education
recognizes, “Health and success in schools are interrelated.
Schools cannot achieve their primary mission of education if
students and staff are not healthy and fit physically, mentally,
and socially”.4 Children and adolescents with poorer oral
health status are more likely to experience oral pain, miss
school, and perform poorly in school compared with their
64 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
school absences for dental appointments. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:64-5.
counterparts with better oral health status. 5 Children with
dental pain may be irritable, withdrawn, or unable to concen-
trate. Pain can affect test performance as well as school attend-
ance.1,6 Left untreated, the pain and infection caused by tooth
decay can lead to problems in eating, speaking, and learning.7
The social impact of oral disease in children is substantial.
More than 51 million school hours are lost each year to
dental-related illness.1 On average, children and adolescents
with oral health problems are absent one school day per
year more than other children or adolescents.8 When these
problems are treated and children no longer are experiencing
pain, their learning and school attendance improve.2
According to the United States Surgeon General, “a
national public health plan for oral health does not exist”. 1
This corresponds with the fact that there is no national policy
on excused absences from school for dental appointments.
Some states (e.g., California, Texas) have very specific laws
excusing students fordental appointments. 9,10 Other state
laws are more general and recognize absences due to doctor’s
appointments or illness.11,12
Policy statement
Dental care is medically necessary, and oral health is integral
to general health. Undiagnosed and untreated oral conditions
may interfere with a child’s ability to eat, sleep, or function
well at home or at school due to discomfort or pain. The
unesthetic nature of caries and dental malocclusion may
compromise a child’s self-esteem and social development.
School policies that prevent or discourage legitimate school
absence for the purpose of delivery of vital health care services
may cause harm to their students.
Children who have their dental conditions corrected
improve learning and attendance in school. State laws and
local school district policies are not uniform on absences from
school for dental appointments. A uniform policy that
recognizes the negative effect of chronic truancy on academic
performance would be useful. Such policies should not restrict
necessary health care delivery. The American Academy of
Pediatric Dentistry supports state law or school policy that
allows the absence for legitimate health care delivery, in-
cluding that of oral health services, and encourages parents,
school administrators, and dentists to work together to ensure
that children receive dental care while minimizing school
absences.

References
1. U.S. Department of Health and Human Services. Oral
Health in America: A Report of the Surgeon General.
Rockville, Md.: U.S. Department of Health and Human
Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health; 2000:12.
2. National Center for Education in Maternal and Child
Health and Georgetown University. Fact sheet: Oral
health and learning. Arlington, Va.: NCEMCH; 2001.
Available at: “http://mchoralhealth.org/PDFs/learning
factsheet.pdf ”. Accessed September 29, 2015.
3. American Academy of Pediatric Dentistry. Policy on
medically-necessary care. Pediatr Dent 2015;37(special
issue):18-22.
4. Bogden JF. General school health policies. Fit, Healthy,
and Ready to Learn: A School Health Policy Guide.
Alexandria, Va.: National Association of State Boards of
Education; 2000. Available at: “http://www.nasbe.org/
wp-content/uploads/C.-General-School-Health-Policies.
pdf ”. Accessed September 29, 2015.
5. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY.
Impact of poor oral health on children’s school attend-
ance and performance. Am J Public Health 2011;101(10):
1900-6.
ORAL HEALTH POLICIES: SCHOOL ABSENCES
6. Serawan H, Faust S, Muligan R. The impact of oral
health on academic performance of disadvantaged chil-
dren. Am J Public Health 2012;102(9):1729-34.
7. U.S. General Accounting Office. Oral Health: Dental
Disease is a Chronic Problem Among Low-income and
Vulnerable Populations. Washington, D.C.: U.S. General
Accounting Office; 2000.
8. Guarnizo-Herreno CC, Wehby GL. Children’s dental
health, school performance, and psychosocial well-being.
J Pediatr 2012;161(6):1153-9.
9. California Education Code. Available at: “http://law.
onecle.com/california/education/48205.html”. Accessed
September 29, 2015.
10. Texas Education Code. Available at: “http://law.onecle.
com/texas/education/25.087.html”. Accessed September
29, 2015.
11. Georgia Department of Education. Available at: “https:
//www.gadoe.org/External-Affairs-and-Policy/State-
Board-of-Education/SBOE%20Rules/160-5-1-.10.pdf ”.
Accessed September 29, 2015.
12. Michigan Department of Education. Available at: “http:
//www.Michigan.gov/documents/mde/compulsory_
attendance_257944_7.pdf ”. Accessed September 29,
2015.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 65
ORAL HEALTH POLICIES: EMERGENCY ORAL CARE
Policy on Emergency Oral Care for Infants, Children,
Adolescents, and Individuals with Special Health
Care Needs
Latest Revision
2021
The American Academy of Pediatric Dentistry recognizes
emergency care for infants, children, adolescents, and indi-
viduals with special health care needs is an essential duty of
every dentist. The American Dental Association’s Principles of
Ethics and Code of Professional Conduct states that “dentists
shall be obliged to make reasonable arrangements for the
emergency care of their patients of record”.1 The American
Academy of Pediatric Dentistry encourages dentists to provide
instructions to the parent2 for accessing emergency care. Den-
tal emergencies include, but are not limited to, facial swelling,
infections, uncontrolled bleeding, pain, and oral-facial trauma.3
Availability of after-hours emergency care is an important
aspect of continuously accessible care provided through a den-
tal home.4 Additionally, when consulted for a dental emergency
by patients not of record, the dentist should make reasonable
arrangements for emergency dental care. If emergency dental
treatment is provided, the dentist should recommend that the
patient return to his dental home unless the parent expresses
a different preference.1
This document was developed by the Policy and Review
Committee and adopted in 1976.5 This document was updated
by the Council on Clinical Affairs from the last revision in
2017.6
66 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
emergency oral care for infants, children, adolescents, and individuals
with special health care needs. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:66.
References
1. American Dental Association. Principles of Ethics and
Code of Professional Conduct. Available at: “https://
www.ada.org/~/media/ADA/Member%20Center/Ethics/
ADA_Code_Of_Ethics_November_2020.pdf?la=en”.
Accessed February 21, 2021.
2. American Academy of Pediatric Dentistry. Definitions:
Parent. Overview. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2021:7-9.
3. American Dental Association. What Constitutes a Den-
tal Emergency? March 31, 2020. Available at: “https://
success.ada.org/~/media/CPS/Files/Open%20Files/ADA
_COVID19_Dental_Emergency_DDS.pdf ”. Accessed
June 3, 2021.
4. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:43-4.
5. American Academy of Pedodontics. Emergency dental
care for children. San Antonio, Texas. May, 1976. Ameri-
can Academy of Pediatric Dentistry Reference Manual
1991-1992. Chicago, Ill.: American Academy of Pediatric
Dentistry; 1991:26.
6. American Academy of Pediatric Dentistry. Policy on
emergency oral care for infants, children, adolescents, and
individuals with special health care needs. Pediatr Dent
2017;39(special issue):46.

Policy on the Role of Dental Prophylaxis in
Pediatric Dentistry
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry recognizes the
dental prophylaxis as an integral component of periodic oral
health assessment, education, and preventive care.
Methods
This policy was developed by the Clinical Affairs Committee,
adopted in 19861, and last revised in 20172. This revision
®
included a new literature search of PubMed /MEDLINE
using the terms: dental prophylaxis, tooth-brushing, profes-
sional tooth cleaning, fluoride uptake, and professional dental
prophylaxis, limited to children (birth to 18 years), the last 10
years, and English language, resulting in 1,390 articles. The
resultant list was filtered to utilize randomized control studies
and systematic reviews only, resulting in 109 papers for review.
When necessary, hand searching for articles and Google
Scholar searches were utilized. Expert and/or consensus opinion
by experienced researchers and clinicians also was considered.
Background
The aim of oral prophylaxis is to remove supragingival
plaque, stain, and calculus from patients’ teeth.3 This may
be accomplished utilizing hand instruments, ultrasonic
scalers, rubber rotary cup, toothbrush, interdental cleaners
(e.g., floss), and air polishing. Persistent gingival inflamma-
tion in young patients with reasonable supragingival home
plaque control often is related to calculus deposits previ-
ously not detected or only partially removed.4 Attachment
loss due to chronic subgingival calculus in young children
has been reported.5 Thus, a dental prophylaxis is an im-
portant component of initial and recall dental appoint-
ments.3 The instrumentation (e.g., toothbrush prophylaxis,
hand-scaling) needed for each patient is determined on an
individual basis. In example, in the young or pre-cooperative
patient, patients with special health care needs, or patients
with no calculus, a toothbrush prophylaxis may be utilized
by the dental professional.
Limited evidence suggests that, although prophylaxis may
lead to short-term reductions in plaque levels and gingival
bleeding, it may not lead to the prevention of gingivitis. 6,7
Nevertheless, prophylaxis is an important component of
pediatric oral health care and, among other benefits detailed
below, facilitates the conduct of a high-quality comprehensive
ORAL HEALTH POLICIES: ROLE OF DENTAL PROPHYLAXIS
How to Cite: American Academy of Pediatric Dentistry. Policy on
the role of dental prophylaxis in pediatric dentistry. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:67-9.
oral examination. The coronal polish procedure typically entails
the application of a dental polishing paste to tooth surfaces
with a rotary rubber cup or bristle brush to remove plaque and
stains from teeth. A toothbrush coronal polish (i.e., toothbrush
and toothpaste) is a procedure that is used to remove plaque
from tooth surfaces and demonstrate brushing techniques
to caregivers for young children and for patients with special
needs who cannot tolerate the use of a rotary rubber cup.8 Air
polishing uses a mix of pressurized air, abrasive powder, and
water to remove supragingival stains, plaque, and deposits from
teeth.9 Dental scaling is a procedure in which hand or ultra-
sonic instruments are used to remove calculus and stain.
Full mouth debridement may be necessary as a preliminary
treatment for those whose medical, psychological, physical, or
periodontal condition result in calculus accumulation beyond
the scope of routine prophylaxis.
These procedures facilitate the clinical examination and
introduce dental procedures to the patient. Additionally, the
accompanying preventive visit demonstrates proper oral hy-
giene methods to the patient and/or caregiver. Professional oral
hygiene instruction and reinforcement can lead to behaviors
that reduce both plaque and gingivitis10, but in the absence
of patient oral hygiene instruction, professional supragingival
and submarginal plaque and calculus removal has little value
in gingivitis prevention.3,11
The frequent disruption or removal of bacterial dental
plaque, known as biofilm, from various areas of the oral cavity
is crucial to oral disease prevention and is achieved through
regular personal oral hygiene and professional prophylaxis.12
Accurate detection of biofilm is critical to effective removal, and
special dyes of iodine, gentian violet, erythrosine, basic fuchsin,
fast green, food dyes, fluorescein, and two-tone disclosing
agents are available in the forms of tablets, solutions, wafers,
lozenges, or mouthrinses.13 Biofilm staining allows for effective
personalized oral health guidance from healthcare providers.
Severe dental caries is most strongly associated with biofilm in
the upper posterior palatal, lower posterior buccal, and lower
posterior lingual spaces, as well as on the tongue.14 Disclosing
agents for both professional and personal use can supplement
a personal oral hygiene protocol.
Flossing is an important part of the prophylaxis that removes
interproximal and subgingival plaque, aids in educating the
patient, and facilitates the oral examination. Since interdental
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 67
ORAL HEALTH POLICIES: ROLE OF DENTAL PROPHYLAXIS

References
Table. BENEFITS OF PROPHYLAXIS OPTIONS
1. American Academy of Pediatric Dentistry. The role of
Plaque Stain Calculus Education Facilitate prophylaxis in pediatric dentistry. Colorado Springs,
removal removal removal of patient/ examination
Colo.: American Academy of Pediatric Dentistry; May,
caregiver
1986.
Toothbrush Yes No No Yes Yes 2. American Academy of Pediatric Dentistry. Policy on role
Rubber cup Yes Yes No Yes Yes of dental prophylaxis in pediatric dentistry. Pediatr Dent
Hand 2017;39(6):47-8.
Yes Yes Yes Yes Yes
instruments 3. American Academy of Pediatric Dentistry. Risk assessment
Ultrasonic
Yes Yes Yes Yes Yes
and management of periodontal diseases and pathologies
scalers in pediatric dental patients. The Reference Manual of
Air polishing Yes Yes Yes Yes Yes Pediatric Dentistry. Chicago,Ill.: American Academy of
Flossing Yes No No Yes Yes Pediatric Dentistry; 2022:466-84.
4. Clerehugh V, Tugnait A. Diagnosis and management of
periodontal diseases in children and adolescents. Perio-
plaque biofilm is not completely removed with brushing10,15, dontol 2000 2001;26:146-68.
interdental cleaning is indicated when interdental spaces are 5. Roberts-Harry EA, Clerehugh V. Subgingival calculus:
filled with gingiva or contacts are closed16,17. Different devices Where are we now? A comparative review. J Dent 2000;28
(e.g., dental floss, interdental brushes, oral irrigations) are used (2):93-102.
to remove plaque interdentally. 10,15 The benefits of various 6. Horowitz AM. Rubber cup dental prophylaxis is not
prophylaxis options are shown in the Table above. needed prior to the topical application of fluorides and
Numerous reports have shown plaque and pellicle are not a rubber cup dental prophylaxis at recall is not effective in
barrier to fluoride uptake in enamel and, consequently, patients the prevention of gingivitis. J Evid Base Dent Pract
who receive rubber cup dental prophylaxis or a toothbrush 2012;12(2):77-8.
prophylaxis before fluoride treatment exhibit no difference in 7. Azarpazhooh A, Main PA. Efficacy of dental prophylaxis
caries rates.6,7,18 Rubber cup prophylaxis is not required prior (rubber cup) for the prevention of caries and gingivitis:
to the topical application of fluoride. A systematic review of literature. Br Dent J 2009;207(7):
A patient’s risks for caries 3 and periodontal disease 19, as E14; discussion 328-9.
determined by the patient’s dental provider, can help establish 8. Ramos-Gomez F, Crystal YO, Ng MW, Tinanoff N,
the interval of the prophylaxis or periodontal maintenance. An Featherstone JD. Caries risk assessment, prevention, and
individualized preventive plan increases the probability of management in pediatric dental care. Gen Dent 2010;58
good oral health through proper oral hygiene methods and (6):505-17; quiz 518-9.
techniques as demonstrated by oral health professionals. In 9. Graumann SJ, Sensat ML, Stoltenberg JL. Air polishing:
addition, removing plaque, stain, calculus, and the factors that A review of current literature. J Dent Hyg 2013;87(4):
influence their buildup increases the probability of good oral 173-80.
health. Patients who exhibit higher risk for developing caries 10. Chapple IL, Van der Weijden F, Doerfer C, et al. Primary
or periodontal disease can benefit from recall visits at more prevention of periodontitis: Managing gingivitis. J Clin
frequent intervals.3,19-21 Periodontol 2015;42(Suppl 16):S71-6.
11. Tonetti MS, Eickholz P, Loos BG, et al. Principles in
Policy statement prevention of periodontal diseases: Consensus report of
The American Academy of Pediatric Dentistry supports a group 1 of the 11th European Workshop on Periodontol-
professional prophylaxis during new patient comprehensive ogy on effective prevention of periodontal and peri-implant
and periodic examinations to: diseases. J Clin Periodontol 2015;42(Suppl 16):S5-11.
• instruct the caregiver and child or adolescent in proper 12. Larsen T, Fiehn NE. Dental biofilm infections – An
oral hygiene techniques. update. APMIS 2017;125(4):376-84.
• remove dental plaque, extrinsic stain, and calculus 13. Dipayan D, Kumar SGR, Narayanan MBA, Selvamary
deposits from the teeth. AL, Sujatha A. Disclosing solutions used in dentistry.
• facilitate the examination of hard and soft tissues. World J Pharmaceut Res 2017;6(6):1648-56.
• introduce dental procedures to the young child and 14. Fasoulas A, Pavlidou E, Petridis D, Mantzorou M, Seroglou
apprehensive patient. K, Giaginis C. Detection of dental plaque with disclosing
agents in the context of preventive oral hygiene training
Determination of interval for periodic examinations takes programs. Heliyon 2019;10;5(7):e02064.
into consideration a patient’s assessed risk for caries3 and peri-
odontal disease19.

68 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


15. Perry DA, Takei HH, Do JH. Plaque biofilm control for
the periodontal patient. In: Newman MG, Takei HH,
Klokkevold PR, Carranza FA, eds. Newman and Car-
ranza’s Clinical Periodontology. 13th ed. Philadelphia,
Pa.: Elsevier; 2019:511-20.
16. Drummond BK, Brosnan MG, Leichter JW. Management
of periodontal health in children: Pediatric dentistry and
periodontology interface. Periodontol 2000 2017;74(1):
158-67.
17. Silva DR, Law CS, Duperon DF, Carranza FA. Gingival
disease in childhood. In: Newman MG, Takei HH,
Klokkevold PR, Carranza FA, eds. Newman and Car-
ranza’s Clinical Periodontology. 13th ed. Philadelphia, Pa.:
Elsevier; 2019:277-86.
18. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride
or caries prevention: Executive summary of the updated
clinical recommendations and supporting systematic
review. J Am Dent Assoc 2013;144(11):1279-91.
ORAL HEALTH POLICIES: ROLE OF DENTAL PROPHYLAXIS
19. 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;
2022:266-72.
20. Patel S, Bay RC, Glick M. A systematic review of dental
recall intervals and incidence of dental caries. J Am Dent
Assoc 2010;141(5):527-39.
21. American Academy of Pediatric Dentistry. Periodicity of
examination, preventive dental services, anticipatory
guidance/counseling, and oral treatment for infants, chil-
dren, and adolescents. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:253-65.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 69
ORAL HEALTH POLICIES: USE OF FLUORIDE
Policy on Use of Fluoride
Latest Revision
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD) affirms
that the use of fluoride as an adjunct in the prevention of
caries is safe and effective. The AAPD encourages dentists
and other health care providers, public health officials, and
parents/caregivers to optimize fluoride exposures to reduce the
risk for caries and to enhance the remineralization of affected
tooth structures.
Methods
This document was developed by the Liaison with Other
Groups Committee and adopted in 1967. This is an update
from the last revision in 2014. An electronic database search
using the terms: fluoride, fluoridation, acidulated phosphate
fluoride, fluoride varnish, fluoride therapy, and topical fluoride
previously was conducted to develop and update this policy.
The current update relied upon systematic reviews, expert
opinions, and best current practices. The use of silver diamine
fluoride is addressed in a separate AAPD policy.1
Background
The adjustment of the fluoride level in community water
supplies to optimal concentration is the most beneficial and
inexpensive method of reducing the occurrence of caries.2
Long-term use of fluorides has reduced the cost of oral health
care for children by as much as 50 percent.3 When public
water is fluoridated to an optimal level, there is a 35 percent
reduction in decayed, missing, and filled primary teeth and 26
percent fewer decayed, missing, and filled permanent teeth.4
The occurrence of fluorosis, causing esthetic concerns, has
been reported to be 12 percent when public water contains
0.7 parts per million (ppm) fluoride.4 When combined with
other dietary, oral hygiene, and preventive measures5, the use
of fluorides can further reduce the incidence of caries.
Professional fluoride products should only be applied by
or under the direction of a dentist or physician who is fa-
miliar with the child’s oral health and has completed a caries
risk assessment. When fluoridation of drinking water is im-
possible, effective fluoride supplementation can be achieved
through the intake of daily fluoride supplements according to
established guidelines.2,6-8 Before supplements are prescribed,
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
fluoride2,9,10 and to take into consideration the caries risk of
the child. The mean fluoride concentration of ready-to-feed
70 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
use of fluoride. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:70-1.
infant formulas in the United States is 0.15 ppm for milk-
based formulas and 0.21 ppm for soy-based formulas.11 The
more important issue, however, is the fluoride content of
concentrated or powdered formula when reconstituted with
fluoridated water. The range of fluoride in ppm for reconsti-
tuted powdered or liquid concentrate, when reconstituted
with water containing one ppm fluoride, is 0.64 -1.07.11 As
the Environmental Protection Agency/Department of Health
and Human Services’ recommendation12 for optimizing com-
munity water supplies to 0.7 ppm fluoride is instituted,
fluorosis due to reconstituting infant formula with fluoridated
water is less of an issue.
Significant cariostatic benefits can be achieved by the use
of over-the-counter fluoride-containing preparations such as
toothpastes, gels, and rinses, especially in areas without water
fluoridation.2 The brushing of teeth with appropriate amounts
of fluoride toothpaste twice daily for all children is encour-
aged.13 Monitoring children’s use of topical fluoride-containing
products, including toothpaste, may prevent ingestion of
excessive amounts of fluoride.13,14 Numerous clinical trials
have confirmed the anti-caries effect of professional topical
fluoride treatments, including 1.23 percent acidulated phos-
phate fluoride ([APF]; 1.23 percent fluoride), five percent
sodium fluoride varnish ([NaFV]; 2.26 percent fluoride), 0.09
percent fluoride mouthrinse, and 0.5 percent fluoride gel/
paste.15 For children under the age of six years, five percent
sodium fluoride varnish in unit doses, which reduce the
potential for harm, is the recommended professionally-applied
topical fluoride agent.15
A significant number of parents and caregivers are con-
cerned about their child receiving fluoride and may refuse
fluoride treatment even though fluoride is safe and effective.16
This is similar to opposition to community water fluorida-
tion.17 Topical fluoride refusal and resistance may be a growing
problem and mirror trends seen with vaccination refusal in
medicine.
Policy statement
The AAPD:
• endorses and encourages the adjustment of fluoride
content of public drinking water supplies to optimal
levels where feasible.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ppm: parts per million.

• endorses the supplementation of a child’s diet with
fluoride according to established guidelines when
fluoride levels in public drinking water are suboptimal
and after consideration of sources of dietary fluoride
and the caries risk of the child.
• encourages the brushing of teeth with appropriate
amounts of fluoride toothpaste twice daily for all
children.11
• encourages the application of professional fluoride
treatments for all individuals at risk for dental caries.
• encourages dental professionals to inform medical
peers of the potential of enamel fluorosis when excess
fluoride is ingested prior to enamel maturation.
• encourages the continued research on safe and
effective fluoride products.
• supports the delegation of fluoride application to
auxiliary dental personnel or other trained allied health
professionals by prescription or order of a dentist after
a comprehensive oral examination or by a physician
after a dental screening has been performed.
• encourages all beverage and infant formula manu-
facturers to include fluoride concentration with the
nutritional content on food labels.
• recognizes that drinking fluoridated water and brush-
ing with fluoridated toothpaste twice daily are the
most effective method in reducing dental caries
prevalence in children.
• encourages dental providers to talk to parents and
caregivers about the benefits of fluoride and to pro-
actively address fluoride hesitance through chairside
and community education.
References
1. American Academy of Pediatric Dentistry. Policy on use
of silver diamine fluoride for pediatric dental patients.
Pediatr Dent 2018;40(6):51-4.
2. Centers for Disease Control and Prevention. Recom-
mendations for using fluoride to prevent and control
dental caries in the United States. MMWR Recomm
Rep 2001;50(RR14):1-42.
3. Griffen SO, Jones K, Tomar, SL. An economic evaluation
of community water fluoridation. J Pub Health Dent
2001;61(2):78-86.
4. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water
fluoridation for the prevention of dental caries. Cochrane
Database Syst Rev 2015;(6):CD010856.
5. Featherstone JD. The science and practice of caries
prevention. J Am Dent Assoc 2000;131(7):887-99.
ORAL HEALTH POLICIES: USE OF FLUORIDE
6. Rozier RG, Adair S, Graham F, et al. Evidence-based
clinical recommendations on the prescription of dietary
fluoride supplements for caries prevention: A report of
the American Dental Association Council on Scientific
Affairs. J Am Dent Assoc 2010;141(12):1480-9.
7. Clark MB, Slayton RL, American Academy of Pediatrics
Section on Oral Health. Clinical report: Fluoride use in
caries prevention in the primary care setting. Pediatrics
2014;134(3):626-33.
8. American Academy of Pediatric Dentistry. Fluoride
therapy. Pediatr Dent 2018;40(6):250-3.
9. Levy SM, Kohout FJ, Kiritsy MC, Heilman JR, Wefel JS.
Infants’ fluoride ingestion from water, supplements, and
dentifrice. J Am Dent Assoc 1995;126(12):1625-32.
10. Adair SM. Evidence-based use of fluoride in contem-
porary pediatric dental practice. Pediatr Dent 2006;28
(2):133-42.
11. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based
clinical recommendations regarding fluoride intake from
reconstituted infant formula and enamel fluorosis. J Am
Dent Assoc 2011;142(1):79-87.
12. U.S. Department of Health and Human Services Federal
Panel on Community Water Fluoridation. U.S. Public
Health Service recommendation for fluoride concentra-
tion in drinking water for the prevention of dental caries.
Public Health Reports 2015;130(4):1-14.
13. American Dental Association Council on Scientific
Affairs. Fluoride toothpaste use for young children. J Am
Dent Assoc 2014;145(2):190-1.
14. Warren JJ, Levy SM. A review of fluoride dentifrice
related to dental fluorosis. Pediatr Dent 1999;21(4):
265-71.
15. Weyant RJ, Tracy SL, Anselmo T, Beltrán-Aguilar
EJ, Donly KJ, Frese WA. Topical fluoride for caries
prevention: Executive summary of the updated clinical
recommendations and supporting systematic review. J
Am Dent Assoc 2013;144(11):1279-91. Erratum in J Am
Dent Assoc 2013;144(12):1335. Dosage error in article
text.
16. Chi DL. Caregivers who refuse preventive care for their
children: The relationship between immunization and
topical fluoride refusal. Am J Public Health 2014;104
(7):1327-33.
17. Melbye ML, Armfield JM. The dentist’s role in pro-
moting community water fluoridation: A call to action
for dentists and educators. J Am Dental Assoc 2013;
144(1):65-75.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 71
ORAL HEALTH POLICIES: USE OF SILVER DIAMINE FLUORIDE
Policy on the Use of Silver Diamine Fluoride for
Pediatric Dental Patients
Latest Revision
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that dental caries continues to be a prevalent and
severe disease in children. This policy addresses the use of
silver diamine fluoride (SDF) as part of an ongoing caries
management plan with the aim of optimizing individualized
patient care consistent with the goals of a dental home. When
SDF is indicated, it is essential that the infants, children,
adolescents, or individuals with special health care needs
receive a comprehensive dental examination, diagnosis, and
plan of ongoing disease management prior to placement of
the material. The dental profession has long viewed dental
caries as an acute disease condition requiring surgical
debridement, cavity preparation, and mechanical restoration
of the tooth, but increasingly, especially for the infant and
child population, practitioners are utilizing individually
tailored strategies to prevent, arrest, or ameliorate the disease
process based on caries risk assessment. One of these strategies
employs application of SDF as an antimicrobial and reminer-
alization agent to arrest caries lesions after diagnosis and at
the direction of a responsible dentist of record.
Methods
This document was developed by the Council on Clinical
Affairs and adopted in 2017. This policy is a review of current
dental and medical literature and sources of recognized pro-
fessional expertise and stature, including both the academic
and practicing health communities, related to SDF and
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
using the terms: diamine silver fluoride and caries, Howe’s
solution, silver nitrate and caries, and silver diamine fluoride;
fields: all; limits: within the last 15 years, humans, English,
birth through age 99. One hundred eight articles matched
these criteria. Papers for review were chosen from this list
and from the references within selected articles. Expert and/
or consensus opinion by experienced researchers and clini-
cians also was considered.
Background
Treatment of incipient caries usually involves early therapeutic
intervention using topical fluoride and non-surgical restorative
techniques such as dental sealants and resin infiltration. The use
and outcomes of these techniques have been well-documented,
72 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
the use of silver diamine fluoride for pediatric dental patients.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:72-5.
and there are current policies and guidelines with recom-
mendations for their use in the practice of dentistry. 1-3 In
contrast, treatment of caries lesions traditionally requires
surgical intervention to remove diseased tooth structure
followed by placement of a restorative material to restore
form and function. Barriers to traditional restorative treatment
(e.g., behavioral issues due to age and/or limited cooperation,
access to care, financial constraints) call for other alternative
caries management modalities.
Silver topical products, such as silver nitrate and SDF have
been used in Japan for over 40 years to arrest caries and reduce
tooth hypersensitivity in primary and permanent teeth. Dur-
ing the past decade, many other countries such as Australia
and China have been using this compound with similar suc-
cess.4,5 As marketed in the United States (U.S.), SDF is a 38
percent silver diamine fluoride which is equivalent to five
percent fluoride in a colorless liquid, with a pH of 10. The
exact mechanism of SDF is not understood. It is theorized that
fluoride ions act mainly on the tooth structure, while silver
ions, like other heavy metals, are antimicrobial. It also is
theorized that SDF reacts with hydroxyapatite in an alkaline
environment to form calcium fluoride (CaF2) and silver phos-
phate as major reaction products. CaF2 provides sufficient
fluoride to form fluorapatite which is less soluble than
hydroxyapatite in an acidic environment.6,7 A side effect is the
discoloration of demineralized or cavitated surfaces. Patients
and parents should be advised regarding the black staining of
the lesions associated with the application of SDF. Ideally,
after images of teeth treated with SDF. Recently, the U.S.
Food and Drug Administration approved SDF as a device for
reducing tooth sensitivity, and off-label use for arresting caries
is now permissible and appropriate for patients.8-12
Many clinical trials have evaluated the efficacy of SDF on
caries arrest and/or prevention,6,10-33 although clinical trials
have inherent bias because of the staining (i.e., since the
difference between control and treated teeth is obvious to the
researcher). However, studies consistently conclude that SDF
is indeed more effective for arresting caries 6,10-12,17-33 than
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. CaF2: Calcium
fluoride. SDF: Silver diamine fluoride. U.S.: United States.

fluoride varnish. SDF reportedly also has approximately two to
three times more fluoride retained than delivered by sodium
fluoride, stannous fluoride, or acidulated phosphate fluoride
(APF) commonly found in foams, gels, and varnishes.28 Addi-
tionally, SDF has not been shown to reduce adhesion of resin
or glass ionomer restorative materials.6,3-37 The use of SDF is
safe when used in adults and children.38-41 Placement of SDF
should follow the AAPD’s Chairside Guide: Silver Diamine
Fluoride in the Management of Dental Caries Lesions.41 Dele-
gation of the application of SDF to auxiliary dental personal
or other trained health professionals, as permitted by state
law, must be by prescription or order of the dentist after a
comprehensive oral examination.
The ultimate decision regarding disease management and
application of SDF are to be made by the dentist and the
patient/parent, acknowledging individuals’ differences in
disease propensity, lifestyle, and environment.42 Dentists are
“required to provide information about the dental health
problems observed, the nature of any proposed treatment, the
potential benefits and risks associated with the treatment, any
alternatives to the treatment proposed, and potential risks and
benefits of alternative treatment, including no treatment.” 43
The SDF informed consent, particularly highlighting expected
staining of treated lesions, potential staining of skin and
clothes, and the need for reapplication for disease control, is
recommended. 41 Careful monitoring and behavioral inter-
vention to reduce individual risk factors should be part of a
comprehensive caries management program that aims not
only to sustain arrest of existing caries lesions, but also to
prevent new caries lesion development.42 Although no severe
pulpal damage or reaction to SDF has been reported, SDF
should not be placed on exposed pulps. 42 Therefore, teeth
with deep caries lesions should be closely monitored clinically
and radiographically by a dentist.42
SDF, when used as a caries arresting agent, is a reimburs-
able fee through billing to a third-party payor, when submitted
with the appropriate dental code recognized by the American
Dental Association’s current dental terminology44. Reimburse-
ment for this procedure varies among states and carriers.
Third-party payors’ coverage is not consistent on the use of the
code per tooth or per visit.42 Because there is a recommended
code for SDF application, billing the procedure using any
other code would constitute fraud, as defined by the Federal
Code of Regulations.45 The AAPD supports the education of
dental students, residents, other oral health professionals and
their staffs to ensure good understanding of the appropriate
coding and billing practices to avoid fraud.46
Policy statement
The AAPD:
• supports the use of SDF as part of an ongoing caries
management plan with the aim of optimizing individ-
ualized patient care consistent with the goals of a
dental home.
ORAL HEALTH POLICIES: USE OF SILVER DIAMINE FLUORIDE
• supports third-party reimbursement for fees associated
with SDF.
• supports delegation of application of SDF to auxiliary
dental personnel or other trained health professionals
according to a state’s dental practice act by prescrip-
tion or order of a dentist after a comprehensive oral
examination.
• supports a consultation with the patient/parent with
an informed consent recognizing SDF is a valuable
therapy which may be included as part of a caries
management plan.
• supports the education of dental students, residents,
other oral health professionals and their staffs to
ensure a good understanding of appropriate coding
and billing practices.
• encourages more practice-based research to be
conducted on SDF to evaluate its efficacy.
References
1. American Academy of Pediatric Dentistry. Fluoride
therapy. Pediatr Dent 2018;40(6):250-3.
2. American Academy of Pediatric Dentistry. Pediatric
restorative dentistry. Pediatr Dent 2018;40(6):330-42.
3. American Academy of Pediatric Dentistry. Policy on use
of fluoride. Pediatr Dent 2018;40(6):49-50.
4. Mei ML, Zhao IS, Ito L, et al. Prevention of secondary
caries by silver diamine fluoride. Int Dent J 2016;66
(2):71-7.
5. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver
diamine fluoride on arresting caries: A literature review.
Int Dent J 2018;68(2):67-76.
6. Fung MHT, Wong MCM, Lo ECM, Chu CH. Arrest-
ing early childhood caries with silver diamine fluoride–
A literature review. J Oral Hyg Health 2013;1:117.
Available at: “https://www.omicsonline.org/open-access/
arresting-early-childhood-caries-with-silver-diamine-
fluoridea-literature-review-2332-0702.1000117.php?aid
=21896”. Accessed September 25, 2017.
7. Yamaga R, Nishino M, Yoshida S, Yokomizo I. Diammine
silver fluoride and its clinical application. J Osaka Univ
Dent Sch 1972;12:1-20.
8. Mei ML, Lo EC, Chu CH. Clinical use of silver diamine
fluoride in dental treatment. Compend Contin Educ
Dent 2016;37(2):93-8; quiz100.
9. Sharma G, Puranik MP, K RS. Approaches to arresting
dental caries: An update. J Clin Diagn Res 2015;9(5):
ZE08-11.
10. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries
remineralisation and arresting effect in children by
professionally applied fluoride treatment – A systematic
review. BMC Oral Health 2016;16:12.
11. Duangthip D, Jiang M, Chu CH, Lo EC. Restorative
approaches to treat dentin caries in preschool children:
Systematic review. Eur J Paediatr Dent 2016;17(2):
113-21.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 73
ORAL HEALTH POLICIES: USE OF SILVER DIAMINE FLUORIDE
12. Duangthip D, Chu CH, Lo EC. A randomized clinical
trial on arresting dentine caries in preschool children by
topical fluorides–18 month results. J Dent 2016;44:
57-63.
13. Li R, Lo EC, Liu BY, et al. Randomized clinical trial on
arresting dental root caries through silver diammine
fluoride applications in community-dwelling elders. J
Dent 2016;51:15-20.
14. Deutsch A. An alternate technique of care using silver
fluoride followed by stannous fluoride in the manage-
ment of root caries in aged care. Spec Care Dentist 2016;
36(2):85-92.
15. Chu CH, Gao SS, Li SK, et al. The effectiveness of the
biannual application of silver nitrate solution followed
by sodium fluoride varnish in arresting early childhood
caries in preschool children: Study protocol for a ran-
domised controlled trial. Trials 2015;16:426.
16. Zhang W, McGrath C, Lo EC, Li JY. Silver diamine
fluoride and education to prevent and arrest root caries
among community-dwelling elders. Caries Res 2013;47
(4):284-90.
17. Mattos-Silveira J, Floriano I, Ferreira FR, et al. Children’s
discomfort may vary among different treatments for
initial approximal caries lesions: Preliminary findings
of a randomized controlled clinical trial. Int J Paediatr
Dent 2015;25(4):300-4.
18. Duangthip D, Jiang M, Chu CH, Lo EC. Non-surgical
treatment of dentin caries in preschool children–
Systematic review. BMC Oral Health 2015;15:44.
19. Mattos-Silveira J, Floriano I, Ferreira FR, et al. New
proposal of silver diamine fluoride use in arresting
approximal caries: Study protocol for a randomized
controlled trial. Trials 2014;15:448.
20. Shah S, Bhaskar V, Venkataraghavan K, et al. Efficacy
of silver diamine fluoride as an antibacterial as well as
antiplaque agent compared to fluoride varnish and
acidulated phosphate fluoride gel: An in vivo study.
Indian J Dent Res 2013;24(5):575-81.
21. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention
of root caries: A literature review of primary and sec-
ondary preventive agents. Spec Care Dentist 2013;33
(3):133-40.
22. Zhi QH, Lo EC, Lin HC. Randomized clinical trial on
effectiveness of silver diamine fluoride and glass ionomer
in arresting dentine caries in preschool children. J Dent
2012;40(11):962-7.
23. Monse B, Heinrich-Weltzien R, Mulder J, et al. Caries
preventive efficacy of silver diammine fluoride (SDF)
and ART sealants in a school-based daily fluoride
toothbrushing program in the Philippines. BMC Oral
Health 2012;12:52.
24. Liu BY, Lo EC, Chu CH, Lin HC. Randomized trial
on fluorides and sealants for fissure caries prevention. J
Dent Res 2012;91(8):753-8.
74 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
25. Castillo JL, Rivera S, Aparicio T, et al. The short-term
effects of diammine silver fluoride on tooth sensitivity:
A randomized controlled trial. J Dent Res 2011;90(2):
203-8.
26. Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A random-
ized trial on root caries prevention in elders. J Dent
Res 2010;89(10):1086-90.
27. Beltrán-Aguilar ED. Silver diamine fluoride (SDF) may
be better than fluoride varnish and no treatment in
arresting and preventing cavitated carious lesions. J Evid
Based Dent Pract 2010;10(2):122-4.
28. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine
fluoride and sodium fluoride varnish in arresting dentin
caries in Chinese pre-school children. J Dent Res 2002;
81(11):767-70.
29. Llodra JC, Rodriguez A, Ferrer B, et al. Efficacy of silver
diamine fluoride for caries reduction in primary teeth
and first permanent molars of schoolchildren: 36-month
clinical trial. J Dent Res 2005;84(8):721-4.
30. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine
fluoride and sodium fluoride varnish in arresting dentin
caries in Chinese pre-school children. J Dent Res 2002;
81(11):767-70.
31. Lo EC, Chu CH, Lin HC. A community-based caries
control program for pre-school children using topical
fluorides: 18-month results. J Dent Res 2001;80(12):
2071-4.
32. Rosenblatt A, Stamford TC, Niederman R. Silver diamine
fluoride: A caries “silver-fluoride bullet”. J Dent Res
2009;88(2):116-25.
33. Lo EC, Chu CH, Lin HC. A community-based caries
control program for pre-school children using topical
fluorides: 18-month results. J Dent Res 2001;80(12):
2071-4.
34. Dos Santos VE Jr., de Vasconcelos FM, Ribeiro AG,
Rosenblatt A. Paradigm shift in the effective treatment
of caries in schoolchildren at risk. Int Dent J 2012;62
(1):47-51.
35. Wu DI, Velamakanni S, Denisson J, et al. Effect of silver
diamine fluoride (SDF) application on microtensile
bonding strength of dentin in primary teeth. Pediatr
Dent 2016;38(2):148-53.
36. Savas S, Kucukyilmaz E, Celik EU, Ates M. Effects of
different antibacterial agents on enamel in a biofilm
caries model. J Oral Sci 2015;57(4):367-72.
37. Han L, Okiji T. Dentin tubule occluding ability of
dentin desensitizers. Am J Dent 2015;28(2):90-4.
38. Vasquez E, Zegarra G, Chirinos E, et al. Short term
serum pharmacokinetics of diammine silver fluoride after
oral application. BMC Oral Health 2012;12:60.
39. Chu CH, Mei L, Seneviratne CJ, Lo EC. Effects of silver
diamine fluoride on dentine carious lesions induced by
Streptococcus mutans and Actinomyces naeslundii biofilms.
Int J Paediatr Dent 2012;22(1):2-10.

40. de Almeida Lde F, Cavalcanti YW, Valenca AM. In vitro
antibacterial activity of silver diamine fluoride in dif-
ferent concentrations. Acta Odontol Latinoam 2011;24
(2):127-31.
41. American Academy of Pediatric Dentistry. Chairside
guide: Silver diamine fluoride in the management of
dental caries lesions. Pediatr Dent 2018;40(6):492-3.
42. 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.
43. American Dental Association Division of Legal Affairs.
Dental Records. Chicago, Ill.: American Dental Associ-
ation; 2007:16.
ORAL HEALTH POLICIES: USE OF SILVER DIAMINE FLUORIDE
44. American Dental Association. Code on Dental Pro-
cedures and Nomenclature (CDT Code). Available at:
“https://www.ada.org/en/publications/cdt”. Accessed
May 2, 2018.
45. U.S. National Archives and Records Administration.
2018. Code of Federal Regulations. Title 42-Public
Health. Part 455-Program Integrity: Medicaid. Section
455.2-Definitions. Available at: “https://wwwecfr.gov/
cgi-bin/text-idx?tpl=/ecfrbrowse/Title42/42cfr455_main
_02.tpl”. Accessed May 2, 2018.
46. American Academy of Pediatric Dentisty. Policy on
third-party payor audits, abuse, and fraud. Pediatr Dent
2018;40(6):126-9.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 75
ORAL HEALTH POLICIES: USE OF XYLITOL
Policy on Use of Xylitol in Pediatric Dentistry
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that there is considerable research on sugar sub-
stitutes, particularly xylitol, and their potential oral health
benefits for infants, children, adolescents, and persons with
special health care needs. This policy is intended to assist oral
health care professionals making informed decisions about the
use of xylitol-based products with the aim of preventing caries
in children.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2006.1 This document is an update of the
previous version, revised in 2015.2 The update is based upon
a review of current dental and medical literature related to
the use of xylitol in caries prevention. A literature search was
®
conducted using PubMed /Ovid with the terms: xylitol
AND dental, systematic review; field: all fields; limits:
within the last 10 years, humans, English, birth through 18.
Twenty-three articles matched these criteria; 16 systematic
reviews and/or meta-analyses were reviewed for this revision.
When data did not appear sufficient or were inconclusive,
policy was based upon expert and/or consensus opinion by
experienced researchers and clinicians.
Background
Xylitol is a five-carbon sugar alcohol derived primarily from
forest and agricultural materials.3 It has been used since the
early 1960s in infusion therapy for postoperative, burn, and
shock patients, in the diet of diabetic patients, and as a sweet-
ener in products aimed at improved oral health.3 Dental
benefits of xylitol first were suggested from Finnish studies
using animal models in 1970.4 The first xylitol studies in
humans, known as the Turku Sugar Studies,5,6 demonstrated
the relationship between dental plaque and xylitol, as well as
the safety of xylitol for human consumption. Xylitol as well as
other sugar alcohols are not readily metabolized by oral bacte-
ria and, thus, are considered noncariogenic sugar substitutes.6
Xylitol is available in many forms (e.g., gums, mints,
chewable tablets, lozenges, toothpastes, mouthwashes, cough
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
gum.7-14 Multiple systematic reviews regarding xylitol show
varying results in the reduction of the incidence of caries,
transmission of mutans streptococci (MS) from mothers to
76 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
use of xylitol in pediatric dentistry. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:76-7.
children, and MS levels in children.5-11,13-16 Such studies have
been performed with xylitol intake ranging from four to 15
grams per day divided into three to seven consumption
periods.7-9 Abdominal distress and osmotic diarrhea have been
reported following the ingestion of xylitol.7-13,15-18
Overall results of systematic reviews suggest insufficient
evidence to show xylitol products reduce caries. 7-13,15-18 All
xylitol studies were reported to have design issues and/or
bias (e.g., insufficient sample size, control group issues, in-
consistent results, randomization, blinding, conflict of
interest).7-13,15-18 Data is inconclusive for caries reduction for
short-term use.7-13,15-18 Data also is inconclusive for long-term
effectiveness for reduction of MS and caries reduction.7-13,15-18
Most studies used a very large dose and at high frequency
(generally four to five times a day), which may be unrealistic
in clinical practice.10-12
Policy statement
The AAPD:
• supports the use of xylitol and other sugar alcohols as
noncariogenic sugar substitutes.
• recognizes that presently there is a lack of consistent
evidence showing significant reductions in MS and
dental caries in children.
• recognizes that the large dose and at high frequency
of xylitol used in clinical trials may be unrealistic in
clinical practice.
• supports further research to clarify the impact of xyli-
tol delivery vehicles, the frequency of exposure, and the
optimal dosage to reduce caries and improve the oral
health of children.
References
1. American Academy of Pediatric Dentistry. Use of xylitol
in caries prevention. Pediatr Dent 2006;28(suppl):31-2.
2. American Academy of Pediatric Dentistry. Use of xylitol.
Pediatr Dent 2015;37(special issue):45-7.
3. Mäkinen KK. Biochemical principles of the use of xylitol
in medicine and nutrition with special consideration
of dental aspects. Experientia Suppl 1978;30:1-160.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. MS: mutans
streptococci.

4. Muhlemann HR, Regolati B, Marthaler TM. The effect
on rat fissure caries of xylitol and sorbitol. Helv Odontol
Acta 1970;14(1):48-50.
5. Scheinin A, Mäkinen KK, Tammisalo E, Rekola M. Turku
sugar studies. XVIII. Incidence of dental caries in rela-
tion to 1-year consumption of xylitol chewing gum. Acta
Odontol Scand 1975;33(5):269-78.
6. Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar studies.
V. Final report on the effect of sucrose, fructose and
xylitol diets on caries incidence in man. Acta Odontol
Scand 1976;34(4):179-216.
7. Riley P, Moore D, Ahmed F, Sharif MO, Worthington
H. Xylitol-containing products for preventing dental
caries in children and adults. Cochrane Database Syst
Rev 2015;(3):CD010743.
8. Antonio AG, Pierro VS, Maia LC. Caries preventive
effects of xylitol-based candies and lozenges: A systematic
review. J Public Health Dent 2011;71(2):117-24.
9. Lin HK, Fang CE, Huang MS, et al. Effect of maternal
use of chewing gums containing xylitol on transmission
of mutans streptococci in children: A meta-analysis of
randomized controlled trials. Int J Paediatr Dent 2016;
26(1):35-44.
10. Chou R, Cantor A, Zakher B, et al. Prevention of Dental
Caries in Children Younger Than 5 Years Old: Systematic
Review to Update the U.S. Preventive Services Task Force
Recommendation [Internet]. Rockville, Md.: Agency for
Healthcare Research and Quality; May 2014. (Evidence
Syntheses, No. 104.) Available at: “https://www.ncbi.nlm.
nih.gov/books/NBK202090/”. Accessed July 22, 2020.
ORAL HEALTH POLICIES: USE OF XYLITOL
11. Janakiram C, Deepan Kumar CV, Joseph J. Xylitol in
preventing dental caries: A systematic review and meta-
analyses. J Nat Sci Biol Med 2017;8(1):16-21.
12. Marghalani AA, Guinto E, Phan M, Dhar V, Tinanoff N.
Effectiveness of xylitol in reducing dental caries in chil-
dren. Pediatr Dent 2017;39(2):103-10.
13. Mickenautsch S, Yengopal V. Anticariogenic effect of
xylitol versus fluoride – A quantitative systematic review
of clinical trials. Int Dent J 2012;62(1):6-20.
14. Nakai Y, Shinga-Ishihara C, Kaji M, Moriya K, Murakami-
Yamanaka K, Takimura M. Xylitol gum and maternal
transmission of mutans streptococci. J Dent Res 2010;
89(1):56-60.
15. Fontana M. Enhancing fluoride: Clinical human studies
of alternatives or boosters for caries management. Caries
Res 2016;50(Suppl 1):22-37.
16. Muthu MS, Ankita S, Renugalakshmi A, Richard K.
Impact of pharmacological interventions in expectant
mothers resulting in altered mutans streptococci levels
in their children. Pediatr Dent 2015;37(5):422-8.
17. Wang Y, Li J, Sun W, Li H, Cannon R, Mei L. Effect of
non-fluoride agents on the prevention of dental caries in
primary dentition: A systematic review. PLoS One 2017;
12(8):e0182221.
18. Xiao J, Alkhers N, Kopycka-Kedzierawskial DT, et al.
Prenatal oral health care and early childhood caries pre-
vention: A systematic review and meta-analysis. Caries
Res 2019;53(4):411-21.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 77
ORAL HEALTH POLICIES: INTERIM THERAPEUTIC RESTORATIONS
Policy on Interim Therapeutic Restorations ( ITR )
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that unique clinical circumstances can result in
challenges in restorative care for infants, children, adolescents,
and persons with special health care needs. When circum-
stances do not permit traditional cavity preparation and/or
placement of traditional dental restorations or when caries
control is necessary prior to placement of definitive restora-
tions, interim therapeutic restorations (ITR)1 may be beneficial
and are best utilized as part of comprehensive care in the
dental home2,3. This policy will differentiate ITR from
atraumatic/alternative restorative techniques (ART)4 and
describe the circumstances for its use.
Methods
This policy was developed by the Council on Clinical Affairs,
adopted in 20015, and revised in 20176. This update is based
upon electronic database and hand searches of medical and
®
dental literature using PubMed /MEDLINE and the terms:
dental caries, cavity, primary teeth, deciduous teeth, atraumatic
restorative treatment, interim therapeutic restoration, AND
glass ionomer; fields: all; limits: within the last 10 years,
humans, English, birth through age 18. Two hundred ninety-
one articles met these criteria. Articles were screened by
viewing titles and abstracts. Articles were chosen for review
from these searches and from the references within selected
articles. Additionally, websites for the AAPD and the American
Dental Association were reviewed. Expert and/or consensus
opinion by experienced researchers and clinicians was also
considered.
Background
ART has been endorsed by the World Health Organization as
a means of restoring and preventing caries in populations with
little access to traditional dental care.4,7,8 In many countries,
practitioners provide treatment in non-traditional settings that
restrict restorative care to placement of provisional restorations.
Because circumstances do not allow for follow-up care, ART
mistakenly has been interpreted as a definitive restoration. 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-
gression of caries lesions in young patients, uncooperative
patients, or patients with special health care needs or when
78 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
interim therapeutic restorations (ITR). The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:78-9.
traditional cavity preparation and/or placement of traditional
dental restorations are not feasible and need to be post-
poned.9-11 Additionally, ITR may serve useful for step-wise
excavation in children with multiple open caries lesions prior
to definitive restoration of the teeth, in erupting molars when
isolation conditions are not optimal for a definitive restoration,
or for caries control in patients with active lesions prior to
treatment performed under general anesthesia.12-14 ITR may be
beneficial for patients who require additional acclimatization
or increased cooperation to complete definitive restorative
treatment.15 The use of ITR has been shown to reduce the
levels of cariogenic oral bacteria (e.g., Mutans streptococci,
lactobacilli) in the oral cavity immediately following its
placement.16-18 However, this level may return to pretreatment
counts over a period of six months after ITR placement if
no other treatment is provided.17 ITR also may help reduce
the risk of decay in teeth adjacent to the interim restoration.19
This technique serves as a viable tool when circumstances
(e.g., coronavirus disease 2019 [COVID-19] pandemic) call
for minimizing the generation of aerosols during restorative
care.20,21
The ITR procedure involves removal of caries using hand
or rotary instruments with caution not to expose the pulp.
Leakage of the restoration can be minimized with maximum
caries removal from the periphery of the lesion. Following
preparation, the tooth is restored with an adhesive restorative
material such as glass ionomer or resin-modified glass ionomer
cement.22 ITR has the greatest success when applied to single
surface or small two surface restorations.14,23,24 Inadequate
cavity preparation with subsequent lack of retention and
insufficient bulk can lead to failure.24,25 Follow-up care with
topical fluorides and oral hygiene instruction may improve
the treatment outcome in high caries-risk dental populations,
especially when glass ionomers (which have fluoride releasing
and recharging properties) are used.26-28
Policy statement
The AAPD recognizes ITR as a beneficial provisional tech-
nique in contemporary pediatric restorative dentistry. The
AAPD supports the use of ITR to restore and prevent the
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ART: Atraumatic/
alternative restorative techniques. ITR: Interim therapeutic
restorations.

progression of dental caries in young patients, uncooperative
patients, patients with special health care needs, and situations
in which traditional cavity preparation or placement of
traditional dental restorations is not feasible. Furthermore, ITR
may be used for caries control in children with multiple caries
lesions prior to definitive restoration of the teeth.
References
1. American Academy of Pediatric Dentistry. Pediatric
restorative dentistry. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:401-14.
2. Nowak AJ, Casamassimo PS. The dental home. J Am
Dent Assoc 2002;133(1):93-8.
3. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:21-2.
4. Frencken J, Pilot T, van Amerongen E, Phantumvanit
P, Songpaisan Y. Manual for the Atraumatic Restorative
Treatment Approach to Control Dental Caries. WHO
Collaboration. Centre for Oral Health Services Research.
Groningen, The Netherlands; 1997. Available at: “http://
vida.gt/clinica/doctores/wp-content/uploads/sites/2/2014/
07/ART_Manual_English.pdf ”. Accessed January 18,
2022.
5. American Academy of Pediatric Dentistry. Policy on
alternative restorative treatment. Pediatr Dent 2001;23
(suppl):13.
6. American Academy of Pediatric Dentistry. Policy on
interim therapeutic restorations (ITR). Pediatr Dent 2017;
39(6):57-8.
7. World Health Organization. WHO Expert Consultation
on Public Health Intervention against Early Childhood
Caries: Report of a meeting, Bangkok, Thailand, 26-28
January 2016. Geneva: World Health Organization; 2017.
(WHO/NMH/PND/17.1). Licence: CC BY-NC-SA 3.0
IGO. Available at: “https://www.who.int/publications/i/
item/who-expert-consultation-on-public-health-interven-
tion-against-early-childhood-caries”. Accessed August 1,
2022.
8. Frencken JE. The ART approach using glass-ionomers in
relation to global oral health care. Dent Mater 2010;26
(1):1-6.
9. Deery C. Atraumatic restorative techniques could reduce
discomfort in children receiving dental treatment. Evid
Based Dent 2005;6:9.
10. Gryst ME, Mount GJ. The use of glass ionomer in special
needs patients. Aust Dent J 1999;44(4):268-74.
11. Canares G, Hsu KL, Dhar V, Katechia, B. Evidence-based
care pathways for management of early childhood caries.
Gen Dent 2018;66(6):24-8.
12. Vij R, Coll JA, Shelton P, Farooq NS. Caries control and
other variables associated with success of primary molar
vital pulp therapy. Pediatr Dent 2004;26(3):214-20.
13. Antonson SA, Antonson DE, Brener S, et al. Twenty-four
month clinical evaluation of fissure sealants on partially
ORAL HEALTH POLICIES: INTERIM THERAPEUTIC RESTORATIONS
erupted permanent first molars: Glass ionomer versus
resin-based sealant. J Am Dent Assoc 2012;143(2):115-22.
14. de Amorim RG, Frencken JE, Raggio DP, Chen X, Hu
X, Leal SC. Survival percentages of atraumatic restorative
treatment (ART) restorations and sealants in posterior
teeth: An updated systematic review and meta-analysis.
Clin Oral Investig 2018;22(8):2703-25.
15. Lim SN, Kiang L, Manohara R, et al. Interim therapeutic
restoration approach versus treatment under general anaes-
thesia approach. Int J Paediatr Dent 2017;27(6):551-7.
16. Bönecker M, Toi C, Cleaton-Jones P. Mutans streptococci
and lactobacilli in carious dentine before and after Atrau-
matic Restorative Treatment. J Dent 2003;31(6):423-8.
17. Roshan NM, Shigli AL, Deshpande SD. Microbiological
evaluation of salivary Streptococcus mutans from children
of age 5-7 years, pre- and post-atraumatic restorative
treatment. Contemp Clin Dent 2010;1(2):94-7.
18. Wambier DS, dos Santos FA, Guedes-Pinto AC, Jaeger
RG, Simionato MRL. Ultrastructural and microbiological
analysis of the dentin layers affected by caries lesions in
primary molars treated by minimal intervention. Pediatr
Dent 2007;29(3):228-34.
19. Ruff RR, Niederman R. Comparative effectiveness of
school-based caries prevention: A prospective cohort
study. BMC Oral Health 2018;18(1):53-9.
20. Al-Halabi M, Salami A, Alnuaimi E, Kowash M, Hussein
I. Assessment of paediatric dental guidelines and caries
management alternatives in the post COVID-19 period.
A critical review and clinical recommendations. Eur Arch
Paediatr Dent 2020;21(5):543-56.
21. Yang F, Yu L, Qin D, Hua F, Song G. Online consultation
and emergency management in paediatric dentistry dur-
ing the COVID-19 epidemic in Wuhan: A retrospective
study. Int J Paediatr Dent 2021;31(1):5-11.
22. Yip HK, Smales RJ, Ngo HC, Tay FR, Chu F. Selection
of restorative materials for the atraumatic restorative
treatment (ART) approach: A review. Spec Care Dent
2001;21(6):216-21.
23. Mandari GJ, Frencken JE, van’t Hof MA. Six-year success
rates of occlusal amalgam and glass-ionomer restorations
placed using three minimal intervention approaches.
Caries Res 2003;37(4):246-53.
24. da Franca C, Colares V, Van Amerongen E. Two-year eval-
uation of the atraumatic restorative treatment approach
in primary molars class I and II restorations. Int J Paediatr
Dent 2011;21(4):249-53.
25. van Gemert-Schriks MCM, van Amerongen WE, ten
Cate JM, Aartman IHA. Three-year survival of single-
and two-surface ART restorations in a high-caries child
population. Clin Oral Investig 2007;11(4):337-43.
26. Tam LE, Chan GP, Yim D. In vitro caries inhibition
effects by conventional and resin modified glass ionomer
restorations. Oper Dent 1997;22(1):4-14.
27. Scherer W, Lippman N, Kaim J, LoPresti J. Antimicrobial
properties of VLC liners. J Esthet Dent 1990;2(2):31-2.
28. Tyas MJ. Cariostatic effect of glass ionomer cements: A
five-year clinical study. Aust Dent J 1991;36(3):236-9.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 79
ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM
Policy on Management of the Frenulum in
Pediatric Patients
Revised
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD) recog-
nizes that a restrictive oral frenulum may affect a child’s health
by hindering the ability to breastfeed or speak. The frequency
of surgical intervention has increased exponentially over the
last two decades.1-4 The AAPD recognizes an evidence-based
policy on frenula would make information more accessible to
dentists, physicians, other allied health professionals, and
parents and help reduce the number of unnecessary or incor-
rectly timed procedures.
Methods
This policy, developed by the Council of Clinical Affairs in
20195, is based on a review of current dental and medical lit-
erature and sources of recognized professional expertise and
stature, including both the academic and practicing health
communities, related to frenula/frenotomies. In addition,
®
literature searches of PubMed /MEDLINE, Web of Science,
and Google Scholar databases were conducted using the
terms: ankyloglossia, ankyloglossia AND breastfeeding out-
comes, breastfeeding with ankyloglossia and/or upper lip tie,
gastroesophageal reflux, frenotomy, frenulotomy, frenectomy,
frenulectomy, systematic reviews of ankyloglossia other than
breastfeeding, lip-tie, superior labial frenulum, maxillary lip-tie,
breastfeeding cessation, frenum, frenulum, tongue-tie, speech
articulation with lingual frenulum, frenuoplasty, midline
diastema, lactation difficulties, nipple pain with breastfeeding,
Hazelbaker Assessment Tool for Lingual Frenulum Function
(ATLFF), Infant Breast-feeding Assessment Tool (IBFAT),
LATCH grading scales, mandibular labial frenulum, perio-
dontal indications for frenectomy, gingival recession associated
with midline diastema; fields: all; limits: within the last 10
years, English. One thousand six hundred twenty-two articles
matched these criteria. Papers for review were chosen from
this list and from references within selected articles. Expert
and/or consensus opinion by experienced researchers and
clinicians also was considered.
Definitions
Ankyloglossia: a congenital developmental anomaly of the
tongue characterized by a short, thick lingual frenulum result-
ing in limitation of tongue movement (partial ankyloglossia)
or by the tongue appearing to be fused to the floor of the
mouth (total ankyloglossia).6,7
80 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
management of the frenulum in pediatric patients. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:80-5.
Frenectomy/frenulectomy: the complete removal of the frenum/
frenulum including its attachment to underlying bone.
Frenotomy/frenulotomy: simple cutting or incision of the
frenum/frenulum.
Frenuloplasty: an extensive frenulum excision that usually
involves repositioning of aberrant muscle and is closed by Z-
plasty or a local flap with placement of sutures.8
Frenulum: a mucosal attachment containing muscle and
connective tissue fibers which connect intraoral structures
such as the lip and cheek to the alveolar mucosa, gingiva, or
periosteum.9
Background
Typically, seven frenula are present in the oral cavity, most
notable the maxillary labial frenulum, the mandibular labial
frenulum, the lingual frenulum, and four buccal (cheek)
frenula.10 Their primary function is to provide stability of the
upper lip, lower lip, and tongue.11 Frenulum attachments and
their impact on oral motor function and development are
topics of interest within the dental community as well as
various healthcare specialties. Studies have shown differences
in treatment recommendations among pediatricians, otolaryn-
gologists, lactation consultants, speech pathologists, surgeons,
and dental specialists.6,12-19 Regardless of the etiology, a 834
percent increase in diagnosed cases of ankyloglossia and an
866 percent increase in frenulum procedures have been re-
ported from 1997 to 2012.2 When the data over this time
span is examined more closely, the average percentage of
patients diagnosed with ankyloglossia undergoing surgical
procedures is 33 percent.2 Most recently, 35 percent of patients
in 2009 received surgery as did 38 percent in 2012.2 In 2020,
a panel of pediatric otolaryngologists released a consensus
statement on the diagnosis, management, and treatment of
ankyloglossia in children less than 18 years old.3
Maxillary frenulum
A prominent maxillary frenulum in infants, children, and
adolescents, although a common finding, can be a concern
to parents. The maxillary labial frenulum attachment can be
classified with respect to its anatomical insertion level10:
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

1. mucosal (frenal fibers are attached up to the muco-
gingival junction);
2. gingival (frenal fibers are inserted within the attached
gingiva);
3. papillary (frenal fibers are extending into the inter-
dental papilla); and
4. papilla penetrating (frenal fibers cross the alveolar
process and extend up to the palatine papilla).
The most commonly observed types are mucosal and gingi-
val.18,19 However, a maxillary frenulum is a dynamic structure
that presents changes in position of insertion, architecture, and
shape during growth and development.18 Evidence suggests
apical migration of the insertion as the alveolar process grows
and descends and the frenulum remains in place.19,20 Infants
have the highest prevalence of papillary penetrating pheno-
type. 18 In severe instances, a restrictive maxillary frenulum
attachment has been associated with breastfeeding and bottle-
feeding difficulties among newborns. 21-24 However, in a
prospective study, anatomical classification of the maxillary
frenulum alone was not correlated with breastfeeding success
or difficulty, pain, or maternally-reported poor latch.25 Studies
suggest a restrictive maxillary frenulum may inhibit an airtight
seal on the maternal breast through flanging of both lips.22-
24,26
For this reason, future studies focusing on assessment of
upper lip flexibility and the ability to flange rather than just
anatomical point of insertion may provide more information.25
The maxillary frenulum can contribute to reflux in babies due
to the intake of air from a poor seal at the breast or bottle
leading to colic or irritability.24,27 With the lack of understand-
ing of the function of the labial frenulum, the universality of
the labial frenulum, and level of attachment in most infants,
the release of the maxillary frenulum based on appearance
alone cannot be endorsed. 28 Although a causal relationship
between a hyperplastic maxillary frenum and facial caries has
not been substantiated, anticipatory guidance for patients with
restrictive tissues may include additional oral hygiene measures
(e.g., swabbing the vestibule after feeding).29
Surgical removal of the maxillary midline frenulum may be
related to presence or prevention of midline diastema forma-
tion, prevention of post orthodontic relapse, esthetics, and
psychological considerations. 16-18,30 Treatment options for
midline diastema and sequence of care vary with patient age
and can include orthodontics, restorative dentistry, frenectomy,
or a combination of these.30 Treatment is suggested (1) when
the attachment exerts a traumatic force on the gingiva caus-
ing the papilla to blanch when the upper lip is pulled, or (2) if
the attachment causes a diastema wider than two millimeters,
which is known to rarely close spontaneously during further
development.18,30,31 When a diastema persists into the perma-
nent dentition, the objectives for treatment involve managing
both the diastema and its etiology. 30 Pediatric dentists and
orthodontists generally agree that most diastemas in the primary
and mixed dentitions are normal, are multifactorial, and tend
to close with maturity; therefore, any surgical manipulation of
ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM
the frenulum is not recommended before the permanent canines
erupt and only following orthodontic closure of the space30,32
or in conjunction with orthodontic treatment 33. This was
recently affirmed in a systematic review.4 Certain surgical inter-
ventions, when performed too early, may result in orthodontic
relapse due to scarring.9 A recent retrospective cohort study
saw a decrease in maxillary midline diastema width when la-
ser labial frenectomy was performed in both the primary and
mixed dentitions.34 Whether or not this early treatment can
prevent the need for orthodontic closure of a persistent di-
astema in adolescence would best be demonstrated by a
prospective investigation utilizing controls with long-term
follow up, which was not present in this study.34
Mandibular labial frenulum
A high frenulum sometimes can present on the labial aspect
of the mandibular ridge. This most often is seen in the perma-
nent central incisor area but also can be found by the canine.15
The mandibular labial frenulum occasionally inserts into the
free or marginal gingival tissue.15 Movements of the lower lip
can cause the frenulum to pull on the fibers inserted into the
free marginal tissue, which creates pocket formation that, in
turn, can lead to food and plaque accumulation.15 Surgical
intervention can be considered to prevent subsequent inflam-
mation, recession, pocket formation, and possible loss of
alveolar bone and/or teeth. 15 However, if factors causing
gingival/periodontal inflammation are controlled, the degree
of recession and the need for treatment decreases.13,15
Lingual frenulum
The World Health Organization has recommended mothers
worldwide exclusively breastfeed infants for the child’s first
six months to achieve optimum growth, development, and
health.35 Thereafter, they may be given complementary foods
and continue breastfeeding up to the age of two years or
beyond. 35 The American Academy of Pediatrics in 2018
reaffirmed its recommendation of exclusive breastfeeding for
about six months, followed by continued breastfeeding as
complementary foods are introduced, with continuation of
breastfeeding for one year or longer as mutually desired by
mother and child.36 Lingual frenula, in addition to the maxil-
lary labial frenula, have been associated by some practitioners
with impedance to successful breastfeeding, thereby leading to
recommendations for frenulotomy. The most common symp-
toms that babies experience from tongue-and lip-tie are poor
or shallow latch on the breast or bottle, slow or poor weight
gain, reflux and irritability from swallowing excessive air, pro-
longed feeding time, milk leaking from the mouth due to a
poor seal, and clicking or smacking noises when nursing/
feeding; maternal symptoms include painful nursing.24,37
An anatomical dissection study determined the lingual
frenulum in neonates is not formed by a discrete submucosal
midline string or band as previously thought; rather, it is a
dynamically formed midline fold created in a layer of fascia
spanning the floor of the mouth and characterized by
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 81
ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM
morphology that varies with tongue movement similar to
that in adults. 38 This fascia runs from the inner surface of
the mandible to join with the connective tissue on the ventral
surface of the tongue. It is the height of the fascial attachment
on the ventral surface of the tongue that alters the visual
prominence of the frenulum when placed under tension as seen
when elevated.38 The lingual frenulum does not have direct
connection to the posterior tongue (also known as the tongue
base). Therefore, the term “posterior tongue-tie” is misleading
and anatomically incorrect. Ankyloglossia can perhaps be
considered an imbalance of the fascial roles, where its provision
of tongue stability impacts tongue movement.38
A methodological review of the term ankyloglossia shows
the use of multiple diagnostic criteria, leading the reported
prevalence of ankyloglossia to vary between 4.2 and 10.7 per-
cent of the population.13,19 Several diagnostic classifications
have been proposed based on anatomical and functional criteria,
but none has been universally accepted.13,39 No single ana-
tomical variable of the frenulum has been shown in isolation
to correlate directly with impaired tongue function. As such,
the use of grading systems simply describes appearance rather
than serving as an objective tool to diagnose or categorize the
frenulum as ankyloglossia.38 The tongue’s ability to elevate
rather than protrude is the most important quality for nursing,
feeding, speech, and development of the dental arches.40,41
Ankyloglossia has been associated with breastfeeding and
bottle-feeding difficulties among neonates, limited tongue
mobility and speech difficulties, malocclusion, and gingival
recession.6,12,13,15-19,31 An ultrasound study has shown that patterns
of tongue motions differed both in infants with ankyloglossia
(with breastfeeding problems) and those without ankyloglos-
sia, 42 but because no anatomical variables of the lingual
frenulum were included in that study, it is not possible to cor-
relate frenum morphology to changes demonstrated on the
ultrasound38. A short frenulum can inhibit tongue movement
and create deglutition problems. 13,42,43 Systematic literature
review articles acknowledge the role of frenotomy/frenectomy
for demonstrable frenal constriction in order to reduce maternal
nipple pain44 and improve successful breastfeeding when the
procedure is provided in conjunction with support of other
allied healthcare professionals.6,13,15,16,19 A Cochrane review44
noted the included randomized control trials were small and
had multiple limitations. Due to those limitations, the review
was unable to determine whether frenotomy in infants younger
than 30 days who had ankyloglossia and feeding difficulties
correlated with longer-term breastfeeding success. Similarly,
the Canadian Agency for Drugs and Technologies in Health
(CADTH) questioned whether frenectomy provides a mean-
ingful incremental benefit over other treatments or procedures
to improve breastfeeding, particularly in the longterm due to
studies’ designs.1 Because breastfeeding is a complex relation-
ship dyad, ankyloglossia may be only one of multiple possible
deficiencies contributing to difficulty breastfeeding.2,45 There-
fore, predicting which infants will have improved breastfeeding
following frenectomy may be difficult.44,46 Some studies show
82 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
a decrease in surgical intervention in infants with feeding
difficulties when a team of allied healthcare professionals is
involved using consistent multidisciplinary assessment and
incorporating alternative intervention strategies.47-49
Limitations in tongue mobility and pathologies of speech
have been associated with ankyloglossia. 13,50,51 However,
opinions vary among health care professionals regarding the
correlation between ankyloglossia and speech disorders. Speech
articulation is largely perceptual in nature; variation in speech
assessment outcomes is very high among individuals and spe-
cialists from different medical backgrounds.6 The difficulties
in articulation for individuals with ankyloglossia are evident
for consonants and sounds like / s /, / z /, / t /, / d /, / l /, / sh /,
/ ch /, / th /, and / dg /, and rolling an R is especially chal-
lenging.6,50 Because parents often do not report speech issues
accurately, an evaluation by a speech-language pathologist
skilled in assessing tongue-ties (although consensus on assess-
ment techniques has not been established) is suggested prior to
recommending a tongue-tie release.52 Speech therapy in con-
junction with frenuloplasty, frenulotomy, or frenulectomy can
be a treatment option to improve tongue mobility and
speech.50,51 One pilot study reported children with moderate
and moderate-to-severe speech and language impairment at-
tained better speech and language outcomes after frenulectomy
when compared with children with mild and mild-to-moderate
impairments.53 However, other studies hint at the subjective
improvement when parents were surveyed. 50,54 Nevertheless,
further evidence is needed to determine the benefit of surgical
correction of ankyloglossia and its relation to speech pathology
as many children and individuals with ankyloglossia may be
able to compensate and do not appear to suffer from speech
difficulty.13,16,39,55-57
A high-arched palate, reduced palate width, and elongated
soft palate have been associated with tongue-tie.40,41 Evidence
relating ankyloglossia and abnormal tongue position to skeletal
development of Class III malocclusion is limited.58,59 A com-
plete orthodontic evaluation, diagnosis, and treatment plan
are necessary prior to any surgical intervention.58
Localized gingival recession on the lingual aspect of the
mandibular incisors has been associated with ankyloglossia in
some cases where frenal attachment causes gingival retraction.13
As with most periodontal conditions, elimination of plaque-
induced gingival inflammation can minimize gingival recession
without any surgical intervention.13 When recession continues
even after oral hygiene management, surgical intervention may
be indicated.13,15
Treatment considerations
Although evidence in the literature to promote the timing,
indication, and type of surgical intervention is limited,
frenulotomy/frenulectomy for functional limitations and symp-
tomatic relief may be considered on an individual basis.6,13,42,51,
60,61
Evaluation for other potential head and neck sources
(e.g., nasal obstruction, airway obstructions, reflux, craniofacial
anomalies) for breastfeeding problems before performing a

frenulotomy on a patient who has feeding difficulties3 may
prevent unnecessary surgeries especially in very young neonates
less than two weeks of age. When indicated, frenuloplasty,
frenulectomy, and frenulotomy may be a successful approaches
in alleviating the problem.6,9,13,18 Each of these procedures in-
volves surgical incision or excision, establishing hemostasis, and
wound management.62 With regards to anatomy, the lingual
nerve has been shown to pass immediately beneath the fascia
on the ventral surface of the tongue with smaller branches
continuing into the lingual frenum.38 As such, sensory input
necessary for tongue shape may be compromised if the lingual
nerve is damaged. 63 Additional complications may occur
during or following frenulum surgical procedures and include
excessive bleeding, formation of a mucus retention cyst, re-
attachment, hematoma formation, numbness or paresthesia,
infection, scar tissue formation, and restriction in tongue move-
ment.64 Dressing placement or the use of antibiotics is not
necessary.62 In older patients, postoperative care may include
maintaining a soft diet, regular oral hygiene, and analgesics
as needed. Postoperative pain has been reported in some
studies and found to persist as a moderate level (6.5 on a scale
of 10) for three days. 65 Although otolaryngologists’ expert
opinion3 and the CADTH66 do not support a standard post-
procedure regimen including stretching, massaging, or other
exercises to prevent reattachment of the frenulum, others have
concluded that exercises after tongue-tie release have elicited
functional improvements in speech, feeding, and sleep. 54,65
These studies have been limited by patient numbers and lack of
control groups. Postoperative pain, especially in the neonate,
may further inhibit postsurgical stretching and exercises and
can lead to oral aversion.67 Oral exercises have been advocated
as a safe and potentially effective adjunct to improve tongue
movements with or without surgical intervention in school-
aged patients.65
The use of electrosurgery or laser technology for frenulotomies/
frenulectomies has demonstrated a shorter operative working
time, improved hemostasis, reduced intra- and postoperative
pain and discomfort, fewer postoperative complications (e.g.,
swelling, infection), no need for suture placement, and in-
creased patient acceptance.68,69 These procedures require extensive
training as well as skillful technique and patient management,
especially in the neonate. 6,9,13,18,51,70-73 As with all surgical
procedures, an informed consent is essential. Informed consent
includes relevant information regarding assessment, diagno-
sis, nature and purpose of proposed treatment, and potential
benefits and risks of the proposed treatment, along with pro-
fessionally-recognized or evidence-based alternative treatment
options – including no treatment – and their risks.74
Policy statement
The AAPD supports additional research on the causative as-
sociation between ankyloglossia and difficulties in breastfeeding
or speech articulation, between a hyperplastic labial frenulum
and increased risk of caries or periodontal disease, and upper
lip restriction and difficulties with breastfeeding/latch. The
ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM
AAPD recognizes that causes other than ankyloglossia are more
common for breastfeeding difficulties and that, while frenulo-
tomy for an infant with ankyloglossia can lead to an improve-
ment in breastfeeding, not all infants with ankyloglossia require
surgical intervention.3 Due to the broad differential diagnosis,
a team-based approach including consultation with other
specialists can aid in treatment planning. Further randomized
controlled trials and other prospective studies of high
methodological quality are necessary to determine the indications
and long-term effects of frenulotomy/frenulectomy.
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65. Zaghi S, Valcu-Pinkerton S, Jabar M, et al. Lingual
frenuloplasty with myofunctional therapy: Exploring
safety and efficacy in 348 cases. Laryngoscope Investig
Otolaryngol 2019;4(5):489-96.
66. Canadian Agency for Drugs and Technologies in Health.
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CADTH; 2019 May. Available at: “https://www.cadth.
ca/sites/default/files/pdf/htis/2019/RB1341%20Stretching
%20tongue%20tie%20Final.pdf ”. Accessed March 13,
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67. Gilliland AM, Bunik M, O’Connor ME. Pediatrician’s
concerns about ankyloglossia and breastfeeding. Pediatrics
2020;146(1_Meeting Abstract):124-5.
68. Olivi G, Chaumanet G, Genovese MD, Beneduce C,
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69. Sezgin G, Özener HÖ, Meseli SE, Kuru L. Evaluation
of patient’s perceptions, healing, and reattachment after
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randomized clinical trial. Photobiomod Photomed Las
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70. Díaz-Pizán M, Lagravère M, Villena R. Midline diastema
and frenum morphology in the primary dentition. J Dent
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71. Hogan M, Wescott C, Griffiths M. Randomized, control-
led trial of division of tongue-tie in infants with feeding
problems. J Paediatr Child Health 2005;41(5-6):246-50.
72. Gontijo I, Navarro R, Haypek P, Ciamponi A, Haddad A.
The applications of diode and Er:YAG lasers in labial
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2022:517-20.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 85
ORAL HEALTH POLICIES: PACIFIERS
Policy on Pacifiers
Adopted
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
encourages health care providers to follow evidence-based
literature to educate parents about the safe practices, benefits,
and risks of pacifier use by infants and children in order to
promote healthy growth andevelopment.
Methods
This policy, developed by the Council on Clinical Affairs, is
based on review of current dental and medical literature, in-
®
cluding a search of the PubMed /MEDLINE database using
the terms: pacifier AND emotional development, safety,
benefits, malocclusion, crossbite, open bite, fields: all; limits:
within the last 10 years, English. Five hundred forty-nine
articles met these criteria. Papers for review were chosen from
this list and from references within selected articles.
Background
Sucking behaviors in infants can be a natural reflex to satisfy
a physiological (i.e., nutritive) or psychological (i.e., non-
nutritive) need. The nonnutritive drive may be satisfied by
sucking a finger or thumb or an available object such as a
pacifier. Pacifier use is common among infants in the United
States (U.S.).1 Cultural background may play a role in pacifier
introduction.2 Considerations when counseling parents on
introducing pacifiers include safety and potential risks and
benefits of pacifier use. Although the American Academy of
Pediatrics (AAP) has recommended delaying pacifier use in
breastfed infants until breastfeeding is established to prevent
breastfeeding disruption,3 a recent Cochrane systematic review
found pacifier use, whether started from birth or after lactation,
did not affect the prevalence or duration of breastfeeding in
healthy, term infants up to four months of age4.
The controlled action of sucking promotes feelings of
security5 and allows infants to self-soothe5,6 and to initiate the
process of self-regulation6. Pacifiers may continue to provide
comfort in the toddler years. Cessation may be carried out
either through self-implementation or caregiver mediation.7 A
recent review found evidence that psychological interventions
such as positive and negative reinforcement effectively im-
prove nonnutritive sucking habits in children.7 Positive reward
for pacifier cessation (e.g., recognition or incentive for each
day of non-use) is preferable to negative reinforcement (e.g.,
criticism, restraint) which can inadvertently cause power
struggles and extend the duration of nonnutritive sucking
habits.6
86 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
pacifiers. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:86-9.
Risks of pacifier use
Practitioners can provide counseling and anticipatory guidance
regarding pacifier selection and safe usage to parents of infants
and children who utilize a pacifier. Pacifiers of single piece
construction are less likely to break apart and become a
choking hazard.8 For safety, AAP recommends a pacifier shield
be firm, have ventholes, and measure at least 1.5 inches across
(i.e., large enough not to pass completely into the mouth).8
Additionally, the U.S. Consumer Product Safety Commission
prohibits straps, cords, or attachments that could pose a
danger to infants or children.9 Regular inspection of the pacifier
by caregivers is recommended to evaluate for any structural
wear that poses a safety risk.8
Pacifier use is a risk factor for otitis media in infants and
children.10-14 The AAP suggests the incidence of acute otitis
media may be reduced by decreasing or eliminating use of a
pacifier in the second six months of life.15 Evidence linking
pacifier use to issues with speech development or speech delay
is limited.16,17 Recent research suggested that while prolonged
day-to-day pacifier use lasting several hours may have sig-
nificance with atypical speech errors, a strong speech-related
justification against pacifier use is not evident.18 The U.S.
Food and Drug Administration recommends that infants and
young children not be given pacifiers containing or dipped
in honey.19 Honey contains spores of a particular bacterium,
Clostridium botulinum, that produces a neurotoxin capable
of causing respiratory difficulty, paralysis, and even death.19
Recent cases of infant botulism in Texas were attributed to
commercially-available honey-filled pacifiers.19
Pacifiers can serve as a reservoir for microbes, and their use
is linked to oral yeast infections.14,20 Sterilization/disinfection,
either by boiling in water for 15 minutes or preferably spray-
ing an anti-microbial agent (e.g., 0.12 percent chlorhexidine),
can minimize and eliminate microbes such as Staphylococcus,
Candida albicans, and Streptococcus mutans.16,21,22
Children using a pacifier 36 months or longer had a
significantly higher incidence of anterior open bite compared
to those not using a pacifier.12,23-32 Pacifier usage beyond one
year also leads to a significantly higher incidence of anterior
open bite,15 although an anterior open bite will improve after
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
of Pediatric Dentistry. SIDS: Sudden infant death syndrome. U.S.:
United States.

elimination of the pacifier before age three.31-33 In addition,
increased pacifier use leads to posterior crossbite,12,26-31,34,35
including crossbite with midline deviation.36-39 A prospective
study examining pacifier use beyond age four concluded the
transverse occlusal relationship should be evaluated before
three years of age.33 To limit the development of a posterior
crossbite, discontinuing or limiting pacifier use when canines
emerge38 (approximately 18 months of age)36 has been recom-
mended.33 Malocclusion was affected by duration more than
frequency,35,39 and the percentage of open bite was significant-
ly greater as the duration of nonnutritive sucking continued
beyond three years of age34. Increased overjet and a Class II
malocclusion are more strongly associated with a finger habit
versus a pacifier habit.33,39
A systematic review noted orthodontic pacifiers induce
less open bite compared to conventional pacifiers.29 While
one study30 showed conventional pacifiers use exhibited higher
odds of posterior crossbite and anterior open bite compared
to orthodontic pacifiers, another28 found pacifier usage had
a significantly higher incidence of posterior crossbite versus
non-habit children although the difference between pacifier
types with regards to posterior crossbite was not significant.
A prospective study introduced a pacifier with a thin-neck to
children (average age 20 months) who had a diagnosed anterior
open bite and already used a conventional pacifier; the study
group was compared to not only the original pacifier group
but also to children not using any pacifier for at least three
months.40 A significant difference (P< 0.001) regarding overbite
and overjet changes between pacifier groups was reported
(i.e., the thin-neck pacifier resulted in less increase in the
overbite and open bite compared to the conventional pacifier);
however, no improvement in either pacifier group compared
to cessation of pacifier use was found.40 Two reviews compar-
ing orthodontic versus conventional pacifiers stated evidence
was insufficient to support a preference for orthodontic paci-
fiers preventing malocclusions.41,42
The pacifier design (orthodontic, conventional, or physio-
logic) and shield design (conventional or flare) have implica-
tions for the use and function of different brand pacifiers.
Pacifiers interact with the palate differently based on their fit
(i.e., design and size) regardless of whether they are labeled
conventional or orthodontic.43 Pacifier sizing has been brought
into focus for the role it plays in providing palatal support
to prevent loss of transverse palatal dimensions and causing
palatal collapse.30,31,43-45 Palatal collapse contributes to the early
development of posterior crossbites.29,45,46 The use of biometrics
to aid pacifier selection has shown promise in recent research.47,48
Benefits of pacifiers use
Based on good-quality patient-oriented evidence, the AAP
recommends offering a pacifier when an infant is placed to
sleep due to its protective effect on the incidence of sudden
infant death syndrome (SIDS), but a pacifier should not be
forced on resistant infants.49 This recommendation is sup-
ported by other organizations such as the International Society
ORAL HEALTH POLICIES: PACIFIERS
for the Study and Prevention of Perinatal and Infant Death50
®
and the Safe to Sleep campaign of the United States Depart-
ment of Health and Human Services51.
Pacifier use may be beneficial when mothers cannot
breast feed due to medication or severe illness, if infants need
early oral stimulation to develop or maintain the sucking re-
flex, or in neonatal intensive care environments when infants
need calming, pain relief, or decreased stress.52 The benefits of
pacifier use also include adjunctive pain relief in newborns
and infants undergoing common, minor procedures in the
emergency department and reducing the likelihood of a
digit-sucking habit.1,12,16,53-55 Children who started using an
orthodontic pacifier before four months old had a lower risk of
developing a finger/thumb sucking habit compared to children
who began after four months.56 Because forced early cessation
of pacifier usage has been associated with prolonged finger
sucking, allowing the habit to continue beyond 14 months of
age may help prevent a persistent finger habit.57
Policy statement
The AAPD supports parents in the decision to introduce a
pacifier based on their infant’s needs and parental preference.
During the first few months of life, pacifiers may be beneficial
in helping premature infants develop the sucking reflex, offer-
ing comfort and soothing, providing an analgesic effect during
minor invasive procedures, decreasing the incidence of SIDS,
and preventing a persistent finger-sucking habit. However, a
prolonged pacifier habit after 12 months of age can increase
the risk of acute otitis media. Pacifier use beyond 18 months
can influence the developing orofacial complex, leading to
anterior open bite, posterior crossbite, and Class II malocclu-
sion. Understanding the safety, benefits, and risks is critical to
counseling parents on the use of pacifiers.
The AAPD encourages additional research regarding the
biometrics for pacifier selection to minimize disturbances of
the developing orofacial complex.
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 89
ORAL HEALTH POLICIES: ECC: CONSEQUENCES & PREVENTIVE STRATEGIES
Policy on Early Childhood Caries (ECC): Consequences
and Preventive Strategies
Latest Revision
2021
Purpose
Early childhood caries (ECC), formerly referred to as nursing
bottle caries and baby bottle tooth decay, remains a significant
chronic disease of childhood and public health problem.1 The
American Academy of Pediatric Dentistry (AAPD) encourages
healthcare providers and caregivers to implement preventive
practices that can decrease a child’s risks of developing this
preventable disease to reduce the burden on the child, the
family, and society.
Methods
This policy was developed in a collaborative effort of the
American Academy of Pedodontics and the American
Academy of Pediatrics (AAP) and adopted in 1978.2 This
document is a revision of the previous version, last revised by
the AAPD in 2016.3 The update used electronic and hand
searches of English written articles in the dental and medical
literature within the last 14 years, using the search terms infant
oral health, infant oral health care, early childhood caries,
early childhood caries AND oral microbiome, ECC AND oral
microbiome, early childhood caries AND prevention, ECC
AND prevention. More than 8000 articles were identified in
the search. When information from these articles did not
appear sufficient or was inconclusive, policies were based
upon expert and consensus opinion by experienced researchers
and clinicians.
Background
In 1978, the American Academy of Pedodontics and the AAP
released a joint statement Nursing Bottle Caries to address a
severe form of caries associated with bottle usage.2 Initial
policy recommendations were limited to feeding habits, con-
cluding that nursing bottle caries could be avoided if bottle
feedings were discontinued soon after the first birthday. An
early policy revision added ad libitum breastfeeding as a
causative factor. Over the next two decades, however, recog-
nizing that ECC was not solely associated with poor feeding
practices, AAPD adopted the term ECC to better reflect its
multifactorial etiology. These factors include susceptible teeth
due to enamel hypoplasia, oral colonization with elevated
levels of cariogenic bacteria (especially Mutans streptococci
[MS]), and the metabolism of sugars by tooth-adherent
bacteria to produce acid which, over time, demineralizes tooth
structure.4
90 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
early childhood caries (ECC): Consequences and preventive strategies.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:90-3.
ECC is defined as “the presence of one or more decayed
(noncavitated or cavitated lesions), missing (due to caries),
or filled tooth surfaces in any primary tooth”5 in a child
under the age of six. The definition of severe early childhood
caries (S-ECC) is 1) any sign of smooth-surface caries in a
child younger than three years of age, 2) from ages three
through five, one or more cavitated, missing (due to caries),
or filled smooth surfaces in primary maxillary anterior teeth,
or 3) a decayed, missing, or filled score of greater than or
equal to four (age three), greater than or equal to five (age
four), or greater than or equal to six (age five).5
Epidemiologic data from a 2011-2012 national survey clearly
indicate that ECC remains highly prevalent in poor and near-
poor United States (U.S.) preschool children.6 For the overall
population of preschool children, the prevalence of ECC,
as measured by decayed and filled tooth surfaces (dfs), is
unchanged from previous surveys, but the filled component
(fs) has greatly increased indicating that more treatment
is being provided.6 The consequences of ECC often include a
higher risk of new caries lesions in both the primary and
permanent dentitions7,8, hospitalizations and emergency room
visits9,10, high treatment costs11, loss of school days12, diminished
ability to learn13, and diminished oral health-related quality of
life14.
Traditional microbial risk markers for ECC include acido-
genic-aciduric bacterial species, namely MS and Lactobacillus
species.15 Studies using direct culture with arbitrarily primed
polymerase chain reaction (AP-PCR) fingerprinting and other
traditional techniques have shown that MS maybe transmit-
ted vertically from parent or caregiver to child and horizontally
from other individuals in his immediate environment.16,17
Newer technologies that sequence DNA and RNA in a rapid
and cost-effective manner, known as high-throughput or new-
generation sequencing (e.g. polymerase chain reaction, rRNA
gene sequencing), reveal the complexity of the oral microbiome
and have highlighted other bacterial species (e.g., Scardovia
wiggsiae, Veillonella ssp.) and fungi (e.g., Candida albicans)
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. AAP: American
Academy of Pediatrics. CWF: Community water fluoridation. ECC:
Early childhood caries. mg: Milligram. MS: Mutans streptococci.
U.S.: United States.

that also may be associated with ECC.18-20 Recent studies on
the development of the oral microbiome since birth continue
to support the concept of vertical and horizontal transmission
as well as the importance of diet and environmental expo-
sures.21,22 Parental education and counseling on the importance
of a healthy microbiome and diet in infancy should be con-
ducted as early as possible.
An associated risk factor to microbial etiology is high
consumption of sugars.23 Nighttime bottle feeding with juice,
repeated use of a sippy or no-spill cup, and frequent in-
between meal consumption of sugar-added snacks or drinks
(e.g., juice, formula, soda) increase the risk of caries.24 Although
there are clear benefits of breastfeeding in a child’s first year
of life25, breastfeeding and baby bottle use beyond 12 months,
especially if frequent and/or nocturnal, are associated with
ECC. 26 The American Heart Association recommends that
sugar in foods and drink should be avoided in children under
two years of age.27 Additionally, the American Academy of
Pediatrics recommends that 100 percent fruit a day for children
between the ages of one and three.28,29
Community water fluoridation (CWF) as a primary preven-
tion method is considered a key strategy for preventing dental
caries.29 Children with lifetime exposure to CWF show signi-
ficantly lower dental caries levels than those without, with the
benefit being most pronounced in primary teeth.30 In addition
to reducing the prevalence of severe caries, the use of CWF in
high-risk populations may reduce caries-related visits and help
avoid preventable dental surgery under general anesthesia. 31
CWF has multiple benefits and attenuates income-related in-
equalities in dental caries in the U.S.32 Apart from an increased
incidence of enamel fluorosis, the literature fails to provide
credible evidence linking CWF with negative health outcome.33
Current best practice to reduce the risk of ECC includes
twice-daily brushing with fluoridated toothpaste for all chil-
dren in optimally-fluoridated and fluoride-deficient commu-
nities.34-36 When determining the risk-benefit of fluoride, the
key issue is mild fluorosis versus preventing dental disease.
A smear or rice-sized amount of fluoridated toothpaste (ap-
proximately 0.1 milligram [mg] fluoride; see Figure) should be
used for children younger than three years of age. A pea-sized
amount of fluoridated toothpaste (approximately 0.25 mg
fluoride) is appropriate for children aged three to six.37 Parents
should dispense the toothpaste onto a soft, age-appropriate
Smear – under 3 yrs. Pea-sized – 3 to 6 yrs.
Figure. Comparison of a smear (left) with a pea-sized (right) amount
of toothpaste.
ORAL HEALTH POLICIES: ECC: CONSEQUENCES & PREVENTIVE STRATEGIES
sized toothbrush and perform or assist with toothbrushing of
preschool-aged children. To maximize the beneficial effect of
fluoride in the toothpaste, rinsing after brushing should be
kept to a minimum or eliminated altogether.38 Less than twice
daily tooth-brushing and difficulties in performing the proce-
dure during the preschool years were significant determinants
of caries prevalence at the age of five years.36
Professionally-applied topical fluoride treatments also are
efficacious in reducing prevalence of ECC. The recommended
professionally-applied fluoride treatment for children at risk
for ECC who are younger than six years is five percent sodium
fluoride varnish (NaFV; 22,500 parts per million F).39.40
Additionally, the use of 38 percent silver diamine fluoride
(SDF) is effective for the arrest of cavitated caries lesions in
primary teeth.41,42 Evidence suggests that preventive interven-
tions within the first year of life are critical.43 For this reason,
establishment of a dental home within six months of the
eruption of the first tooth and no later than 12 months of age
is especially important in populations at risk. This may be
best implemented with the help of medical providers who,
in many cases, are being trained to provide oral screenings,
apply preventive measures, counsel caregivers, and refer infants
and toddlers for dental care.44
Policy statement
The AAPD recognizes early childhood caries as a significant
chronic disease resulting from an imbalance of multiple risk
and protective factors over time. To decrease the risk of devel-
oping ECC, the AAPD encourages professional and at-home
preventive measures that provide evidence-based prevention of
ECC such as:
1. establishing a dental home within six months of eruption
of the first tooth and no later than 12 months of age to
conduct caries risk assessment, parental education, and
anticipatory guidance.
2. modifying diets to avoid frequent consumption of liquids
and/or solid foods containing sugar45, and
• eliminating baby bottle- and breastfeeding beyond
12 months, especially if frequent or nocturnal.
• encouraging children between six and 12 months old
to drink four to six ounces of water per day.46
• avoiding sugar in foods and drink in children under
two years of age.45
• abstaining from 100 percent fruit juice before 12
months of age.
• limiting juice to no more than four ounces a day for
children between the ages of one and three years.
3. implementing early oral hygiene measures no later than
the time of eruption of the first primary tooth. Tooth-
brushing should be performed for children by a parent
twice daily, using a soft toothbrush of age-appropriate
size. In children under the age of three years, a smear or
rice-sized amount of fluoridated toothpaste should be
used. In children ages three to six years, a pea-sized
amount of fluoridated toothpaste should be used.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 91
ORAL HEALTH POLICIES: ECC: CONSEQUENCES & PREVENTIVE STRATEGIES
4. providing professionally-applied fluoride varnish
treatments for children at risk for ECC.
5. supporting CWF as a primary prevention for dental caries
to reach underserved and vulnerable communities.
6. working with medical providers to ensure all infants and
toddlers have access to dental screenings, counseling, and
preventive procedures with a consistent unified message.
7. educating legislators, policy makers, and third-party
payors regarding the consequences of and preventive
strategies for ECC, emphasizing the importance of access
to care for all.
8. raising awareness of ECC with parents and oral health
and medical professionals.
9. advocating for reimbursement systems to allow access
for all children and educational reforms that emphasize
evidence-based preventive and comprehensive manage-
ment of ECC.
References
1. American Academy of Pediatric Dentistry. Proceedings
of the conference: Innovations in the Prevention and
Management of Early Childhood Caries. October, 2014.
Chicago, Ill. Pediatr Dent 2015;37(3):198-299.
2. American Academy of Pedodontics, American Academy of
Pediatrics. Nursing bottle caries. January, 1978. Reference
Manual 1991-1992. Chicago, Ill.: American Academy of
Pediatric Dentistry; 1991:27.
3. American Academy of Pediatric Dentistry. Policy on early
childhood caries (ECC): Classifications, consequences,
and preventive strategies. Pediatr Dent 2016;38(special
issue):52-4.
4. Tinanoff N. Introduction to the conference: Innovations
in the Prevention and Management of Early Childhood
Caries. Pediatr Dent 2015;37(4):198-9.
5. Drury TF, Horowitz AM, Ismail AI, et al. Diagnosing and
reporting early childhood caries for research purposes. J
Public Health Dent 1999;59(3):192-7.
6. Dye BA, Hsu K-L, Afful J. Prevalence and measurement
of dental caries in young children. Pediatr Dent 2015;
37(3):200-16.
7. O’Sullivan DM, Tinanoff N. The association of early child-
hood caries patterns with caries incidence in preschool
children. J Public Health Dent 1996;56(2):81-3.
8. Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor
decay before age 4 as a risk factor for future dental caries.
Pediatr Dent 1997;19(1):37-41.
9. Ladrillo TE, Hobdell MH, Caviness C. Increasing pre-
valence of emergency department visits for pediatric dental
care 1997-2001. J Am Dent Assoc 2006;137(3):379-85.
10. Griffin SO, Gooch BF, Beltran E, Sutherland JN, Barsley
R. Dental services, costs, and factors associated with
hospitalization for Medicaid-eligible children, Louisiana
1996-97. J Public Health Dent 2000;60(3):21-7.
92 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
11. Griffin SO, Barker LK, Wei L, Li C-H, Albuquerque MS,
Gooch BF. Use of dental care and effective preventive
services in preventing tooth decay among U.S. children
and adolescents — Medical Expenditure Panel Survey,
United States, 2003–2009 and National Health and Nu-
trition Examination Survey, United States, 2005–2010.
MMWR Suppl 2014;63(2):54-60. Available at: “https:
//www.cdc.gov/mmwr/preview/mmwrhtml/su6302a9.
htm?s_cid=su6302a9_w”. Accessed March 17, 2021.
12. Edelstein BL, Reisine S. Fifty-one million: A mythical
number that matters. J Am Dent Assoc 2015;146(8):565-6.
13. Blumenshine SL, Vann WF, Gizlice Z, Lee JY. Children’s
school performance: Impact of general and oral health. J
Public Health Dent 2008;68(2):82-7.
14. Filstrup SL, Briskie D, daFonseca M, Lawrence L, Wandera
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.
15. Kanasi E, Johansson J, Lu SC, et al. Microbial risk
markers for childhood caries in pediatrician’s offices. J
Dent Res 2010;89(4):378-83.
16. Doméjean S, Zhan L, DenBesten PK, Stamper J, Boyce
WT, Featherstone JD. Horizontal transmission of mutans
streptococci in children. J Dent Res 2010;89(1):51-5.
17. Berkowitz RJ. Mutans streptococci: Acquisition and
transmission. Pediatr Dent 2006;28(2):106-9.
18. Li Y, Tanner A. Effect of antimicrobial interactions on
the oral microbiota associated with early childhood caries.
Pediatr Dent 2015;37(3):226-44.
19. Hahishengallis E, Parsaei Y, Klein MI, Koo H. Advances in
the microbial etiology and pathogenesis of early childhood
caries. Mol Oral Microbiol 2017;32(1):24-34.
20. Mira A. Oral microbiome studies: Potential diagnostic and
therapeutic implications. Adv Dent Res 2018;29(1):71-7.
21. Dashper SG, Mitchel HL, Lê Cao KA, et al. Temporal
development of the oral microbiome and prediction of
early childhood caries. Sci Rep 2019;9(1):19732. Available
at: “https://doi.org/10.1038/s41598-019-56233-0”.
Accessed September 8, 2020.
22. Dzidic M, Collado MC, Abrahamsson T, et al. Oral mi-
crobiome development during childhood: An ecological
succession influenced by postnatal factors and associated
with tooth decay. ISME J 2018;12(9):2292-306. Available
at: “https://doi.org/10.1038/s41396-018-0204-z”. Accessed
September 8, 2020.
23. Moynihan PJ, Kelly SAM. Effect on caries of restricting
sugars intake: Systematic review to inform WHO guide-
lines. J Dent Res 2014;93(1):8-18.
24. Tinanoff NT, Kanellis MJ, Vargas CM. Current under-
standing of the epidemiology, mechanism, and prevention
of dental caries in preschool children. Pediatr Dent 2002;
24(6):543-51.

25. Salone LR, Vann WF, Dee DL. Breastfeeding: An over-
view of oral and general health benefits. J Am Dent Assoc
2013;144(2):143-51.
26. Peres KG, Chaffee BW, Feldens CA. Breastfeeding and oral
health: Evidence and methodological challenges. J Dent
Res 2018;97(3):251-8.
27. Voss MB, Kaar JL, Welsh JA, et al. Added sugars and
cardiovascular disease risk in children: American Heart
Association. Circulation 2017;135(19):e1017-e1034.
28. Heyman MB, Abrams SA, American Academy of
Pediatrics Committee on Nutrition. Fruit juice in infants,
children, and adolescents: Current recommendations.
Pediatrics 2017;139(6):e20170967.
29. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water
fluoridation for the prevention of dental caries. Cochrane
Database Syst Rev 2015;2015(6):CD010856. Available
at: “https://doi.org/10.1002/14651858.CD010856.pub2”.
Accessed October 18, 2021.
30. Slade GD, Grider WB, Maas WR, Sanders AE. Water
fluoridation and dental caries in U.S. children and adoles-
cents. J Dent Res 2018;97(10):1122-8.
31. Lee HH, Faundez MA, LoSasso AT. A cross-sectional
analysis of community water fluoridation and prevalence
of pediatric dental surgery among Medicaid enrollees.
JAMA Network Open 2020;3(8):e205882. Available at:
“https://jamanetwork.com/journals/jamanetworkopen/
article-abstract/2769230”. Accessed November 11, 2020.
32. Sanders AE, Grider WB, Mass WR, Curiel JA, Slade GD.
Association between water fluoridation and income-
related dental caries of U.S. children and adolescents.
JAMA Pediatr 2019;173(3):288-90.
33. Centers for Disease Control and Prevention. Community
Water Fluoridation: 75 years of community water fluo-
ridation. Division of Oral Health National Center of
Chronic Disease Prevention and Health Promotion. January
2020. Available at: “www.cdc.gov/fluoridation/basics/
anniversary.htm”. Accessed March 23, 2021.
34. Santos AP, Oliveira BH, Nadanovsky P. Effects of low
and standard fluoride toothpastes on caries and fluorosis:
Systematic review and meta-analysis. Caries Res 2013;47
(5):382-90.
35. American Dental Association Council on Scientific Affairs.
Fluoride toothpaste use for young children. J Am Dent
Assoc 2014;145(2):190-1.
36. Boustedt K, Dahlgren J, Twetman S, Roswall J. Tooth-
brushing habits and prevalence of early childhood caries:
A prospective cohort study. Eur Arch Paediatr Dent 2020;
21(1):155-9.
ORAL HEALTH POLICIES: ECC: CONSEQUENCES & PREVENTIVE STRATEGIES
37. Wright JT, Hanson N, Ristic H, Whall CW, Estrich CG,
Zentz RR. Fluoride toothpaste efficacy and safety in
children younger than 6 years. J Am Dent Assoc 2014;
145(2):182-9.
38. Sjögren K, Birkhed D. Factors related to fluoride retention
after toothbrushing and possible connection to caries
activity. Caries Res 1993;27(6):474-7.
39. Weyant RJ, Tracy SL, Anselmo T, Beltrán-Aguilar
EJ, Donly KJ, Frese WA. Topical fluoride for caries
prevention: Executive summary of the updated clinical
recommendations and supporting systematic review. J
Am Dent Assoc 2013;144(11):1279-91.
40. American Academy of Pediatric Dentistry. Fluoride ther-
apy. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2020:
288-91. Available at: “https://www.aapd.org/globalassets/
media/policies_guidelines/bp_fluoridetherapy.196 pdf ”.
Accessed March 23, 2021.
41. Gao SS, Zhao IS, Hiraishi N, et al. Clinical trials of SDF
in arresting caries among children: A systematic review.
JDR Clin Trans Res 2016;1(3):201-10.
42. Crystal YO, Marghalani Abdullah AA, Ureles SD, et al.
Use of SDF for dental caries management in children
and adolescents, including those with special health care
needs. Pediatr Dent 2017;39(5):135E-145E.
43. Lee JY, Bouwens TJ, Savage MF, Vann WF. Examining
the cost-effectiveness of early dental visits. Pediatr Dent
2006;28(2):102-5, discussion 192-8.
44. Douglass AB, Douglass JM, Krol DM. Educating pedi-
atricians and family physicians in children’s oral health.
Academic Pediatr 2009;9(6):452-6.
45. Centers for Disease Control and Prevention. Nutrition.
Infant and toddler nutrition. Food and drinks for 6 to
24 months old. Food and drinks to limit. Available at:
“https://www.cdc.gov/nutrition/infantandtoddlernutrition/
foods-and-drinks/foods-and-drinks-to-limit.html”. Accessed
June 29, 2021.
46. Centers for Disease Control and Prevention. Nutrition.
Infant and toddler nutrition. Food and drinks for 6 to 24
months old. Food and drinks to encourage. November
6, 2020. Available at: “https://www.cdc.gov/nutrition/
infantandtoddlernutrition/foods-and-drinks/foods-and-
drinks-to-encourage.html”. Accessed June 29, 2021.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 93
ORAL HEALTH POLICIES: ECC: UNIQUE CHALLENGES, TREATMENT OPTIONS
Policy on Early Childhood Caries (ECC): Unique
Challenges and Treatment Options
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD), to
promote appropriate, quality oral health care for infants and
children with early childhood caries (ECC), must educate
the health community and society about the unique chal-
lenges and management of this disease, including the need
for advanced preventive, restorative, and behavioral guidance
techniques.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2000.1 This document is a revision of the
previous version, last revised in 2016.2 Electronic and hand
searches of English written articles in the dental and medical
literature within the last 10 years were conducted using the
search terms infant oral health, infant oral health care, and
early childhood caries. When information from these articles
did not appear sufficient or was inconclusive, policies were
based upon expert and/or consensus opinion by experienced
researchers and clinicians.
Background
Epidemiologic data from a 2011-2012 national survey clearly
indicate that ECC remains highly prevalent in poor and near
poor United States preschool children.3 For the overall popula-
tion of preschool children, the prevalence of ECC, as measured
by decayed and filled tooth surfaces (dfs), is unchanged from
previous surveys, but the filled component (fs) has greatly
increased, indicating that more treatment is being provided.3
The consequences of ECC often include a higher risk of new
caries lesions in both the primary and permanent dentitions4,5,
hospitalizations and emergency room visits6,7, high treatment
costs8, loss of school days9, diminished ability to learn10, and
reduced oral health-related quality of life11.
Because restorative care to manage ECC in young chidren
often requires the use of sedation and general anesthesia
with its associated high costs and possible health risks,12
and because there is high recurrence of lesions following the
procedures,13 more emphasis now is placed on prevention
and arrestment of the disease processes. Approaches include
methods that have been referred to as 1) chronic disease
management in combination with 2) active surveillance and
3) minimal intervention.
Chronic disease management includes parent engagement to
facilitate and promote preventive measures while encouraging
the identification and reduction of individual risk factors. The
94 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
early childhood caries (ECC): Unique challenges and treatment
options. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:94-5.
aim is to sustain oral health in the long term.14,15 Active
surveillance emphasizes careful monitoring of caries progres-
sion and prevention programs (e.g., frequent fluoride varnish
applications) in children with incipient lesions.16,17 Minimal
intervention approaches includes caries arrest with silver
diamine fluoride18, interim therapeutic restorations (ITR)19
that temporarily restore teeth in young children until a time
when traditional cavity preparation and restoration is possible,
and the use of Hall-style crowns20.
Children with known risk factors for ECC should have
care provided by a practitioner who has the training and
expertise to manage both the child and the disease process.
The use of anticariogenic agents, especially twice daily brush-
ing with fluoridated toothpaste and the frequent application
of fluoride varnish, may reduce the risk of development and
progression of caries. In some children for whom preventive
programs are not successful, areas of demineralization and
hypoplasia can rapidly develop cavitation and, if untreated,
the disease process can rapidly involve the dental pulp, lead-
ing to infection and possibly life-threatening fascial space
involvement. Such infections may result in a medical emer-
gency requiring hospitalization, antibiotics, and extraction of
the offending tooth.21 The extent of the disease process as well
as the patient’s developmental level and comprehension skills
affect the practitioner’s management decisions. The establish-
ment of a dental home22 when the first tooth erupts is
imperative to be able to implement preventive and early
intervention treatments before advanced disease becomes
established. Definitive restorative treatment in young children,
in many cases, can be postponed by use of ITR or silver
diamine fluoride treatments.23 For advanced cases of ECC, the
practitioner may need the aid of advanced behavior guidance
techniques24 to complete the necessary treatment. Also in
such situations, stainless steel crowns often are indicated to
restore teeth with large caries lesions, interproximal lesions, and
extensive white spot lesions since stainless steel crowns are less
likely than other restorations to require retreatment.25 The
success of restorations may be influenced by the child’s level
of cooperation during treatment, and general anesthesia may
provide better conditions to perform restorative procedures.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ECC: Early childhood
caries. ITR: Interim therapeutic restorations.

Policy statement
The AAPD recognizes the unique and often virulent nature of
ECC. Nondental healthcare providers who identify ECC in a
child should refer the patient to a dentist for treatment and
establishment of a dental home.22 Immediate intervention is
indicated, and nonsurgical interventions should be imple-
mented when possible to postpone or reduce the need for
surgical treatment approaches. Because children who experience
ECC are at greater risk for subsequent caries development,
preventive measures (e.g., dietary counseling, reinforcement of
toothbrushing with fluoridated toothpaste), more frequent
professional visits with applications of topical fluoride, and
restorative care are necessary.
References
1. American Academy of Pediatric Dentistry. Policy on early
childhood caries: Unique challenges and treatment options.
Pediatr Dent 2000;22(suppl):21.
2. American Academy of Pediatric Dentistry. Policy on early
childhood caries: Unique challenges and treatment options.
Pediatr Dent 2016;38(special issue):55-6.
3. Dye BA, Hsu K-L, Afful J. Prevalence and measurement of
dental caries in young children. Pediatr Dent 2015;37(3):
200-16.
4. O’Sullivan DM, Tinanoff N. The association of early
childhood caries patterns with caries incidence in pre-school
children. J Public Health Dent 1996;56(2):81-3.
5. Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor
decay before age 4 as a risk factor for future dental caries.
Pediatr Dent 1997;19(1):37-41.
6. Griffin SO, Gooch BF, Beltrán E, Sutherland JN, Barsley R.
Dental services, costs, and factors associated with hospital-
ization for Medicaid-eligible children, Louisiana 1996-97.
J Public Health Dent 2000;60(3):21-7.
7. Ladrillo TE, Hobdell MH, Caviness C. Increasing preva-
lence of emergency department visits for pediatric dental
care 1997-2001. J Am Dent Assoc 2006;137(3):379-85.
8. Agency for Healthcare Research and Quality. Total dental
care expenditure, 2010, Medical Expenditure Panel Survey.
Available at: “http://meps.ahrq.gov/mepsweb/data_files/
publications/st415/stat415.pdf ”. Accessed August 24, 2020.
9. Edelstein BL, Reisine S. Fifty-one million: A mythical
number that matters. J Am Dent Assoc 2015;146(8):565-6.
10. Blumenshine SL, Vann WF, Gizlice Z, Lee JY. Children’s
school performance: Impact of general and oral health. J
Public Health Dent 2008;68(2):82-7.
11. Filstrup SL, Briskie D, daFonseca M, Lawrence L, Wandera
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.
12. Sinner B, Beck K, Engelhard K. General anesthetics and
the developing brain: An overview. Anesthesia 2014;69(9):
1009-22.
13. Berkowitz RJ, Amante A, Kopycka-Kedzierawski DT,
Billings RJ, Feng C. Dental caries recurrence following
clinical treatment for severe early childhood caries. Pediatr
Dent 2011;33(7):510-4.
ORAL HEALTH POLICIES: ECC: UNIQUE CHALLENGES, TREATMENT OPTIONS
14. Edelstein BL, Ng MW. Chronic disease management
strategies of early childhood caries: Support from the med-
ical and dental literature. Pediatr Dent 2015;37(7):281-7.
15. Featherstone JDB, Crystal YO, Alston P, et al. Evidence-
based caries management for all ages – Practical guidelines.
Front Oral Health 2021;2(657518):1-19. Available at:
“https://doi.org/10.3389/froh.2021.657518”. Accessed
October 18, 2021.
16. American Academy of Pediatric Dentistry. Caries-risk
assessment and management for infants, children, and ad-
olescents. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:252-7. Available at: “https://www.aapd.org/research
/oral-health-policies--recommendations/caries-risk-
assessment-and-management-for-infants-children-and-
adolescents/”. Accessed March 18, 2021.
17. Weintraub JA, Ramos-Gomez F, Jue B, et al. Fluoride
varnish efficacy in preventing early childhood caries. J
Dent Res 2006;85(2):172-6.
18. 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.
19. American Academy of Pediatric Dentistry. Policy on
interim therapeutic restorations (ITR). The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2021:74-5. Available at:
“https://www.aapd.org/media/policies_guidelines/p_itr.pdf ”.
Accessed March 18, 2021.
20. Crystal YO, Janal M, Kim S, Nelson T. Teaching and
utilization of SDF and Hall-style crowns in U.S. pediatric
dental programs. J Am Dent Assoc 2020;151(10):755-63.
21. Sheller B, Williams BJ, Lombardi SM. Diagnosis and
treatment of dental caries-related emergencies in a children’s
hospital. Pediatr Dent 1997;19(8):470-5.
22. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:43-4. Available at: “https://www.aapd.org/global
assets/media/policies_guidelines/p_dentalhome.pdf ”.
Accessed June 22, 2021.
23. Crystal YO, Niederman R. Silver diamine fluoride treat-
ment considerations in children’s caries management.
Pediatr Dent 2016;38(7):466-71.
24. American Academy of Pediatric Dentistry. Behavior guid-
ance for the pediatric dental patient. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy
of Pediatric Dentistry; 2021:306-24. Available at: “https:
/ / w w w. a a p d . o r g / r e s e a r c h / o r a l - h e a l t h - p o l i c i e s - -
recommendations/behavior-guidance-for-the-pediatric
-dental-patient/”. Accessed March 18, 2021.
25. Azadani EN, Peng J, Kumar A, et al. A survival analysis of
primary second molars in children treated under general
anesthesia. J Am Dent Assoc 2020;151(8):568-75.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 95
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
Policy on Dietary Recommendations for Infants,
Children, and Adolescents
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes its role in promoting well-balanced, low caries-risk,
and nutrient-dense diets for infants, children, adolescents,
and persons with special health care needs. A healthy diet is
essential to optimal growth and development and prevention
of chronic diet-related diseases such as caries, obesity, and
cardiovascular disease.
Methods
This policy was developed by the Clinical Affairs Committee,
adopted in 19931, and last revised in 20172. This revision is
based upon a review of current dental and medical literature,
®
including a search of the PubMed /MEDLINE database using
the terms: childhood, obesity, dental caries, diet, nutrition,
health education, breastfeeding, food habits, dietary guidelines,
sugar, sugar-sweetened beverages, and body mass index; fields:
all; limits: within the last 10 years, humans, English, clinical
trials, and ages birth through 18. Papers for review were chosen
from the resultant lists and from hand searches. Expert and
consensus opinions by experienced researchers and clinicians,
including recommendations3 developed through a collaboration
of the Academy of Nutrition and Dietetics (AND), the AAPD,
the American Academy of Pediatrics (AAP), and the American
Heart Association (AHA) under the leadership of Healthy
Eating Research, also were considered.
Background
A healthy diet in early childhood is essential to supporting
optimal growth and development and preventing chronic diet-
related diseases. Experts across health care disciplines recognize
the importance of breastfeeding during infancy.3,4 Human
milk and breastfeeding of infants provide general health,
nutritional, developmental, psychological, social, economic, and
environmental advantages while significantly decreasing risk for a
large number of acute and chronic diseases.5 A systematic review
of cariogenic potential of milk and infant formulas in animal
models found that cow’s milk and human milk are less cariogenic
than sucrose solutions.6 Another systematic review concluded
that children exposed to long durations of breastfeeding up to
age 12 months had reduced risk of caries.7 However, children
breastfed more than 12 months had an increased risk of caries,
and those children breastfed nocturnally or more frequently
had a further increased caries risk.7
96 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
dietary recommendations for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:96-100.
The causes of dental caries and obesity are multifactorial,
with both having significant dietary components. Beverages
contribute significantly to the early diet. A 2019 consensus
statement, Healthy Beverage Consumption in Early Childhood:
Recommendations from Key National Health and Nutrition
Organizations, was developed through a collaboration of AND,
AAPD, AAP, and AHA under the leadership of Healthy Eating
Research, a nutrition research organization.3,4 These organiza-
tions recommend breast milk, infant formula, water, and plain
milk for children under age five.3 They suggest that plain
(i.e., not flavored, sweetened, or carbonated) fluoridated water
should be introduced beginning at six months of age for
children who have started solid foods to familiarize the child
with water as well as with drinking from a cup; the volume
of water offered is based on the intake of other recommended
beverages.3,4 Drinking fluoridated water is a safe and effective
method of reducing caries.8 Fluoridated water is preferred
beverage for children one to five years of age when consumed
outside of meals or snacks.4 The consensus statement cautioned
against beverages that are sources of added sugars, including
flavored milks (e.g., chocolate, strawberry), or contain low-
calorie sweeteners (LCS).3 Because the long-term health effects
of consumption of LCS by children is unknown,4 the
statement recommended against consumption of LCS through
age five.3 In addition, it advised against a wide variety of new
beverages on the market targeted to children (e.g., toddler
formulas) and caffeinated beverages.3 Plant-based/non-dairy
milks (e.g., almond, rice, oat) were noted to provide no
unique nutritional value, but unsweetened varieties may be
useful when medically indicated (e.g., allergy or intolerance
to cow’s milk) or to meet specific dietary preferences (e.g.,
vegan).3,4
Food and flavor preferences may be established during the
early years.4,9 Establishing health dietary patterns during the
first two years of life can have lifelong health benefits.9 The
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
Pediatric Dentistry. AND: Academy of Nutrition and Dietetics. AHA:
American Heart Association. BMI: Body mass index. LCS: Low-calorie
sweetners. NHANES: National Health and Nutrition Examination
Survey. SCB: Sugar-containing beverages. SSBs: Sugar-sweetened
beverages. U.S.: United States. USDA: United States Department
of Agriculture.

AHA recommends that children less than two years of age
avoid added sugars in their diets.10 Sugar-sweetened beverages
(SSB) include any liquid (e.g., regular soda, fruit drinks,
sports drinks, tea and coffee drinks, energy drinks) with added
sugar (e.g., fructose, corn syrup, sucrose [table sugar]).11 A
longitudinal study found introduction of SSB before age one
was associated with obesity at age six.12 Sugar-containing bev-
erages (SCB) include SSB as well as beverages in which sugar,
generally glucose or fructose, is naturally present, such as 100
percent fruit juice. In 2017, the AAP reaffirmed that 100 per-
cent juice and juice drinks have no essential role in a healthy
diet for children and contribute to excessive calorie intake and
risk of dental caries in children.13 AAP recommendations in-
clude: juice should not be introduced to infants before one year
of age; intake of juice should be limited to four ounces a day
for children one through three years of age, four to 6 ounces
for children four through six years of age, and eight ounces for
children seven through 18 years of age; toddlers should not
be given juice in containers that foster easy consumption; and
toddlers should not be given juice at bedtime.13 The mentioned
volumes are recommended maximums, not daily requirements,
and fresh fruit is preferred to fruit juice.13
Unfortunately, many parents do not adhere to evidence-
based dietary recommendations for their children. For example,
many infants are provided 100 percent juice and cow’s milk
before age one, which can increase their risk for nutrient
(e.g., iron14) deficiencies.4 Nearly half of two- to five-year olds
consume a SSB daily, with the prevalence increasing through-
out childhood.4 Children and adolescents in the United States
(U.S.) consumed an average of 143 calories/day from SSB
between 2011-2014, and 7.3 percent of their daily energy
intake came from SSB.15 Significant differences in beverage
intake by race/ethnicity and income groups in early childhood
have been noted.4
Dental caries prevalence in children has been variable, but
remains high.16 The prevalence of dental caries (untreated and
treated) in primary or permanent teeth among children aged
two through 19 years has been estimated at 45.8 percent.16
The causes of dental caries involve a combination of factors
and include diet, bacteria capable of fermenting carbohydrates,
fluoride exposure, and a susceptible host.17 While sugar,
especially high frequency consumption, contributes to dental
caries, a systematic study of sugar consumption and caries risk
concluded that the relationship between sugar consumption
and caries risk is weaker after the introduction of fluoride
exposure.18
The causes of obesity include genetic components, life-
style, and environmental variables, as well as nutritional
factors.19 When consumed in excess, beverages containing sugar
or saturated fats can be harmful.3 Health initiatives in the
U.S. and other countries have specifically targeted SSB in an
effort to reduce the number of calories that children and
adolescents consume per day.20 Data from the 2017-2018 Na-
tional Health and Nutrition Examination Survey (NHANES)
indicate that for children and adolescents aged two through
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
19, the prevalence of obesity is an estimated 19.3 percent,
including 6.1 percent with severe obesity and another 16.1
percent overweight.21 The obesity rate increases through
childhood and adolescence, and youth with obesity are at
increased risk for health problems (e.g., heart disease, type 2
diabetes) during the teenage years and beyond.22
While dental caries and obesity are both significant
pediatric health problems, the relationship between caries and
anthropometric measurements is complex. Multiple systematic
reviews have reported inconsistent and inconclusive evidence
on the relationship between caries and body mass index
(BMI).23-26 BMI is a simple, non-invasive means to monitor
growth patterns and help assess the risk of obesity. Forms to
record BMI for age and gender can be downloaded from the
website of the Centers for Disease Control and Prevention at
“https://www.cdc.gov/growthcharts/clinical_charts.htm#Set1”.27
Because of the persistent high prevalence of dental caries and
childhood obesity, the need remains for research, policy,
advocacy, education, and professional engagement to further
advance healthy dietary practices for infants, children, and
adolescents.
The U.S. Department of Health and Human Services and
the U.S. Department of Agriculture (USDA) develop dietary
guidelines every five years to help Americans aged two and
older make healthy food choices to help prevent chronic disease
and enjoy a healthy diet. The 2020-2025 Dietary Guidelines
for Americans includes four overarching guidelines:
• “Follow a healthy dietary pattern at every life stage.
• Customize and enjoy nutrient-dense food and beverage
choices to reflect personal preferences, cultural traditions,
and budgetary considerations.
• Focus on meeting food group needs with nutrient-dense
foods and beverages, and stay within calorie limits.
• Limit foods and beverages higher in added sugars, satu-
rated fat, and sodium, and limit alcoholic beverages.”22
The Dietary Guidelines for Americans also provides specific
quantitative recommendations including limiting:
• “Added sugars—Less than 10 percent of calories per
day starting at age two. Avoid foods and beverages with
added sugars for those younger than age two.
• Saturated fat—Less than 10 percent of calories per day
starting at age two.
• Sodium—Less than 2,300 milligrams per day—and even
less for children younger than age 14.”22
To prevent unhealthy weight gain, the World Health
Organization recommends energy intake and expenditure be
balanced, with a goal of total fat not exceeding 30 percent of
energy intake and a shift from away from saturated fat and
trans-fats.28 Limiting intake of free sugars to less than five
percent of total energy intake per day offers additional health
benefits.28 Additionally, the AHA recommends limiting con-
sumption of added sugars to no more than six percent of
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 97
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
calories29; for children and adolescents, their recommended
limit is less than 25 grams (100 calories or approximately six
teaspoons) of added sugar per day.10 One should note that
eight ounces (i.e., one measured cup) of regular soft drink
contain approximately 26 grams of sugar; a 12 ounce can of
regular soda contains approximately 10 teaspoons of sugar and
has no nutritional value29.
Snacking can help a child meet daily nutritional require-
ments. Nearly 25 percent of children’s daily caloric intake
may come from snacks.30 The AAP recommends that toddlers
be given two to three healthy snacks daily to supply nutrients
that the child cannot consume at mealtime; they should be
consumed at a planned time while seated with adult super-
vision.31 The AAP cautions against confusing snack time with
treats for fun as well as continuous/all day snacking.31 Fre-
quent (more than three times/day) exposure to between-meal
sugar-containing snacks or beverages categorizes a child at
high risk for dental caries.32 If a child is given continuous
access to a bottle or cup, it should contain only water.
The USDA has established guidelines for healthy snacks
at school.30 Standards for foods to qualify as a school “smart
snack” include:
• “Be a grain product that contains 50 percent or more
whole grains by weight (have a whole grain as the first
ingredient); or
• Have as the first ingredient a fruit, a vegetable, a dairy
product, or a protein food; or
• Be a combination food that contains at least ¼ cup of
fruit and/or vegetable (for example, ¼ cup of raisins
with enriched pretzels); and
• The food must meet the nutrient standards for calories,
sodium, fats, and total sugars”.30
Using 2017-2018 NHANES data, the USDA reported
approximately 20 percent of youth aged 12 through 19 years
consumed more than three snacks daily.33
Establishment of a dental home by 12 months of age
provides time-critical opportunities to assess caries risk and
implement individualized caries-preventive strategies, includ-
ing dietary recommendations and appropriate oral hygiene
instruction, as the primary teeth begin to erupt.34 A diet that
avoids frequent consumption of liquids and foods containing
sugar is essential to good oral health. The dental home also
can influence general health by instituting additional practices
related to general health promotion, disease prevention, and
screening for non-oral health related concerns. For example,
oral health professionals can calculate and monitor BMI to
help identify children at risk for obesity and provide appro-
priate referral to pediatric or nutritional specialists. A 2016
survey of pediatric dentists reported that 17 percent offer
childhood obesity interventions, while 94 percent offer infor-
mation or other interventions on the consumption of sugar
sweetened beverages.35 Barriers to providing healthy weight
interventions include fear of offending the parent, appearing
judgmental, creating parent dissatisfaction, and lack of parental
acceptance of advice about weight management from a
dentist.35
98 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Policy statement
The AAPD recognizes a healthy diet in early childhood is
essential to optimal growth and development and prevention
of chronic diet-related diseases such as caries, obesity, and
cardiovascular disease. Through dietary and nutritional coun-
seling, dentists assume a significant role in preventing oral
disease and promoting overall health among children. The
AAPD especially recognizes the importance of and supports:
• breastfeeding of infants prior to 12 months of age to
ensure the best possible health and developmental and
psychosocial outcomes for infants.
• the introduction of plain, fluoridated water to the
infant’s diet beginning at age six months for hydration,
to familiarize the child with the taste, and for the caries-
protective benefits of fluoride.
• fluoridated water as the preferred beverage for children
from one to five years of age when not part of a meal or
snack.
• avoiding added sugars in the diet of children younger
than age two and minimizing exposure to sweet-tasting
drinks and foods during early life to reduce taste prefer-
ences for sweets.
• recommendations from the USDA for individuals aged
two and older to consume a diet of nutrient-dense, lean
or low-fat foods from across five food groups (i.e., fruits,
vegetables, protein, grains, and dairy) that are prepared
without added salt, starches, sugars, or fat.
• limiting consumption of sugar to less than five percent
of total energy intake to reduce children’s risk of weight
gain and dental caries.
• establishing healthy beverage consumption patterns
during the first five years to promote intake of healthy
nutrients, limit excess intake of sugars and saturated fats,
and initiate beneficial long-term dietary habits.
• non-sweetened nutrient-dense snacks that supplement
meals to meet daily nutritional requirements.
• additional health practices such as meal portion control
and energy balance to help prevent overweight and
obesity.
Furthermore, the AAPD encourages:
• education of health professionals and the public regard-
ing healthy beverage choices and daily sugar-consumption
recommendations, as well as the sugar content of foods
and beverages.
• dental professionals to identify children whose dietary
patterns place them at increased risk for dental caries and
obesity and, when necessary, refer for dietary counseling
from a pediatric or nutritional specialist.
• a healthy, active lifestyle so energy consumption and
energy expenditure promote general health and well-
being.
• additional research on the benefits and effects of
long-term use of low-calorie sweeteners by children.

References
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Chicago, Ill.; 1993.
2. American Academy of Pediatric Dentistry. Policy on dietary
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Pediatr Dent 2017;39(6):64-6.
3. Lott M, Callahan E, Welker Duffy E, Story M, Daniels
S. Healthy Beverage Consumption in Early Childhood:
Recommendations from Key National Health and Nutri-
tion Organizations. Consensus Statement. Durham, N.C.:
Healthy Eating Research; 2019. Available at: “https://
healthyeatingresearch.org/wp-content/uploads/2019/
09/HER-HealthyBeverage-ConsensusStatement.pdf ”.
Accessed February 24, 2022.
4. Lott M, Callahan E, Welker Duffy E, Story M, Daniels S.
Healthy Beverage Consumption in Early Childhood:
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N.C.: Healthy Eating Research, 2019. Available at: “https:
//healthyeatingresearch.org/wp-content/uploads/2019/
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February 24, 2022.
5. American Academy of Pediatrics. Policy statement:
Breast-feeding and the use of human milk. Pediatrics
2012;129(3):e827-41.
6. Aarthi J, Muthu S, Sujatha S. Cariogenic potential of
milk and infant formulas: A systematic review. Eur Arch
Paediatr Dent 2013;14(5):289-300.
7. Tham R, Bowatte G, Dharmage SC, et al. Breastfeeding
and the risk of dental caries: A systematic review and
meta-analysis. Acta Paediatr 2015;104(467):62-84.
8. Centers for Disease Control and Prevention. Recommen-
dations for using fluoride to prevent and control dental
caries in the United States. MMWR Recomm Rep 2001;
50(RR14):1-42.
9. Saavedra JM, Deming D, Dattilo A, Reidy K. Lessons
from the Feeding Infants and Toddlers Study in North
America: What children eat, and implications for obesity
prevention. Ann Nutr Metab 2013;62(suppl 3):27-36.
10. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and
cardiovascular disease risk in children: A scientific state-
ment from the American Heart Association. Circulation
2017;135(19):e1017-e1034.
11. Centers for Disease Control and Prevention. Get the
Facts: Sugar-Sweetened Beverages and Consumption.
March 11, 2021. Available at: “https://www.cdc.gov/
nutrition/data-statistics/sugar-sweetened-beveragesintake.
html#:~:text=Sugar%2Dsweetened%20beverages%20
(SSBs),sugars%20in%20the%20American%20diet.&
text=Limiting%20the%20amount%20of%20SSB,and
%20have%20a%20healthy%20diet”. Accessed February
24, 2022.
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
12. Pan L, Li R, Park S, Galuska DA, Sherry B, Freedman
DS. A longitudinal analysis of sugar-sweetened beverage
intake in infancy and obesity at 6 years. Pediatrics 2014;
134(suppl 1):S29–S35.
13. Heyman MB, Abrams SA. Fruit juice in infants, children,
and adolescents: Current recommendations. Pediatrics
2017;139(6):1-8.
14. Ziegler EE. Consumption of cow’s milk as a cause of
iron deficiency in infants and toddlers. Nutr Rev 2011;
69(Suppl 1):S37-42.
15. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened
beverage consumption among U.S. youth, 2011–2014.
NCHS data brief, no 271. Hyattsville, Md.: National
Center for Health Statistics; 2017.
16. Fleming E, Afful J. Prevalence of Total and Untreated
Dental Caries Among Youth: United States, 2015–2016.
NCHS Data Brief, no 307. Hyattsville, Md.: National
Center for Health Statistics; 2018.
17. Slayton RL, Fontana M, Young D, et al. Dental caries
management in children and adults. Institute of Medicine,
2016; National Academy of Medicine, Washington, D.C.
Available at: “https://nam.edu/dental-caries-management-
in-children-and-adults/”. Accessed March 13, 2022.
18. Burt BA, Pai S. Sugar consumption and caries risk: A
systematic review. J Dent Ed 2001;65(10):1017-23.
19. Lee A, Cardel M, Donahoo WT. Social and environmental
factors influencing obesity. [Updated 2019 Oct 12]. In:
Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext
[Internet]. South Dartmouth (MA): MDText.com, Inc.;
2000. Available at: “https://www.ncbi.nlm.nih.gov/books
/NBK278977/”. Accessed March 13, 2022.
20. von Philipsborn P, Stratil JM, Burns J, et al. Environ-
mental interventions to reduce the consumption of
sugar-sweetened beverages and their effects on health.
Cochrane Database Syst Rev 2019;6(6):CD012292.
Available at: “https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC6564085/”. Accessed February 23, 2022.
21. Fryar CD, Carroll MD, Afful J. Prevalence of over-
weight, obesity, and severe obesity among children and
adolescents aged 2–19 years: United States, 1963–1965
through 2017–2018. NCHS Health E-Stats; 2020.
Available at: “https://www.cdc.gov/nchs/data/hestat/
obesity-child-17-18/overweight-obesity-child-H.pdf ”.
Accessed August 18, 2022.
22. U.S. Department of Agriculture and U.S. Department
of Health and Human Services. Dietary Guidelines for
Americans, 2020-2025. 9th ed. December 2020.
Available at: “https://www.dietaryguidelines.gov/sites/
default/files/2021-03/Dietary_Guidelines_for_Americans
-2020-2025.pdf ”. Accessed June 14, 2022.
References continued on the next page.
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23. Alshehri YFA, Park JS, Kruger E, Tennant M. Association
between body mass index and dental caries in the
Kingdom of Saudi Arabia: Systematic review. Saudi Dent
J 2020;32(4):171-80.
24. Paisi M, Kay E, Bennett C, et al. Body mass index and
dental caries in young people: A systematic review.
BMC Pediatr 2019;19(1):122.
25. Chen D, Zhi Q, Zhou Y, Tao Y, Wu L, Lin H. Association
between dental caries and BMI in children: A systematic
review and meta-analysis. Caries Res 2018;52(3):230-45.
26. Hayden C, Bowler JO, Chambers S, et al. Obesity and
dental caries in children: A systematic review and meta-
analysis. Community Dent Oral Epidemiol 2013;41(4):
289-308.
27. Centers for Disease Control and Prevention. Clinical
charts with 5th and 95th percentiles. Available at: “https:
//www.cdc.gov/growthcharts/clinical_charts.htm#Set1”.
Accessed February 24, 2022.
28. World Health Organization. Healthy Diet. April 29,
2020. Available at: “https://www.who.int/news-room/fact
-sheets/detail/healthy-diet”. Accessed February 24, 2022.
29. American Heart Association. Added Sugars. Available at:
“https://www.heart.org/en/healthy-living/healthy-eating/
eat-smart/sugar/added-sugars”. Accessed February 18,
2022.
30. U.S. Department of Agriculture Food and Nutrition Serv-
ice. A Guide to Smart Snacks in School. Slightly revised
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sites/default/files/resource-files/smartsnacks.pdf ”. Accessed
August 28, 2022.
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31. American Academy of Pediatrics. Toddler Food and Feed-
ing: Healthy Snacking. Updated July 8, 2021. Available
at: “https://www.aap.org/en/patient-care/healthy-active-
living-for-families/toddler-food-and-feeding/”. Accessed
June 26, 2022.
32. 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;
2022:266-72.
33. U.S. Department of Agriculture, Agricultural Research
Service. 2020. Snacks: Distribution of Snack Occasions,
by Gender and Age, What We Eat in America, NHANES
2017-2018. Available at: “https://www.ars.usda.gov/ARS
UserFiles/80400530/pdf/1718/Table_29_DSO_GEN
_17.pdf ”. Accessed February 19, 2022.
34. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Den-
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Dentistry; 2022:21-2.
35. Wright R, Casamassimo PS. Assessing the attitudes and
actions of pediatric dentists toward childhood obesity
and sugar-sweetened beverages. J Pub Health Dent 2017;
77(Suppl 1):S79-S87.

Policy on Snacks and Sugar-Sweetened Beverages
Sold in Schools
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that targeted marketing and easy access to foods
and beverages by children and adolescents may increase the
amount and frequency of their consumption which, in turn,
may contribute to an increase in caries risk and a negative
influence on overall nutrition and health.
Methods
This document was developed by the Council on Clinical
Affairs, adopted in 20021, and last revised in 20172. This revi-
sion is based upon a review of current dental and medical
®
literature, including a search of the PubMed /MEDLINE
database using the terms: schools, vending machines, AND
caries; fields: all; limits: within the last 10 years, humans,
English, clinical trials, and ages birth through 18. The update
also included a review of the American Academy of Pediatrics’
(AAP) policy statement: Soft Drinks in Schools 3, the AAP’s
policy statement: Snacks, Sweetened Beverages, Added Sugars
and Schools4, and the United States Department of Agriculture
(USDA) standards on school foods5. Papers for review were
chosen from the resultant lists and from hand searches.
Expert and/or consensus opinion by experienced researchers
and clinicians also was considered.
Background
Contemporary changes in beverage consumption patterns have
the potential to increase dental caries rates in children. Vending
machines provide ready access to excess calories from added
sugars, especially sugar-sweetened beverages (SSB). Consump-
tion of SSB in the form of sodas or sport, energy, and fruit-
flavored drinks and, to a lesser extent, 100 percent juice has
been associated with an increased risk for developing dental
caries.6-9 The acids present in carbonated beverages can have
a greater deleterious effect (i.e., erosion) on enamel than the
acids generated by oral flora from the sugars present in
sweetened drinks. 10 Analysis of the National Health and
Nutrition Examination Survey (NHANES) 2011-2014 indi-
cated that two-thirds of children aged two through 19 years
consumed at least one SSB on a given day 7, and children
who consumed SSB had significantly higher dental caries
experience and untreated dental caries than did children who
consumed other beverage types 9. A significant increase in
ORAL HEALTH POLICIES: SNACKS AND BEVERAGES IN SCHOOLS
How to Cite: American Academy of Pediatric Dentistry. Policy on
snacks and sugar-sweetened beverages sold in schools. The
Reference of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:101-2.
caries scores has been reported for children who attended
schools that had vending machines.11
That vending machine items which provide little to no
nutritional value are competitive foods and result in snack
options of poor nutritional quality is a significant concern.12-14
As teenage girls’ consumption of SSB increases, their con-
sumption of milk decreases, which may contribute to a
decrease in bone density, subsequent increase in fractures, and
future risk of osteoporosis. 15,16 Increased ingestion of SSB
also has been linked to the increased incidence of childhood
obesity.17,18 Of all beverages, increasing soda consumption pre-
dicted the greatest increase of body mass index (BMI) and the
lowest increase in calcium intake.19 Carbonated soda consump-
tion was negatively associated with vitamin A intake in all
age strata, calcium intake in children younger than 12 years,
and magnesium intake in children aged six years and older.20
Many soft drinks also contain significant amounts of caffeine
which, if consumed regularly, may lead to increased, even
habitual, usage.21
In 2013, the USDA initiated Smart Snacks in Schools
nutrition standards prompting school districts to offer healthier
food and beverages in vending machines, school stores, and
à la carte cafeteria lines. 22 The final rules released by the
USDA in July, 2016 state that schools must continue to
meet strong nutritional guidelines for snacks/drinks sold to
children, and they prevent marketing of foods and drinks
inconsistent with those standards.5 The USDA’s rules establish
a national baseline of these standards with the overall goal of
improving health and nutrition of our children.
Policy statement
The AAPD:
• encourages collaboration with other dental and medical
organizations, governmental agencies, education offi-
cials, parent and consumer groups, and corporations
to increase public awareness of the adverse effects of
frequent and/or inappropriate intake of sugar-sweetened
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
Pediatric Dentistry. SSB: Sugar-sweetened beverages. USDA: U.S.
Department of Agriculture.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 101
ORAL HEALTH POLICIES: SNACKS AND BEVERAGES IN SCHOOLS
beverages and low nutrient-dense snack foods on chil-
dren’s oral health and general health.
• promotes educating and informing the public regarding
the importance of good nutritional habits as they pertain
to consumption of items available in vending machines.
• encourages school officials and parent groups to consider
the importance of maintaining healthy choices in vend-
ing machines in schools and encourages the promotion
of food and beverages of high nutritional value; bottled
water and other more healthy choices should be avail-
able instead of soft drinks.
• opposes any arrangements that may decrease access to
healthy nutritional choices for children and adolescents
in schools.
References
1. American Academy of Pediatric Dentistry. Policy on
beverage vending machines in schools. Pediatr Dent
2002;24(suppl issue):27.
2. American Academy of Pediatric Dentistry. Policy on
snacks and beverages sold in schools. Pediatr Dent 2017;
39(6):67-8.
3. American Academy of Pediatrics Committee on School
Health. Policy statement: Soft drinks in schools. Pediatrics
2004;113(1Pt+1):152-4. Reaffirmed December, 2012.
4. American Academy of Pediatrics. Policy statement:
Snacks, sweetened beverages, added sugars, and schools.
Pediatrics 2015;135(3):575-83.
5. U.S. Department of Agriculture Food and Nutrition
Service. National School Lunch Program and School
Breakfast Program: Nutrition Standards for All Foods Sold
in School as Required by the Healthy, Hunger-Free Kids
Act of 2010. A Rule by the Food and Nutrition Service
on 07/29/2016. Available at: “https://www.federalregister.
gov/documents/2016/07/29/2016-17227/national-school
-lunch-program-and-school-breakfast-program-nutrition
-standards-for-all-foods-sold-in”. Accessed June 26, 2022.
6. Marshall TA, Levy SM, Broffitt B, et al. Dental caries
and beverage consumption in young children. Pediatr
2003;112(3 Pt 1):e184-91.
7. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened
beverage consumption among U.S. youth, 2011-2014.
NCHS data brief, no 271. Hyattsville, Md.: National
Center for Health Statistics. 2017. Available at: “https:
//www.cdc.gov/nchs/data/databriefs/db271.pdf ”. Accessed
June 26, 2022.
8. Muth ND, Dietz WH, Magge SN, Johnson RK. Public
policies to reduce sugary drink consumption in children
and adolescents. Pediatrics 2019;143(4):e20190282.
9. Laniado N, Sanders AE, Godfrey EM, Salazar CR, Badner
VM. Sugar-sweetened beverage consumption and caries
experience: An examination of children and adults in
the United States, National Health and Nutrition Exam-
ination Survey 2011-2014. J Am Dent Assoc 2020;151
(10):782-9.
102 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
10. American Dental Association. Joint Report of the American
Dental Association Council on Access, Prevention, and
Interprofessional Relations and Council on Scientific
Affairs to the House of Delegates. Response to Resolution
73H-2000. Chicago, Ill.: American Dental Association;
2001.
11. Maliderou M, Reeves S, Nobel C. The effect of social
demographic factors, snack consumption, and vending
machine use on oral health of children living in London.
British Dent J 2006;201(7):441-4.
12. U.S. Government Accountability Office. Report to Con-
gressional Requests: School Meal Programs Competitive
Foods are Widely Available and Generate Substantial
Revenues for Schools. 2005. Available at: “https://www.
gao.gov/assets/gao-05-563.pdf ”. Accessed March 16,
2022.
13. Kakarala M, Keast DR, Hoerr S. Schoolchildren’s con-
sumption of competitive foods and beverages, excluding
à la carte. J Sch Health 2010;80(9):429-35.
14. Pasch KE, Lytle LA, Samuelson AC, Farbakhsh K, Kubik
MY, Patnode CD. Are school vending machines loaded
with calories and fat: An assessment of 106 middle and
high schools. J Sch Health 2011;81(4):212-8.
15. Kalkwarf HJ, Khoury JC, Lanphear BP. Milk intake
during childhood and adolescence, adult bone density,
and osteoporotic fractures in US women. Am J Clin
Nutr 2003;77(1):257-65.
16. Ahn H, Park YK. Sugar-sweetened beverage consumption
and bone health: A systematic review and meta-analysis.
Nutr J 2021;20(1):41.
17. Fox MK, Dodd AH Wilson A, Gleason PM. Association
between school food environment and practices and
body mass index of US public school children. J Am
Diet Assoc 2009;109(2 Suppl):S108-17.
18. Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk
V, Farpour-Lambert N. Sugar-sweetened beverages and
weight gain in children and adults: A systematic review
from 2013 to 2015 and a comparison with previous
studies. Obes Facts 2017;10(6):674-93.
19. Striegel-Moore RH, Thompson D, Affenito SG, et al.
Cor-relates of beverage intake in adolescent girls: The na-
tional heart, lung, and blood institute growth and health
study. J Pediatr 2006;148(2):183-7.
20. Ballew C, Kuester S, Gillespie C. Beverage choices affect
adequacy of children’s nutrient intakes. Arch Pediatr
Adolesc Med 2000;154(11):1148-52.
21. Majewski R. Dental caries in adolescents associated with
caffeinated carbonated beverages. Pediatr Dent 2001;23
(3):198-203.
22. U.S. Department of Agriculture Food and Nutrition
Service. Child Nutrition Programs: Smart Snacks in
School. October 31, 2013. Available at: “https://www.
fns.usda.gov/cn/smart-snacks-school”. Accessed June 26,
2022.

Policy on Tobacco Use
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD), in
order to reduce pain, disability, and death caused by nicotine
addiction, recommends routine screening for tobacco use,
treating tobacco dependence, preventing tobacco use among
children and adolescents, and educating the public on the
enormous health and societal costs of tobacco.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2000.1 This document is an update of the
previous version, revised in 2015.2 This policy revision is based
upon a review of current dental, medical, and public health
literature related to tobacco use which included a search of
®
the PubMed /MEDLINE database using the terms: child and
adolescent tobacco use, smokeless tobacco and oral disease,
adolescent pregnancy and tobacco, secondhand smoke, and
caries and smoking; fields: all; limits: within the last 10 years,
humans, English, clinical studies, meta-analysis, systematic
reviews, birth through age 18. The search returned 525 articles
that matched the criteria. The articles were evaluated by title
and/or abstract. Forty-nine articles were chosen from this
method and from references within selected articles. Websites
for the American Lung Association, American Cancer Society,
Centers for Disease Control and Prevention (CDC), Environ-
mental Protection Agency, Campaign for Tobacco Free Kids,
and United States Department of Health and Human Services
also were reviewed.
Background
Tobacco is a risk factor for six of the eight leading causes of
deaths in the world, and it kills nearly more than eight million
people a year.3 Tobacco use is considered one of the largest
public health threats the world has ever faced.3,4 More than
1.2 million deaths are the result of non-smokers being exposed
to second-hand smoke.3 Up to half of current users eventually
will die of a tobacco-related disease.3 In the United States
(U.S.), the Surgeon General’s report states that smoking is the
single greatest avoidable cause of death.4 According to the
report, “The epidemic of smoking-caused disease in the twen-
tieth century ranks amongst the greatest public catastrophes
of the century, while the decline of smoking consequent to
tobacco control is one of public health’s greatest successes.”4
ORAL HEALTH POLICIES: TOBACCO USE
How to Cite: American Academy of Pediatric Dentistry. Policy on
tobacco use. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:103-7.
Youth use of tobacco
The CDC has conducted a National Youth Tobacco Survey
(NYTS) for the years 1999, 2000, 2002, 2004, 2006, 2009,
2011, and 2012 through 2019 as part of the Healthy People
2010 and 2020 objectives on tobacco use.5 The NYTS also
serves as a baseline for comparing progress toward meeting
select Healthy People 2020 goals for reducing tobacco use
among youth, especially in adolescents in grades 6-12. Data
show that:
• smoking and smokeless tobacco use are initiated and
established primarily during adolescence.4 Nearly nine
out of 10 smokers started smoking by age 18, and 98
percent started by age 26.6
• each day in the U.S., about 2000 people younger than
18 years of age smoke their first cigarette, and more than
300 youth under 18 years of age become daily cigarette
smokers.7
• if smoking persists at the current rate among youth in
this country, 5.6 million of today’s population younger
than 18 years of age are projected to die prematurely
from a smoking-related illness.4 This represents about
one in every 13 Americans aged 17 years or younger
alive today.4
• in 2017, 5.6 percent of middle school and 19.6 percent
of high school students currently used tobacco products,
including cigarettes, cigars, smokeless tobacco, pipe
tobacco, bidis (unfiltered cigarettes from India), and
electronic cigarettes.8
• from 2011 to 2019, current use of smokeless tobacco
decreased among middle and high school students.9
Nearly two of every 100 middle school students (1.8
percent) reported in 2019 that they had used smokeless
tobacco in the last 30 days, a decrease from 2.2 percent
in 2011.9 Nearly six out of every 100 high school stu-
dents (5.9 percent) reported in 2019 that they used
smokeless tobacco in the last 30 days, a decrease from
7.9 percent in 2011.9 Smokeless tobacco use remains a
mostly male behavior,9 being seen in 7.5 percent of male
high school students and 1.8 percent of females.9
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CDC: Centers for
Disease Control and Prevention. ETS: Environmental tobacco smoke.
NYTS: National Youth Tobacco Survey. U.S.: United States.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 103
ORAL HEALTH POLICIES: TOBACCO USE
Reports show that most people who use cigarettes begin
smoking as a teen.4,6 Aggressive marketing of tobacco prod-
ucts by manufacturers, 6,10-13 smoking by parents, 10,13,14 peer
influence,6,10,13 a functional belief in the benefits and normalcy
of tobacco,10,13,15 availability and price of tobacco products,10,13
low socioeconomic status, 10 low academic achievement, 6,10
lower self-image, 10 and a lack of behavioral skills to resist
tobacco offers10 all contribute to the initiation of tobacco use
during childhood and adolescence. Teens who use tobacco are
more likely to use alcohol and other drugs10 and engage in
high risk sexual behaviors.16,17
If youth can be discouraged from starting smoking, it is less
likely that they will start smoking as an adult. The 2012 Report
of the Surgeon General’s report concluded that there is a large
evidence base for effective strategies to prevent and minimize
tobacco use by children and young adults by decreasing the
number of children who initiate tobacco use and by increasing
the current users who quit.6 Oral health professionals can have
success with tobacco cessation by counseling patients during
the oral examination component of dental visits.18
Consequences of tobacco use
Smoking increases the risk for: coronary heart disease by 2-4
times, stroke by 2-4 times, men developing lung cancer by
25 times, and women developing lung cancer 25.7 times.19
Smoking causes diminished overall health, increased absen-
teeism from work, and increased health care utilization and
cost.6,20 Other catastrophic health outcomes are cardiovascular
disease; reproductive effects; pulmonary disease; leukemia;
cataracts; and cancers of the cervix, kidney, pancreas, stomach,
lung, larynx, bladder, oropharynx, and esophagus.19
Environmental tobacco smoke ([ETS]; secondhand or
passive smoke) imposes significant risks as well. Secondhand
exposure results in the death of 41,000 nonsmoking adults
and 400 infants each year.21 The Surgeon General reported a
25 to 30 percent increased risk for coronary heart disease for
nonsmokers exposed to secondhand smoke and a 20 to 30 per-
cent increased risk for lung cancer for those living with a
smoker.22 Infants and children who are exposed to smoke are
at risk for sudden infant death syndrome (SIDS)3,19,22,23, acute
respiratory infections23, middle ear infections23, bronchitis23,
pneumonia23, asthma23-25, allergies26,27, and infections during
infancy. 28 In addition, caries in the primary dentition is
related to secondhand smoke exposure.29-31 Enamel hypoplasia
in both the primary and permanent dentition may be related
to secondhand cigarette smoke exposure during childhood.32
Prenatal exposure to secondhand smoke has been associated
with cognitive deficits23 (e.g., reasoning abilities) and deficits
in reading, mathematics, and visuospatial relationships.33
Thirdhand smoke refers to the particulate residual toxins
that are deposited in layers all over the home after a cigarette
has been extinguished. 34 These volatile compounds are
deposited and emit gas into the air over months. 35,36 Since
children inhabit these low-lying contaminated areas and
because the dust ingestion rate in infants is more than twice
104 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
that of an adult, they are even more susceptible to third-
hand smoke. Studies have shown that these children have
associated cognitive deficits in addition to the other associated
risks of secondhand smoke exposure.34
Tobacco use can result in oral disease. Oral cancer,3,4,19
periodontitis,4,23,37-41 compromised wound healing, a reduction
in the ability to smell and taste23, smoker’s palate (red inflam-
mation turning to harder white thickened tissues), and
melanosis (dark pigmenting of the oral tissues), coated tongue,
staining of teeth23 and restorations23,41, implant failure4, and
leukoplakia41,42 are all seen in tobacco users.42,43 Use of smoke-
less tobacco is a risk factor for oral cancer, leukoplakia, and
erythroplakia, loss of periodontal support, and staining of
teeth and composite restorations.41
The monetary costs of this addiction and resultant morbid-
ity and mortality are staggering. Annually, cigarette smoking
costs the U.S. $300 billion, based on lost productivity (more
than $156 billion) and health care expenditures (nearly
$170 billion).44 Lost productivity due to exposure to second-
hand smoke is about $5.6 billion annually.44 Contrast this
with tobacco industry expenditures on advertising and political
promotional expenses of $ 8.4 billion in 2018 in the U.S.
alone.44
Current trends indicate that tobacco use will cause more
than eight million deaths a year by 2030.3 It is incumbent on
the healthcare community to reduce the burden of tobacco-
related morbidity and mortality by supporting preventive
measures, educating the public about the risks of tobacco,
and screening for tobacco use and nicotine dependence.
Policy statement
The AAPD opposes the use of all forms of tobacco including
cigarettes, pipes, cigars, bidis, kreteks, and smokeless tobacco
and alternative nicotine delivery systems, such as tobacco
lozenges, nicotine water, nicotine lollipops, or heated tobacco-
cigarette substitutes (electronic cigarettes). The AAPD supports
national, state, and local legislation that eliminates tobacco
advertising and promotions that appeal to or influence children,
adolescents, or special groups. The AAPD supports prevention
efforts through merchant education and enforcement of state
and local laws prohibiting tobacco sales to minors. As ETS is
a known human carcinogen and there is no evidence to date
of a safe exposure level to ETS,23 the AAPD also supports the
enactment and enforcement of state and local clean indoor air
and/or smoke-free policies or ordinances prohibiting smoking
in public places.
Furthermore, the AAPD encourages oral health profes-
sionals to:
• determine and document tobacco use by patients and the
smoking status of their parents, guardians, and caregivers.
• promote and establish policies that ensure dental offices,
clinics, and/or health care facilities, including property
grounds, are tobacco free.
• support tobacco-free school laws and policies.

• serve as role models by not using tobacco and urging
staff members who use tobacco to stop.
• routinely examine patients for oral signs of and changes
associated with tobacco use.
• educate patients, parents, and guardians on the serious
health consequences of tobacco use and exposure to ETS
in the home.
• provide both prevention and cessation services using
evidence-based interventions identified as best practice
for treating tobacco use and nicotine addiction.
• work to ensure all third-party payors include best practice
tobacco cessation counseling and pharmacotherapeutic
treatments as benefits in health packages.
• work with school boards to increase tobacco-free envi-
ronments for all school facilities, property, vehicles, and
school events.
• work on the national level and within their state and
community to organize and support anti-tobacco cam-
paigns and to prevent the initiation of tobacco use among
children and adolescents, eliminate cigarette sales from
vending machines, and increase excise tax on tobacco
products to reduce demand.
• work with legislators, community leaders, and health care
organizations to ban tobacco advertising, promotion, and
sponsorships.
• organize and support efforts to pass national, state, and
local legislation prohibiting smoking in businesses such
as day-care centers where children routinely visit and other
establishments where adolescents frequently are em-
ployed.
• establish and support education/training activities and
prevention/cessation services throughout the community.
• recognize the U.S. Public Health Service Clinical Practice
Guideline Treating Tobacco Use and Dependence 45 as a
valuable resource.
References
1. American Academy of Pediatric Dentistry. Policy on
tobacco use. Pediatr Dent 2000;22(suppl iss):39.
2. American Academy of Pediatric Dentistry. Tobacco use.
Pediatr Dent 2015;37(special issue):61-5.
3. World Health Organization. Tobacco key facts. Available
at: “http://www.who.int/mediacentre/factsheets/fs339/en/”.
Accessed August 7, 2020.
4. U.S. Department of Health and Human Services. The
Health Consequences of Smoking – 50 Years of Progress:
A Report of the Surgeon General. Rockville, Md.: U.S.
Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center of
Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health; 2014. Available at:
“https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/
Bookshelf_NBK179276.pdf ”. Accessed August 7, 2020.
ORAL HEALTH POLICIES: TOBACCO USE
5. U.S. Department of Health and Human Services. Healthy
people 2020: Tobacco use and healthy people 2020
objectives-Tobacco priority area. Washington, D.C., 2014
Available at: “https://www.healthypeople.gov/2020/
topics-objectives/topic/tobacco-use”. Accessed August
7, 2020.
6. U.S. Department of Health and Human Services. Pre-
venting Tobacco Use Among Youth and Young Adults:
A Report of the Surgeon General. Atlanta, Ga.: U.S.
Department of Health and Human Services, Centers for
Disease Control and Prevention, Office on Smoking and
Health; 2012. Available at: “https://www.ncbi.nlm.nih.
gov/books/NBK99237/”. Accessed August 7, 2020.
7. Centers for Disease Control and Prevention. Smoking
and Tobacco Use: Fast Facts. Available at: “https://www.
cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.
htm#beginning”. Accessed August 7, 2020.
8. Wang, TW, Gentzke A, Sharapova S, Cullen KA, Ambrose
BK, Jamal A. Tobacco product use among middle and
high school students-United States, 2011-2017. MMWR
Morb Mortal Wkly Rep 2018;67:629-33. Available at:
“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
5991815/”. Accessed November 11, 2020.
9. Centers for Disease Control and Prevention. Youth and
Tobacco Use. Available at: “https://www.cdc.gov/tobacco
/data_statistics/fact_sheets/youth_data/tobacco_use/
index.htm”. Accessed November 11, 2020.
10. Elders MJ, Perry CL, Eriksen MP, Giovino GA. The
report of the Surgeon General: Preventing tobacco use
among young people. Am J Public Health 1994;84(4):
543-7. Available at: “https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1614776/”. Accessed August 7, 2020.
11. Centers for Disease Control and Prevention. Cigarette
brand preference among middle and high school students
who are established smokers – United States, 2004 and
2006. MMWR Morb Mortal Wkly Rep 2009;58(5):
112-5.
12. Lavoto C, Linn G, Stead LF, Best A. Impact of tobacco
advertising and promotion on increasing adolescent
smoking behaviours. Cochrane Database Syst Rev 2003;
(4):CD003439.
13. American Lung Association. Why kids start smoking.
March 19, 2020. Available at: “https://www.lung.org/
quit-smoking/helping-teens-quit/why-kids-start-smoking”.
Accessed August 7, 2020.
14. Gilman SE, Rende R, Boergers J, et al. Parental smoking
and adolescent smoking initiation: An intergenerational
perspective on tobacco control. Pediatrics 2009;123(2):
e274-81.
15. Song AV, Morrell HE, Cornell JL, et al. Perceptions of
smoking-related risks and benefits as predictors of adoles-
cent smoking initiation. Am J Public Health 2009;99
(3):487-92.
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 105
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16. Centers for Disease Control and Prevention. Best Prac-
tices for Comprehensive Tobacco Programs-2014. Atlanta,
Ga.: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health Pro-
motion, Office on Smoking and Health; 2014. Available
at: “https://www.cdc.gov/tobacco/stateandcommunity/
best_practices/pdfs/2014/comprehensive.pdf ”. Accessed
August 7, 2020.
17. American Cancer Society. Health Risks of Smoking
Tobacco. November 15, 2018. Available at: “https://
www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/
health-risks-of-smoking-tobacco.html”. Accessed August
7, 2020.
18. Carr AB, Ebbert J. Interventions for tobacco cessation in
the dental setting. Cochrane Database Syst Rev 2012;
6:CD005084.
19. Centers for Disease Control and Prevention. Smoking and
tobacco use: Health effects of cigarette smoking. April 28,
2020. Available at: “https://www.cdc.gov/tobacco/data_
statistics/fact_sheets/health_effects/effects_cig_smoking/
index.htm”. Accessed August 7, 2020.
20. Campaign for Tobacco Free Kids. The daily toll of tobacco
use in the USA. October 23, 2019. Available at: “https:
//www.tobaccofreekids.org/assets/factsheets/0300.pdf ”.
Accessed August 7, 2020.
21. Centers for Disease Control and Prevention. Smoking and
Tobacco: Secondhand smoke. Available at: “https://www.
cdc.gov/tobacco/basic_information/secondhand_smoke”.
Accessed August 7, 2020.
22. U.S. Department of Health and Human Services. The
Health Consequences of Involuntary Exposure to Tobacco
Smoke: A Report of the Surgeon General. Atlanta, Ga.:
U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office
on Smoking and Health; 2006. Available at: “https://
www.ncbi.nlm.nih.gov/books/NBK44324/pdf/Bookshelf_
NBK44324.pdf ”. Accessed August 7, 2020.
23. Campaign for Tobacco-Free Kids. Tobacco harm to kids.
December 6, 2019. Available at: “https://www.tobacco-
freekids.org/assets/factsheets/0077.pdf ”. Accessed August
7, 2020.
24. Burke H, Leonardi-Bee J, Hashim A, et al. Prenatal and
passive smoke exposure and incidence of asthma and
wheeze: Systematic review and meta-analysis. Pediatrics
2012;129(4):735-44.
25. Goodwin RD, Cowles RA. Household smoking and
childhood asthma in the United States: A state-level
analysis. J Asthma 2008;45(7):607-10.
26. Dietert RR, Zelikoff JT. Early-life environment, devel-
opmental immunotoxicology, and the risk of pediatric
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27. Lannerö E, Wickman M, van Hage M, Bergström A,
Pershagen G, Nordvall L. Exposure to environmental
tobacco smoke and sensitisation in children. Thorax
2008;63(2):172-6.
28. Ladomenou F, Kafatos A, Galanakis E. Environmental
tobacco smoke exposure as a risk factor for infections in
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29. Leroy R, Hoppenbrouwers K, Jara A, Declerck D. Parental
smoking behavior and caries experience in preschool
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249-57.
30. Hanioka T, Nakamura E, Ojima M, Tanaka K, Aoyama
H. Dental caries in 3-year-old children and smoking
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546-50.
31. Hanioka T, Ojima M, Tanaka K, Yamamoto M. Does
secondhand smoke affect the development of dental caries
in children? A systematic review. Int J Environ Res Public
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32. Ford D, Seow WK, Kazoullis S, Holcombe T, Newman
B. A controlled study of risk factors for enamel hypoplasia
in the permanent dentition. Pediatr Dent 2009;31(5):
382-8.
33. Yolton K, Dietrich K, Auinger P, Lanphear BP, Hornung
R. Exposure to environmental tobacco smoke and cogni-
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Environ Health Perspect 2005;113(1):98-103.
34. Winickoff JP, Friebely J, Tanski SE, et al. Beliefs about the
health effects of “thirdhand” smoke and home smoking
bans. Pediatrics 2009;123(1):e74-9.
35. Matt GE, Quintana PJ, Hovell MF, et al. Households
contaminated by environmental tobacco smoke: Sources
of infant exposures. Tob Control 2004;13(1):29-37.
36. Singer BC, Hodgson AT, Guevarra KS, Hawley EL, Nazaroff
WW. Gas-phase organics in environmental tobacco
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2002;36(5):846-53.
37. Johnson GK, Hill M. Cigarette smoking and the
periodontal patient. J Periodontol 2004;75(2):196-209.
38. Bergström J, Eliasson S, Dock J. A 10-year prospective
study of tobacco smoking and periodontal health. J
Periodontol 2000;71(8):1338-47.
39. Albandar JM, Streckfus CF, Adesanya MR, Winn DM.
Cigar, pipe, and cigarette smoking as risk factors for
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40. Johnson GK, Slach NA. Impact of tobacco use on
periodontal status. J Dent Educ 2001;65(4):313-21.
41. Muthukrishnan A, Warnakulasuri S. Oral health conse-
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 ORAL HEALTH POLICIES: TOBACCO USE

42. Vellappally S, Fiala Z, Smejkalová J, Jacob V, Somanathan 45. Tobacco Use and Dependence Guideline Panel. Treating
R. Smoking related systemic and oral diseases. Acta Tobacco Use and Dependence: 2008 Update. Clinical
Medica 2007;50(3):161-6. Practice Guideline. Rockville, Md.: U.S. Department
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with recommendations. Med Princ Pract 2003;12(Suppl 2008. Available at: “https://www.ncbi.nlm.nih.gov/books/
1):22-32. Available at: “https://www.karger.com/Article/ NBK63952/”. Accessed August 7, 2020.
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August 7, 2020.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 107

ORAL HEALTH POLICIES: E–CIGARETTES
Policy on Electronic Nicotine Delivery Systems (ENDS)
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the increased use of electronic cigarettes (e-cigarettes)
among children and adolescents. This policy intends to educate
professionals, parents, and patients about electronic nicotine
delivery systems (ENDS). Nicotine is highly addictive and has
negative effects on brain development from the prenatal period
into adolescence.1 In order to reduce health risks caused by
nicotine addiction, the AAPD supports routine screening for
tobacco use, treating tobacco dependence, preventing tobacco
use among children and adolescents, and educating the public
on the health and societal costs of use of e-cigarettes/ENDS.
Methods
This policy was developed by the Council of Clinical Affairs
and adopted in 2015.2 This revision is based on a review of
dental and medical literature and sources of recognized profes-
sional expertise and stature, including both the academic and
practicing health care communities, related to ENDS use by
the pediatric patient. In addition, a search of the PubMed /
MEDLINE database was performed using the terms: e-
® likely to report using traditional cigarettes21 despite having
cigarette use in children, e-cigarette use in adolescents, ENDS
use in children, ENDS use in adolescents, nicotine effects on
health; fields: all; limits: within the last 10 years, humans,
English, birth through age 18. Papers for review were chosen
from this search and from references within selected articles.
When data did not appear sufficient or were inconclusive,
policies were based upon expert and/or consensus opinion by
experienced researchers and clinicians.
Background
E-cigarettes, also called ENDS, are handheld devices that
produce an aerosol from a solution typically containing nico-
tine, flavoring chemicals, and other additives to be inhaled by
the user.3-5 The act of using an e-cigarette/ENDS commonly is
called vaping due to the vapors that are inhaled and exhaled;
however, the emission from an ENDS is most accurately clas-
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
aid to stop smoking tobacco-containing products,8,9 although
studies relating to the effectiveness of e-cigarettes as a smoking
cessation tool have had mixed results, and the use of e-cigarettes
for tobacco cessation is not clearly supported by scientific evi-
dence.10-12 There currently are no federally-approved e-cigarette
108 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
electronic nicotine delivery systems (ENDS). The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:108-11.
products for adult smoking cessation.13 E-cigarette solutions
come in a variety of flavors and nicotine concentrations.7,13
The United States (U.S.) Preventive Services Task Force
found that two of the strongest factors associated with
initiation of smoking by children are parental smoking and
parental nicotine dependence. 14 Studies have shown that
exposure to nicotine has a deleterious effect on the brain of
children and adolescents.1,15 E-cigarette use is rising among
adolescents at an alarming rate, and recent studies show that
e-cigarette use among teens has surpassed tobacco cigarette
use.5,16 In 2019, 27 percent of high school students and 10.5
percent of middle school students reported current e-cigarette
usage. 17 Since 90 percent of all adult tobacco smokers
reported starting smoking as a teenager,18 and almost 38 per-
cent of habitual e-cigarette users never smoked tobacco
products,19,20 the potential for increased use of e-cigarettes is
a public concern. E-cigarettes may serve as an entry point for
use of nicotine, an addictive drug.16 Adolescents and young
adults who used e-cigarettes were found to be 3.5 times more
lower behavioral and social risk factors than those who smoked
conventional cigarettes22.
Due to lack of regulation in e-cigarette marketing, the
sleek designs of the new products, and the appealing flavors,
children who are impressionable and model the behavior of
adults are at risk from marketing that normally is banned for
tobacco-containing products.3 ENDS solutions are available in
a number of enticing and appealing flavors, including fruit,
candy, and dessert flavors such as Belgian waffle and choco-
late.23 Although they have not been banned for e-cigarettes,
these flavors have been banned in tobacco cigarettes due to
their appeal to children, adolescents, and first-time users.24 In
2016, 78.2 percent of middle and high school students were
exposed to ENDS advertising from at least one source.3
In 2016, the Family Smoking Prevention and Tobacco
Control Act25 was expanded to include regulation of ENDS.
Among the regulations set forth are a requirement that manu-
facturers submit an application for review to determine the
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. E-cigarettes:
Electronic cigarettes. ENDS: Electronic nicotine delivery systems.
EVALI: E-cigarette or vaping product use lung illness. FDA: U.S.
Food and Drug Administration. mg: Milligram. mL: Milliliter.
THC: Tetrahydrocannabinol. U.S.: United States.

safety of their products by 2020.26 Previously, manufacturers
were not required to disclose their ingredients.27,28 The U.S.
Food and Drug Administration (FDA)’s “deeming rule” also
bans the sale of ENDS to anyone under 18 years old, requires
producers to cease giving free samples, and requires warning
labels stating that nicotine is addictive.26 Unfortunately, the
regulation does not address flavors or nicotine strength and
does not appropriately restrict the advertising of ENDS.
The base solution contains propylene glycol which can
cause eye, throat, and airway irritation and with long term
exposure can cause asthma in children.29 A five milliter (mL)
vial of e-cigarette refill solution can contain a nicotine concen-
tration of 20 milligrams (mg)/mL or 100 mg per vial.30 The
known lethal dose of nicotine has been estimated to be about
10 mg in children and between 30 and 60 mg in adults.30
Recently, there has been a national outbreak of lung-associated
injuries and deaths reported with e-cigarette use and vaping.31
The liquid can contain nicotine, tetrahydrocannabinol (THC)
and cannabinoid (CBD) oils, and other substances and addi-
tives.31 The current chemical exposure causing lung injuries
remains unknown; however, recent analyses of bronchoalveolar
lavage fluid samples of those affected has shown vitamin E
acetate to be associated with e-cigarette or vaping product use
lung illness (EVALI).31 THC is present in most of the samples
tested by the FDA.31 No one compound or ingredient has
emerged to cause the illness to date, and many different
product sources are being investigated at this time.31 That the
components of ENDS are not entirely disclosed and can vary
according to manufacturer poses pressing concerns.31
As e-cigarettes have become popular as a substitute for
tobacco smoking due to indoor smoking restrictions,32 the
effect of the exhaled vapors is also a concern. A number of
toxic and potentially carcinogenic compounds have been
found in the vapors of e-cigarettes.33,34 Unrestricted access to
smoking of e-cigarettes not only poses health risks to the user,
but also may pose health risks to people nearby due to
secondhand exposure of the vapors. 31 One study showed
a similar effect on serum levels of cotinine (a biomarker for
exposure to tobacco smoke) with an one-hour exposure to
both secondhand cigarette smoke and e-cigarette vapors.35
Policy statement
The AAPD:
• recognizes the potential hazards associated with the
use of electronic nicotine delivery systems.
• encourages all members to educate patients, parents,
and guardians on the health consequences of e-cigarettes
and other forms of nicotine delivery systems.
• encourages the enactment of FDA regulations on e-
cigarette/ENDS distribution including, but not limited
to, prohibiting sales to children under 21, banning the
child-friendly flavoring of e-cigarettes, and limiting the
use for smoking cessation purposes.
ORAL HEALTH POLICIES: E–CIGARETTES
• supports more studies being done on the effects of the
secondhand vapors and the compounds produced from
e-cigarettes.
• supports the inclusion of e-cigarettes in the non-smoking
laws in restaurants and public places.
• supports national, state, and local legislation that bans
the sale of e-cigarettes to children and eliminates adver-
tising and/or promotion of e-cigarettes that appeals to
or influences children, adolescents, or special groups.
• opposes the use of all forms of unregulated nicotine
delivery systems, such as tobacco lozenges, nicotine
water, nicotine lollipops, and heated tobacco cigarette
substitutes.
References
1. Dwyer J, McQuown S, Leslie F. The dynamic effects of
nicotine on the developing brain. Pharmacol Ther 2009;
122(2):125-39.
2. American Academy of Pediatrics Dentistry. Policy on
e-cigarettes. Pediatr Dent 2015;37(special issue):66-8.
3. Jenssen BP, Walley SC, AAP Section on Tobacco Control.
E-cigarettes and similar devices. Pediatrics 2019;143(2):
e20183652. Available at: “https://pediatrics.aappublica
tions.org/content/pediatrics/143/2/e20183652.full.pdf ”.
Accessed July 7, 2020.
4. Sutfin EL, McCoy TP, Morrell HER, Hoeppner BB,
Wolfson M. Electronic cigarette use by college students.
Drug and Alcohol Depend 2013;131(3):214-21.
5. U.S. Department of Health and Human Services E-
Cigarette Use Among Youth and Young Adults. A Report
of the Surgeon General. Atlanta, Ga.: U.S. Department of
Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking
and Health, 2016. Available at: “https://e-cigarettes.
surgeongeneral.gov/documents/2016_SGR_Full_Report
_non-508.pdf ”. Accessed July 7, 2020
6. Grana R, Ling P. Smoking revolution: A content analysis
of electronic cigarette retail websites. Am J Prev Med
2014;46(4):395-403.
7. Taylor N, Choi K, Forster J. Snus use and smoking
behaviors: Preliminary findings from a prospective cohort
study among U.S. Midwest young adults. Am J Public
Health 2015;105(4):683-5.
8. Ayers J, Ribisl K, Brownstein J. Tracking the rise in
popularity of electronic nicotine delivery systems (elec-
tronic cigarettes) using search query surveillance. Am J
Prev Med 2011;40(4):448-53.
9. Dawkins L, Turner J, Roberts A, Soar K. ‘Vaping’ profiles
and preferences: An online survey of electronic cigarette
users. Addiction 2013;108(6):1115-25.
10. Bullen C, Howe C, Laugesen M, et al. Electronic cig-
arettes for smoking cessation: A randomized controlled
trial. Lancet 2013;382(9905):1629-37.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 109
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11. Ghosh A, Coakley RC, Mascenik T, et al. Chronic e-
cigarette exposure alters the human bronchial epithelial
proteome. Am J Respir Crit Care Med 2018;198(1):67-
76. Available at: “https://www.atsjournals.org/doi/10.11
64/rccm.201710-2033OC”. Accessed October 3, 2020.
12. National Academies of Sciences, Engineering, and Med-
icine. Public Health Consequences of E-Cigarettes.
Washington, D.C.: The National Academies Press; 2018.
Available at: “https://www.ncbi.nlm.nih.gov/books/
NBK507171/pdf/Bookshelf_NBK507171.pdf ”. Accessed
October 5, 2020.
13. Walley SC, Wilson KM, Winickoff JP, Groner J. A public
health crisis: Electronic cigarettes, vape, and JUUL.
Pediatrics 2019;143(6):e20182741.
14. Moyer VA, U.S. Preventive Task Force. Primary care
interventions to prevent tobacco use in children and
adolescents: U.S. Preventive Task Force recommendation
statement. Ann Intern Med 2013;159(8):552-7.
15. Goriounova NA, Mansvelder HD. Nicotine exposure
during adolescence alters the rules for prefrontal cortical
synaptic plasticity during adulthood. Front Synaptic
Neurosci 2012;4:3. Available at: “https://www.frontiers
in.org/articles/10.3389/fnsyn.2012.00003/full”. Accessed
July 7, 2020.
16. Johnston LD, O’Malley PM, Miech RA, et al. Monitoring
the future national results on adolescent drug use, 1975-
2015. Overview, key findings on adolescent drug use.
Ann Arbor, Mich.: Institute for Social Research, The
University of Michigan; 2016. Available at: “https://files.
eric.ed.gov/fulltext/ED578539.pdf ”. Accessed October
5, 2020.
17. Cullen KA, Gentzke AS, Sawdey MD, et al. E-cigarette
use among youth in the United States, 2019. J Am Med
Assoc 2019;322(21):2095-103. Available at: “https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC6865299/”.
Accessed October 5, 2020.
18. U.S. Department of Health and Human Services. Prevent-
ing Tobacco Use Among Youth and Young Adults, Fact
Sheet, U.S. Department of Health and Human Services,
Washington, D.C. Available at: “https://www.hhs.gov/
surgeongeneral/reports-and-publications/tobacco/
preventing-tobacco-use-factsheet/index.html”. Accessed
October 5, 2020.
19. Kong G, Morean ME, Cavallo DA, Camenga DR,
Krishnan-Sarin S. Reasons for electronic cigarette
experimentation and its continuation among adolescents
and young adults. Nicotine Tob Res 2015;17(7):847-54.
20. Wills T, Knight R, Williams R, Pagano I, Sargent J. Risk
factors for exclusive e-cigarette use and dual e-cigarette
use and tobacco use in adolescents. Pediatrics 2015;135
(1):43-51.
21. Soneji S, Barrington-Trimis JL, Wills TA, et al. Associ-
ation between initial use of e-cigarettes and subsequent
cigarette smoking among adolescents and young adults:
A systematic review and meta-analysis. JAMA Pediatr
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2017;171(8):788-97. [published correction appears in
JAMA Pediatr 2018;172(1):98].
22. Wills TA, Sargent JD, Gibbons FX, Pagano I, Schweitzer
R. E-cigarette use is differentially related to smoking onset
among lower risk adolescents. Tob Control 2016;26(5):
534-9.
23. Walley SC, Jenssen BP, Section on Tobacco Control.
Electronic nicotine delivery systems. Pediatrics 2015;
136(5):1018-26. Available at: “https://pediatrics.aap
publications.org/content/136/5/1018”. Accessed October
31, 2020.
24. U.S. Department of Health and Human Services. Pre-
venting Tobacco Use Among Youth and Young Adults:
A Report of the Surgeon General. Atlanta, Ga.: U.S.
Department of Health and Human Services, Centers for
Disease Prevention and Control, National Center for
Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health; 2012. Available at:
“https://www.ncbi.nlm.nih.gov/books/NBK99237/”.
Accessed October 3, 2020.
25. U.S. Congress. Family smoking prevention and tobacco
control act. June 22, 2009. Available at: “https://www.
govinfo.gov/content/pkg/PLAW-111publ31/pdf/PLAW
-111publ31.pdf ”. Accessed July 7, 2020.
26. Sharpless N. FDA Voices: How FDA is regulating e-
cigarettes. September 10, 2019. U.S. Food and Drug
Administration. Available at: “https://www.fda.gov/news
-events/fda-voices/how-fda-regulating-e-cigarettes”.
Accessed October 5, 2020.
27. Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos
C, Romagna G, Voudris V. Nicotine absorption from
electronic cigarette use: Comparison between first and
new-generation devices. Sci Rep 2014;4:4133. Available
at: “https://doi.org/10.1038/srep04133”. Accessed July
7, 2020.
28. Cobb NK, Byron M, Abrams D, Sheilds P. Novel nicotine
delivery systems and public health: The rise of the
“e-cigarette”. Am J Public Health 2010;100(12):2340-2.
29. Choi H, Schmidbauer N, Spengler J, Bornehag C. Sources
of propylene glycol and glycol ethers in air at home. Int
J Environ Res Public Health 2010;7(12):4213-37.
30. Cameron JM, Howell D, White J, Andrenyak D, Layton
M, Roll M. Variable and potentially fatal amounts of
nicotine in ENDS nicotine solutions. Tob Control 2014;
23(1):77-8.
31. Centers for Disease Control and Prevention. Smoking
and tobacco use: Outbreak of lung injury associated with
the use of e-cigarette, or vaping, products. February
2020. Available at: “https://www.cdc.gov/tobacco/basic
_information/e-cigarettes/severe-lung-disease.html”.
Accessed July 7, 2020.
32. Etter J, Bullen C. Electronic cigarette: Users profile,
utilization, satisfaction and perceived efficacy. Addiction
2011;106(11):2017-28.
 ORAL HEALTH POLICIES: E–CIGARETTES

33. Talhout R, Schultz T, Florek E, van Benthem J, Wester 35. Flouris AD, Chorti M, Poulianiti K, Jamourtas A, Kostikas
P, Opperhuizen A. Hazardous compounds in tobacco K, Tzatzarakis M. Acute impact of active and passive
smoke. Int J Environ Res Public Health 2011;8(2): electronic cigarette smoking on serum cotinine and lung
613-28. function. Inhalation Toxicol 2013;25(2):91-101.
34. Geiss O, Bianchi I, Barahona F, Barrero-Moreno J. Charac-
terisation of mainstream and passive vapors emitted by
selected electronic cigarettes. Int J Hyg Environ Health
2015;218(1):169-80. Available at: “https://www.science
direct.com/science/article/pii/S1438463914000972?via
%3Dihub”. Accessed October 5, 2020.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 111

ORAL HEALTH POLICIES: SUBSTANCE MISUSE IN ADOLESCENTS
Policy on Substance Misuse in Adolescent Patients
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that substance misuse in adolescents is a significant
health, social, and familial issue in the United States. The
increasing prevalence of substance misuse among adolescents
obligates dental personnel to identify behaviors characteristic
of active use, recognize clinical signs and symptoms of
active use or withdrawal, modify dental treatment accordingly,
and facilitate referral to medical providers or behavioral
addiction specialists. This policy addresses the harmful effects
of alcohol and drug misuse in the adolescent and the dental
provider’s role in recognition, initiation of appropriate
interventions, and referrals.
Methods
This policy, developed by the Council on Clinical Affairs and
adopted in 20161, is based upon a review of current dental
and medical literature, including a literature review through
®
the PubMed /MEDLINE database using the terms: adolescent
substance abuse, adolescent substance misuse, substance use in
adolescents, alcohol use in adolescents, illicit drug and alcohol
use in teenagers, adolescent alcohol and/or drug abuse, and
prescription drug use/misuse in teenagers; fields: all; limits:
within the last five years, humans, English, birth through age
18. The search resulted in 741 papers that were reviewed by
abstract and title. Papers for review were chosen from this list
and from the references within selected articles. Websites and
documents from select healthcare and public policy organiza-
tions, as well as governmental agencies, also were reviewed.
Definitions
Adolescence: “11 to 21 years of age, dividing the group into
early (ages 11-14 years), middle (ages 15-17 years), and late
(ages 18-21 years) adolescence.”2
Binge or heavy episodic drinking: “pattern of drinking alcohol
that brings blood alcohol concentration (BAC) to 0.08 percent
– or 0.08 grams of alcohol per deciliter – or higher. For a
typical adult, this pattern of excessive alcohol use corresponds
to consuming four or more drinks (female), or five or more
drinks (male) in about two hours. Research shows that fewer
drinks in the same timeframe result in the same BAC in
youth; only three drinks for girls, and three to five drinks for
boys, depending on their age and size”.3
Substance misuse: “used to distinguish improper or unhealthy
use from use of a medication as prescribed or alcohol in
moderation. These include the repeated use of drugs to
112 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
substance misuse in adolescent patients. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:112-6.
produce pleasure, alleviate stress, and/or alter or avoid reality.
It also includes using prescription drugs in ways other than
prescribed or using someone else’s prescription”.4
Substance use disorder (SUD): “a cluster of cognitive, be-
havioral, and physiological symptoms indicating that the
individual continues using the substance despite significant
substance-related problems”.5
Withdrawal syndrome: “the development of a substance-specific
maladaptive behavioral change, usually with uncomfortable
physiological and cognitive consequences, that is the result of
a cessation of, or reduction in, heavy and prolonged sub-
stance use”.6
Background
Many physical, social, and behavioral changes occur during
the adolescent years. The developing adolescent may encounter
difficulties and pressures without effective coping skills or
maturity. Unfortunately, some teenagers do not have familial,
peer, or other support systems to provide help and guidance
in adjusting to changes or with decision making. As a result,
they may turn to alcohol or drugs to seek comfort and reduce
the stresses associated with this erratic time in their lives.7
Substances misused by adolescents include alcohol, in-
halants, opiates, amphetamines, cocaine, marijuana, barbiturates,
benzodiazepines, hallucinogens, and anabolic steroids.8 In a
2019 survey of eighth, tenth, and twelfth grade students, trends
revealed alcohol use at 7.9, 18.4, and 29.3 percent respectively
in the previous 30 days, reflecting a five-year decreasing trend
in comparison to survey results from 2014.9 Prevalence of
binge drinking in the past 30 days demonstrated a five-year
decline, reported at 3.8, 8.5, and 14.4 percent.9 Use of any
illicit drug was reported to be 8.5 percent for eighth graders,
19.8 percent for tenth graders, and 23.7 percent for twelfth
graders.9
Findings from the 2019 Monitoring the Future (MTF)
survey demonstrate the strong desire for vaping in adoles-
cence, as seen in the increased prevalence of marijuana use as
well as nicotine vaping.9 Past-month marijuana vaping among
twelfth graders nearly doubled in a single year from 7.5 to
14 percent.9 Marijuana was the most commonly used illicit
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. COVID-19: Corona-
virus disease 2019. ENDS: Electronic nicotine delivery systems.
MTF: Monitoring the Future. SUD: Substance use disorder.

drug among teenagers.9 A national sample study of adoles-
cents and young adults demonstrated use of electronic
nicotine delivery systems (ENDS) and coupled use of ENDS
and cigarettes are significant underlying risk factors for
coronavirus disease 2019 (COVID-19).10 Association of the
prevalence of individuals who vaped (vapers) in each United
States state and daily number of COVID-19 cases and deaths
per state suggested vapers may be more susceptible to
COVID-19 cases and deaths.11 The MTF survey found rates
remaining unchanged for other illegal drug use in this
population, including methamphetamine, cocaine, and over-
the-counter cough and cold preparations.9 A 2015 survey
found more than 2.3 million youth aged 12-17 years were
current (i.e., in the past 30 days) users of illicit drugs,
equivalent to 9.4 percent of adolescents.12 In 2015, alcohol
use was higher, reported at 11.5 percent, corresponding
to 2.9 million adolescents, with binge drinking shown to
occur in 6.1 percent.12 Among the same age group, current
marijuana use was at 7.4 percent (approximately 1.8 million
adolescents).12 Misuse of prescription drugs (i.e., analgesics,
stimulants, anxiolytics, sedatives) for non-medical purposes
was reported by 2.6 percent of adolescents.12 Based on a
2019 survey, alcohol use among adolescents reduced to 9.4
percent, and the percent of binge drinkers reduced to 4.9
percent.13 Despite the decrease, about one in 11 adolescents
was a current alcohol user, and one in 21 adolescents was a
current binge drinker in 2019.13 Approximately one in six
(17.2 percent) adolescents aged 12 to 17 in 2019 was a
past-month illicit drug user.13 Between 2015 to 2019, the
percentage of adolescents who used illicit drugs in the past
year ranged from 15.8 to 17.2 percent.13
In 2019, 4.5 percent of adolescents (one in 22 adolescents)
had SUD, which was lower than five percent of adolescents
diagnosed in 2015.13 Similarly, the percentage of adolescents
with alcohol use disorder decreased from 2.7 percent in 2015
to 1.7 percent in 2019.13 Adolescents regularly and frequently
consume caffeine-containing beverages, considered harmless
and non-addictive, such as coffee, tea, cocoa, carbonated bev-
erages, energy drinks, and energy shots.14 Though caffeine use
disorder is not officially classified in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5), caffeine
intoxication and caffeine withdrawal are listed disorders.5
Prescription drug monitoring programs (PDMPs) have
been implemented in most states and have been effective in
reducing the number of prescriptions and opiates available for
misuse by adolescents.15 However, many adolescents are resort-
ing to heroin and fentanyl.16 In 2017, misuse of prescription
opioids, heroin, and fentanyl analogs increased the overall
death rate (per 100,000) to 12.6 in adolescents and young
adults, up from 3.7 in 2000.17 Drug use at an early age is an
important predictor of development of a SUD later in life.7
Of people who started drinking by age 14, 15.2 percent
eventually developed an alcohol use disorder as compared to
just 2.1 percent of those who waited until they were 21 years
or older.18 Thirteen percent of those who developed an SUD
ORAL HEALTH POLICIES: SUBSTANCE MISUSE IN ADOLESCENTS
began using marijuana by the time they were 14 years of age.18
Of individuals who misused prescription drugs at age 13 or
younger, 25.3 percent developed a SUD at some time in their
lives.19 Recurrent use of drugs or alcohol causes significant
clinical and functional impairment such as health issues, dis-
ability, and failure to fulfill important responsibilities at work,
school, or home.20
Due to the prevalence of substance misuse, it would not
be uncommon for the dental provider to encounter signs of
substance misuse. Staff should be attentive to similar signs
displayed by the parent. Clinical presentations of substance
use may include odor of alcohol on breath, odor of marijuana
on clothing, impaired behavior, slurred speech, staggering
gait, visual hallucinations, disorientation, rhinitis, scratching,
physical injuries including lacerations, needle marks, cellulitis,
diaphoresis, tachycardia, sensory impairment, and pupillary
dilation or constriction.21 Cognitive and behavioral manifesta-
tions may present as mood changes or emotional instability,
loud obnoxious behavior, laughing at nothing, withdrawn/
depressed affect, lack of communication/silence, hostility/
anger/uncooperative behavior, inability to speak intelligibly or
to focus, rapid-fire speech, hyperactivity, and unusually elated
mood.21,22 Perioral and oral signs may include sores around the
mouth, continual wetting or licking of lips, clenched teeth,
bruxism, trismus, enamel chips or coronal fractures, neglected/
poor oral hygiene, multiple cervical caries lesions, gingivitis,
gingival ulceration, periodontitis, pale mucosa, leukoplakia,
and intraoral burns.8,21,23 Adolescents experiencing withdrawal
syndrome may demonstrate behaviors such as altered mental
status, agitation, irritability, restlessness, increased anxiety or
panic, and inattentiveness.6,8 Clinical signs and reported symp-
toms of substance withdrawal include rhinorrhea, tachycardia,
elevated temperature, yawning, tremors, hallucinations, and
seizures.6,8
Adolescent substance misuse frequently co-occurs with
mental disorders.5,7,8,24,25 SUD often coexists with psychiatric
conditions such as depression, anxiety disorders, attention-
deficit hyperactivity disorder, oppositional defiant disorder,
conduct disorder, bipolar disorder, post-traumatic stress disor-
der, bulimia nervosa, social phobia, and schizophrenia.4,25-27
Substance use may induce the deterioration, emergence,
or reoccurrence of psychiatric disorders, or it may work in
reducing, masking, or enabling an adolescent to cope with
symptoms.24-26,28 Behaviors consistent with both SUD and
mental disorders may be confusing to dental providers.
Professionals must be cautious not to assume clinical signs
are associated with substance misuse when, in fact, they are
presentations consistent with mental disorders and vice
versa.7,8,25-27 Such caution prevents inaccurate diagnoses and
judgment or labelling of an adolescent patient, which could
lead to emotional harm and diversion from necessary treat-
ment.25,26,28
Dentists are in a position to identify clinical manifestations
of substance misuse, present brief interventions, and provide
referrals to medical providers or behavioral health or addiction
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 113
ORAL HEALTH POLICIES: SUBSTANCE MISUSE IN ADOLESCENTS
specialists. They also can assist the patient and family in
finding treatment facilities, self-help groups, and community
resources which address alcohol and drug misuse specific to
adolescents.7,8,29-31 When substance misuse is suspected or con-
firmed, an empathetic, non-judgmental style of discussion
facilitates a trusting patient-doctor relationship.8,31 Asking
open-ended questions may garner more information as they
tend to be less threatening to the patient.8 Brief interventions
may include educating the patient or family, or both, on health
risks of use or misuse of alcohol or other drugs, strong encour-
agement for avoiding drugs and alcohol, motivational inter-
viewing,27,32 and initiating referrals for assessment and treatment
by other health care providers.7,8,29-31,33 Although the dental
practitioner may grant patient confidentiality, he must abide
by state laws when treating minors.8 Involvement of the parent
and other authorities is imperative when substance misuse
places the adolescent patient or others in a high-risk or life-
threatening situation.8,34 In such circumstances, the patient
should receive notification when disclosure of confidential
information will occur and be provided an opportunity to
join the conversation.34
When providing treatment to a patient suspected of sub-
stance use, the dentist may need to modify sedation procedures,
administration of local anesthetics, and prescribing practices.
Administration of nitrous oxide or anxiolytic or sedative medi-
cations to an adolescent who is actively using or has a current
history of substance misuse can lead to unfavorable drug
interactions, over-sedation, or respiratory depression.8,29 Use
of these agents during remission/recovery from a SUD can
predispose a patient to relapse.7,8,25 Dentists should use local
anesthetics containing vasoconstrictors judiciously in patients
who misuse stimulant medications such as methylphenidate,
amphetamine and dextroamphetamine, methamphetamine,
and cocaine.30 Drug interactions between vasoconstrictors and
stimulants can cause tachycardia, hypertension or hypotension,
palpitations, hyperthermia, cardiac dysrhythmias, myocardial
infarction, and cerebrovascular accidents.8,35-37 Dentists should
be knowledgeable of the various SUDs (e.g., alcohol, opiate,
benzodiazepine) when recommending or prescribing medica-
tions.30 When pain management is necessary, an adolescent
with an opioid use disorder should receive non-opioid anal-
gesics (e.g., acetaminophen, non-steroidal anti-inflammatory
drugs [NSAIDS]).6,8 Prior to prescribing medications that
have the potential to be misused, the practitioner should assess
adolescent patients with risk factors such as active substance
use, past SUD, current medications, and a family history of
SUD.7,38 For patients at high risk, the dentist should consider
prescribing alternative medications with less abuse poten-
tial, closely monitoring the patient, reducing length of time
between visits for refills, prescribing smaller amounts of liquid
medications or fewer pills, and educating both patients and
parents about proper use and potential risks of prescription
medications, including the risk of sharing them with others.7
114 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Policy statement
The number of adolescents who misuse alcohol, drugs, or both
is a public health problem.9,13 The AAPD recognizes providing
dental care to adolescents with substance use disorders requires
awareness of clinical manifestations and implementation of dif-
ferent treatment approaches. Therefore, the AAPD encourages
dental professionals to:
• gain knowledge of SUD and associated behavioral,
physiological, and cognitive effects in adolescents.
• use a specific adolescent medical history documenting
past history, current use, and previous treatments for
SUD.
• recognize behaviors, clinical signs, and symptoms of
adolescent substance misuse.
• provide brief interventions to educate the adolescent and
his family regarding the risks of substance misuse.
• provide brief interventions for encouragement, support,
and positive reinforcement for avoiding substance use.
• provide referrals to primary care providers or behavioral
health or addiction specialists for assessment and/or
treatment of SUD in adolescents when indicated.
• be familiar with community resources, such as self-help
groups and treatment facilities, specific to adolescents
with SUD.
• use local anesthetics containing vasoconstrictors with
caution in patients having a stimulant use disorder.
• limit or decline use of nitrous oxide and anxiolytic or
sedative medications in adolescents with SUD.
• recommend non-opioid analgesics or prescribe non-
controlled medications with a low potential for misuse
when medications are indicated for disease management/
pain control.
• if non-controlled medications are ineffective, prescribe
only small amounts of medications that have the potential
to be misused, preferably with no refills.
• respect patient confidentiality in accordance with state
and federal laws.
References
1. American Academy of Pediatric Dentistry. Policy on sub-
stance abuse in adolescent patients. Pediatr Dent 2016;
38(6):70-3.
2. Hagan JF Jr, Shaw JS, Duncan P, eds. Bright Futures:
Guidelines for the Health Supervision of Infants, Chil-
dren, and Adolescents. 3rd ed. Elk Grove Village, Ill.:
American Academy of Pediatrics; 2008:733-820.
3. Chung T, Creswell KG, Bachrach R, et al. Adolescent
binge drinking: Developmental context and opportunities
for prevention. Alcohol Res 2018;39(1):5-15.
4. National Institute on Drug Abuse. The science of drug
abuse and addiction: The basics. Bethesda, Md.: National
Institutes of Health; 2014. Available at: “https://www.
drugabuse.gov/publications/media-guide/science-drug-use-
addiction-basics”. Accessed October 18, 2021.

5. American Psychiatric Association. Diagnostic and Statisti-
cal Manual of Mental Disorders. 5th ed. Arlington, Va.:
American Psychiatric Association; 2013:483.
6. Center for Substance Abuse Treatment. Detoxification and
substance abuse treatment. Treatment Improvement Pro-
tocol (TIP) Series, No. 45, Rockville, Md.: Center for
Substance Abuse Treatment; 2006. HHS publication no.
(SMA) 15-4131. Available at: “http://www.ncbi.nlm.nih.
gov/books/NBK64119/#A85324”. Accessed October 18, 2021.
7. National Institute on Drug Abuse. Principles of adolescent
substance use disorder treatment: A research-based guide.
Bethesda, Md.: National Institutes of Health; 2014. NIH
publication no. 14-7953. Available at: “https://teens.dru-
gabuse.gov/sites/default/files/podata_1_17_ 14_0.pdf ”.
Accessed October 18, 2021.
8. Kulig J, Ammermann SD, Moreno MA, et al. Substance
abuse. In: Fisher MM, Aldermann EM, Kreipe RE,
Rosenfeld WD, eds. American Academy of Pediatrics
Textbook of Adolescent Health Care. Elk Grove Village,
Ill.: American Academy of Pediatrics; 2011:1726-813.
9. Johnson LD, Miech RA, O’Malley PM, Bachman JG,
Schulenberg JE, Patrick ME. Monitoring the Future na-
tional survey results on drug use: 1975-2019: Overview,
key findings on adolescent drug use. Ann Arbor, Mich.:
Institute for Social Research, University of Michigan;
2020. Available at: “http://www.monitoringthefuture.
org/pubs/monographs/mtf-overview2019.pdf ”. Accessed
October 18, 2021.
10. Gaiha SM, Cheng J, Halpern-Felsher B. Association
between youth smoking, electronic cigarette use, and
COVID-19. J Adolesc Health 2020;67(4):519-23.
11. Li D, Croft DP, Ossip DJ, Xie Z. The association between
statewide vaping prevalence and COVID-19. Prev Med
Rep 2020;20:101254. Available at: “https://doi.org/10.
1016/j.pmedr.2020.101254”. Accessed October 18, 2021.
12. Centers for Behavioral Health Statistics and Quality.
Behavioral health trends in the United States: Results
from the 2014 national survey on drug use and health.
Rockville, Md.: Substance Abuse and Mental Health
Services Administration; 2015. HHS publication no.
SMA 15-4927, NSDUH series H-50. Available at: “https:
//www.samhsa.gov/data/sites/default/files/NSDUH-FRR1
-2014/NSDUH-FRR1-2014.pdf ”. Accessed October 18,
2021.
13. Substance Abuse and Mental Health Services Administra-
tion. Key substance use and mental health indicators in
the United States: Results from the 2019 National
Survey on Drug Use and Health (HHS Publication No.
PEP20-07-01-001, NSDUH Series H-55). Rockville,
Md: Center for Behavioral Health Statistics and Quality,
Substance Abuse and Mental Health Services Adminis-
tration; 2020. Available at: “https://www.opioidlibrary.
org/wp-content/uploads/2020/10/SAMHSA-2020
-Key-SU-and-Mental-Health-Indicators-report.pdf ”.
Accessed October 18, 2021.
ORAL HEALTH POLICIES: SUBSTANCE MISUSE IN ADOLESCENTS
14. Pagliaro LA, Pagliaro AM. Caffeine and nicotine. In:
Child and Adolescent Drug and Substance Abuse. New
York, N.Y.: Routledge; 2020:275-383.
15. Centers for Disease Control and Prevention. Opioid
overdose. Understanding the epidemic. Centers for Disease
Control and Prevention, National Center for Injury Pre-
vention and Control; 2020. Available at: “https://www.
cdc.gov/drugoverdose/epidemic/index.html”. Accessed
October 18, 2021.
16. O’Donnell J, Halpin J, Mattson CL, Goldberger BA,
Gladden RM. Deaths involving fentanyl, fentanyl analogs,
and U-47700 - 10 States, July-December 2016. MMWR
Morb Mortal Wkly Rep 2017;66(43):1197-202.
17. Ford JA. Prescription opioid misuse among adolescents.
Pediatr Clin N Am 2019;66(6):1099-108.
18. Substance Abuse and Mental Health Services Administra-
tion. Results from the 2012 National Survey on Drug Use
and Health: Summary of National Findings. NSDUH
Series H-46, HHS Publication No. (SMA) 13-4795
Rockville, Md.: Substance Abuse and Mental Health
Services Administration; 2013. Available at: “https://www.
samhsa.gov/data/sites/default/files/NSDUHresults2012/
NSDUHresults2012.pdf ”. Accessed October 18, 2021.
19. McCabe SE, West BT, Morales M, Cranford JA, Boyd
CJ. Does early onset of non-medical use of prescription
drugs predict subsequent prescription drug abuse and
dependence? Results from a national study. Addiction
2007;102(12):1920-30.
20. Substance Abuse and Mental Health Services Adminis-
tration. Mental health and substance use disorders.
Rockville, Md.; 2015. Available at: “http://www.samhsa.
gov/disorders”. Accessed October 18, 2021.
21. Partnership to End Addiction. How to spot the signs of
teen or young adult substance use. Drugfree.org; 2020.
Available at: “https://drugfree.org/article/spotting-drug-
use/”. Accessed October 18, 2021.
22. Williams JF, Storck M, American Academy of Pediatrics
Committee on Substance Abuse; American Academy of
Pediatrics Committee on Native American Child Health.
Inhalant abuse. Pediatrics 2007;119(5):1009-17.
23. Saini GK, Gupta ND, Prabhat KC. Drug addiction and
periodontal diseases. J Indian Soc Periodontol 2013;17
(5):587-91.
24. Fishman M. Relationship between substance use disorders
and psychiatric comorbidity. In: Kaminer Y, ed. Youth
Substance Abuse and Co-occurring Disorders. Arlington,
Va.: American Psychiatric Association Publishing; 2016:
21-47.
25. Center for Substance Abuse Treatment. Substance abuse
treatment for persons with co-occurring disorders. Treat-
ment Improvement Protocol (TIP) Series, No. 42. Rock-
ville, Md.: Substance Abuse and Mental Health Services
Administration; 2005. HHS publication no. (SMA) 05-
3922. Available at: “http://www.ncbi.nlm. nih.gov/books/
NBK64184/#A74167”. Accessed October 18, 2021.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 115
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26. Chan YF, Dennis ML, Funk RR. Prevalence and co-
morbidity of major internalizing and externalizing
problems among adolescents and adults presenting to
substance abuse treatment. J Subst Abuse Treat 2008;
34(1):14-24.
27. Kaminer Y, Winters KC, Kelly J. Screening, assessment,
and treatment options for youths with a substance use
disorder. In: Kaminer Y, ed. Youth Substance Abuse and
Co-occurring Disorders. Arlington, Va.: American Psychi-
atric Association Publishing; 2016:49-80.
28. Garito PJ. Assessing and treating psychiatric co-morbidity
in chemically abusing adolescents. In: O’Connell D,
Beyer E, eds. Managing the Dually Diagnosed Patient:
Clinical Issues and Clinical Approaches. 2nd ed. New
York, N.Y.: The Haworth Press; 2002:153-88.
29. Yepes JF, Dean JA. Examination of the mouth and other
relevant structures. In: Dean JA, senior ed., Jones JE,
Sanders BJ, Vinson LAW, Yepes JF, eds. McDonald and
Avery’s Dentistry for the Child and Adolescent. 11th ed.
St. Louis, Mo.: Elsevier; 2022:14-6.
30. American Dental Association. Statement on provision
of dental treatment for patients with substance use dis-
orders. October, 2005. Available at: “https://www.ada.
org/en/advocacy/current-policies#substanceusedisorders”.
Accessed October 18, 2021.
31. Fingerhood MI. Special populations: Adolescents. In:
Rastegar DA, Fingerhood MI, eds. American Society of
Addiction Medicine Handbook of Addiction Medicine.
2nd ed. New York, N.Y.: Oxford University Press; 2020;
380-5.
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32. Miller WR, Rollnick S. Applying motivational interview-
ing. In: Motivational Interviewing: Helping People
Change. 3rd ed. New York, N.Y.: The Guilford Press;
2013:335-51.
33. Levy SJ, Williams JF, American Academy of Pediatrics
Committee on Substance Use and Prevention. Substance
use screening, brief intervention, and referral to treatment.
Pediatrics 2016;138(1):e20161211.
34. Moon MR. Confidentiality in dealing with adolescents.
In: Miller SC, Fiellin DA, Rosenthal RN, Saitz R, eds.
American Society of Addiction Medicine Principles of
Addiction Medicine. 6th ed. Philadelphia, Pa.: Wolters
Kluwer; 2019:1664-6.
35. Klein-Schwartz W. Abuse and toxicity of methylphenidate.
Curr Opin Pediatr 2002;14(2):219-23.
36. Hamamoto DT, Rhodus NL. Methamphetamine abuse
and dentistry. Oral Dis 2009;15(1):27-37.
37. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. The
pathophysiology, medical management, and dental im-
plications of children and young adults having attention-
deficit hyperactivity disorder. J Calif Dent Assoc 2003;
31(9):669-78.
38. Bukstein OG. Adolescents with substance use disorders:
How did they get there? In: Treating Adolescents with
Substance Use Disorders. New York, N.Y.: The Guilford
Press; 2019:19-21.

Policy on Human Papilloma Virus Vaccinations
Revised
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes there is a link between human papilloma virus
(HPV) and development of oral pharyngeal cancers. The
purpose of this policy is to provide a perspective on a dental
provider’s role in discussing oral cancers and their associations
with HPV, and HPV vaccination for age-appropriate patients.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2017.1 This revision is based on a review of
current dental and medical literature. An electronic search
®
was conducted using the PubMed /MEDLINE database
using the terms: HPV vaccines, HPV and oral cancer, HPV
®
and cancer, Gardasil and prevention of cancer; fields: all;
limits: within the last 10 years, humans, English, birth
through age 99. The search returned over 5,296 articles. Papers
for review were chosen from this list and from the references
within selected articles.
Background
HPV is associated with anogenital, skin, and oral and oropha-
ryngeal cancers (OOPC)2-4. It also is observed in oral squa-
mous cell carcinoma, the most common type of OOPC. 5
Based on epidemiological trends, 53,260 new cases and 10,750
deaths due to OOPC were expected to occur in 2019.6 HPV
is a critical factor, with the HPV 16 strain being the most
prevalent. 7 The association between HPV infection and
OOPC may be responsible for the recent epidemiologic change
with OOPC affecting younger population groups.
Vaccines for prevention of HPV infections via subtypes
16 and 18 have been available since 2006.8 The Centers for
Disease Control and Prevention (CDC) found that the preva-
lence of HPV infection decreased 56 percent among females
aged 14-19 years since the vaccine was introduced.8 A recent
study showed 88 percent reduction in prevalence in females
and males age 18-33 years.10 HPV vaccine efficacy against
anal and oral infection is high and similar to that against
cervical infection.11 Because the same viral strains are strongly
associated with OOPC, it is reasonable to assume that HPV
vaccines play an important role in oral pharyngeal cancer
prevention. Although there are no studies showing that the
HPV vaccine prevents the development of OOPC, it is
reasonable to postulate the vaccine’s potential since the vaccine
has been shown to prevent HPV infection. 9 Despite the
ORAL HEALTH POLICIES: HPV VACCINATIONS
How to Cite: American Academy of Pediatric Dentistry. Policy on
human papilloma virus vaccinations. The Reference Manual of Pedi-
atric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:117-8.
increased availability of the HPV vaccines, HPV-related
OOPC incidence has continued to increase significantly.12
In 2016, the CDC Advisory Committee on Immunization
Practices (ACIP) recommended a two-dose schedule for chil-
dren younger than 15 years with both doses 6-12 months
apart. 13 For children age 15 or older at the time of initial
vaccination and for those with immunocompromising
conditions, a three-dose series is recommended. 13 The
American Academy of Pediatrics (AAP) updated their HPV
vaccination policy in 2017 to reflect the CDC/ACIP
recommendations. 14 Low compliance rates for completion
of the vaccination series are due to access, willingness of
physicians to discuss with parents, and cost.14-17
Adolescent patients have unique needs related to oral
healthcare. Anticipatory guidance for adolescent patients
includes tobacco and nutritional counseling.18,19 Given that
dental professionals are already involved in secondary and
tertiary prevention and, to a limited extent, in the treatment of
OOPC, offering primary prevention in dental clinics seems a
logical and clinically-appropriate approach. As adolescent
patients tend to see the dentist twice yearly and more often
than their medical doctor, this is a window of opportunity
for the dental professional to provide counseling to the patient
and parent about HPV’s link to oral cancer and potential
benefits of the HPV vaccine.20
Policy statement
The AAPD supports measures that prevent OOPC, including
the prevention of HPV infection, a critical factor in the
development of oral squamous cell carcinoma.
The AAPD encourages oral health care providers to:
• educate patients, parents, and guardians on the serious
health consequences of OOPC and the relationship
of HPV to OOPC.
• counsel patients, parents, and guardians regarding the
HPV vaccination, in accordance with CDC recommen-
dations, as part of anticipatory guidance for adolescent
patients.
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
of Pediatric Dentistry. ACIP: Advisory Committee on Immunization
Practices. CDC: Centers for Disease Control and Prevention. HPV:
Human papilloma virus. OOPC: Oral and oropharyngeal cancer.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 117
ORAL HEALTH POLICIES: HPV VACCINATIONS
• routinely examine patients for oral signs of and changes
consistent with OOPC.
• follow current literature and consider incorporating
other approaches for HPV prevention in their practices
so as to minimize the risk of disease transmission.
References
1. American Academy of Pediatric Dentistry. Policy on
human papilloma virus vaccinations. Pediatr Dent 2017;
39(6):81-2.
2. National Cancer Institute. HPV and cancer. 2014. Avail-
able at: “https://www.cancer.gov/about-cancer/causes-
prevention/risk/infectious-agents/hpv-and-cancer”.
Accessed May 11, 2020.
3. American Cancer Society. Cancer facts and figures 2019.
Available at: “https://www.cancer.org/content/dam/
cancer-org/research/cancer-facts-and-statistics/annual-
cancer-facts-and-figures/2019/cancer-facts-and-figures
-2019.pdf ”. Accessed January 3, 2020.
4. Cogliano V, Baan R, Straif K, Grosse Y, Secretan B, El
Ghissassi F. Carcinogenicity of human papillomaviruses.
World Health Organization International Agency for
Research on Cancer. Lancet Oncol 2005;6:204.
5. Daley E, DeBate R, Dodd V, et al. Exploring awareness,
attitudes, and perceived role among oral health providers
regarding HPV-related oral cancers. J Public Health Dent
2011;71(2):136-42.
6. American Cancer Society. Cancer A-Z. Oral Cavity and
Oropharyngeal Cancer: Causes, Risk Factors, and Preven-
tion. Available at: “https://www.cancer.org/cancer/oral
-cavity-and-oropharyngeal-cancer/causes-risks-prevention.
html”. Accessed May 11, 2020.
7. Weatherspoon DJ, Chattopadhyay A, Boroumand S,
Garcia I. Oral cavity and oropharyngeal cancer incidence
trends and disparities in the United States: 2000-2010.
Cancer Epidemiol 2015;39(4):497-504. Available at:
“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC453
2587/”. Accessed January 3, 2020.
8. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent
human papillomavirus vaccine: Recommendations of the
Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep 2007;56(RR-2):1-24.
9. Markowitz LE, Hariri S, Lin C, et al. Reduction in human
papillomavirus (HPV) prevalence among young women
following HPV vaccine introduction in the United States,
National Health and Nutrition Examination Surveys,
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.
118 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
11. Beachler CK. Multisite HPV 16/18 vaccine efficacy
against cervical, anal, and oral HPV infection. J Natl
Canc Inst 2015;108(1):djv302. Available at: “https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC4862406/”.
Accessed October 31, 2020.
12. Senkomago V, Henley SJ, Thomas CC, Mix JM.
Markowitz LE, Saraiya M. Human papillomavirus—
Attributable cancers—United States 2012-2015. MMWR
Mor Mortal Wkly Rep 2019;68:724-8.
13. Meites E, Kempe A, Markowitz LE. Use of a 2-dose
schedule for human papillomavirus vaccination —
Updated recommendations of the Advisory Committee
on Immunization Practices. Morb Mortal Wkly Rep
2016;65(49):1405-8. Available at: “https://www.cdc.gov
/mmwr/volumes/65/wr/mm6549a5.htm”. Accessed
October 31, 2020.
14. American Academy of Pediatrics. HPV Vaccine Imple-
mentation Guidance Updated February 2017. Available
at: “https://www.aap.org/en-us/Documents/immunization
_hpvimplementationguidance.pdf ”. Accessed January 3,
2020.
15. McRee AG. HPV vaccine hesitancy: Findings from a
statewide survey of health care providers. J Pediatr Health
Care 2014;28(6):541-9.
16. Siddiqui M, Salmon DA, Omer SB. Epidemiology of
vaccine hesitancy in the United States. Hum Vaccin
Immunother 2013;9(12):2643-8.
17. Henrikson NB, Opel DJ, Grothaus L, et al. Physician
communication training and parental vaccine hesitancy:
A randomized trial. Pediatrics 2015;136(1):70-9.
18. American Academy of Pediatric Dentistry. Adolescent oral
health care. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:257-66.
19. American Academy of Pediatric Dentistry. Periodicity of
examination, preventive dental services, anticipatory
guidance/counseling, and oral treatment for infants, chil-
dren, and adolescents. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:232-42.
20. Irwin CE Jr, Adams SH, Park MJ, Newacheck PW.
Preventive care for adolescents: Few get visits and fewer
get services. Pediatr 2009;123(4):e565-72. Available at:
“https://dx.doi.org/10.1542/peds.2008-2601”. Accessed
January 3, 2020.

Policy on Intraoral / Perioral Piercing and Oral
Jewelry / Accessories
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry recognizes the
importance of educating the public and health professionals
on the health implications of intraoral/perioral piercings and
oral jewelry/accessories.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2000.1 This document is a revision of the
previous version, revised in 2016.2 The update included a
new review of current dental and medical literature, including
®
a search of the PubMed and Cochrane Central Register of
Controlled Trials electronic databases through October, 2020
with the terms: oral jewelry, body piercing, and oral piercing
paired with dental and oral piercing; fields: all; limits: within
the last 10 years, humans, English, birth through age 99.
Fifty-five articles matched these criteria. Alternate strategies
such as appraisal of references from recent evidence-based
reviews, controlled clinical trials, and meta-analyses and hand
searches were performed. This strategy yielded 21 manuscripts
which were evaluated further by abstract. Papers for review
were chosen from this list and from the references within
selected articles.
Background
The use of intraoral jewelry and piercings of oral and perioral
tissues have been gaining popularity among adolescents and
young adults. Intraoral jewelry or other oral accessories may
lead to increased plaque levels, periodontal pathogenic bacteria,
gingival inflammation and/or recession, caries, diminished
articulation, and metal allergy.3-7 Oral piercings involving the
tongue, lips, cheeks, and uvula have been associated with
pathological conditions including pain, infection, scar forma-
tion, tooth fractures, metal hypersensitivity reactions, localized
periodontal disease, speech impediment, Ludwig’s angina,
hepatitis, and nerve damage.3-22 Specifically, gingival recession
was evident in up to 50 percent of all patients with lip pier-
cing and up to 44 percent of patients with tongue piercing.4-8
Permanent tooth injuries were observed in up to 26 percent
of patients with lip piercing and up to 46 percent of
patients with tongue piercings.4-8 Life-threatening complica-
tions (e.g., bleeding, edema, endocarditis, airway obstruction)
have been reported with oral piercings.3-22 Additionally, the
use of dental jewelry (e.g., grills) has been documented to
ORAL HEALTH POLICIES: INTRAORAL / PERIORAL PIERCING
How to Cite: American Academy of Pediatric Dentistry. Policy on
intraoral/perioral piercing and oral jewelry/accessories. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:119-20.
cause dental caries and periodontal problems.9-11 Unregulated
piercing parlors and techniques have been identified as a
possible vector for disease (e.g., hepatitis, tetanus, tuberculosis)
transmission and as a cause of bacterial endocarditis in sus-
ceptible patients.7,11 Between January 1, 2002 and December
31, 2008, an estimated 24,459 patients presented to United
States emergency departments with oral piercing-related
injuries.12 The annual average number of estimated emergency
department visits was 3,494, with a range from 2,675 (in
2005) to 4,380 (in 2006).12
Policy statement
The American Academy of Pediatric Dentistry strongly opposes
the practice of piercing intraoral and perioral tissues and use
of jewelry on intraoral and perioral tissues due to the poten-
tial for pathological conditions and sequelae associated with
these practices.
References
1. American Academy of Pediatric Dentistry. Policy on
intraoral and perioral piercing. Pediatr Dent 2000;22
(suppl):33.
2. American Academy of Pediatric Dentistry. Policy on
intraoral/perioral piercing and oral jewelry/accessories.
Pediatr Dent 2016;38(special issue):74-5.
3. Ziebolz D, Söder F, Hartl JF. Prevalence of periodon-
tal pathogenic bacteria at different oral sites of patients
with tongue piercing – Results of a cross sectional study.
Diagn Microbiol Infect Dis 2019;95(4):114888. Epub
2019 Aug 12.
4. Ziebolz D, Hildebrand A, Proff P, Rinke S, Hornecker
E, Mausberg R. Long-term effects of tongue piercing – A
case control study. Clin Oral Investig 2012;16(1):231-7.
5. Plessas A, Pepelassi E. Dental and periodontal complica-
tions of lip and tongue piercing: Prevalence and influen-
cing factors. Aust Dent J 2012;57(1):71-8.
6. Hennequin-Hoenderdos NL, Slot DE, Van der Weijden
GA. The incidence of complications associated with lip
and/or tongue piercings: A systematic review. Int J Dent
Hyg 2016;14(1):62-73.
7. Covello F, Salerno C, Giovannini V, Corridore D,
Ottolenghi L, Vozza I. Piercing and oral health: A study
on the knowledge of risks and complications. Int J
Environ Res Public Health 2020;17(2):613.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 119
ORAL HEALTH POLICIES: INTRAORAL / PERIORAL PIERCING
8. Ziebolz D, Söder F, Hartl JF, Kottmann T, Rinke S,
Schmalz G. Comprehensive assessment of dental be-
haviour and oral status in patients with tongue piercing
—Results of a cross-sectional study. Clin Oral Investig
2020;24:971-7.
9. Hollowell WH, Childers NK. A new threat to adolescent
oral health: The grill. Pediatr Dent 2007;29(4):320-2.
10. American Dental Association Division of Communica-
tions. Grills, ‘grillz’ and fronts. J Am Dent Assoc 2006;
137(8):1192. Available at: “https://www.ada.org/~/media/
ADA/Publications/Files/patient_65.pdf?la=en”. Accessed
June 22, 2021.
11. American Dental Association. ADA statement on oral
piercing/jewelry, July, 2020. Available at: “http://www.
ada.org/en/ member-center/oral-health-topics/oral-piercing-
jewelry”. March 22, 2021.
12. Gill JB, Karp JM, Kopycka-Kedzierawski DT. Oral
piercing injuries treated in United States emergency de-
partments, 2002-2008. Pediatr Dent 2012;34(1):56-60.
13. GÖlz L, Papageorgiou SN, Jäger A. Nickel hypersensitiv-
ity and orthodontic treatment: A systematic review and
meta-analysis. Contact Dermatitis 2015;73(1):1-14.
14. Hennequin-Hoenderdos NL, Slot DE, Van der Weijden
GA. The prevalence of oral and perioral piercings in
young adults: A systematic review. Int J Dent Hyg 2012;
10(3):223-8.
120 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
15. Kapferer I, Beier US. Lateral lower lip piercing--prevalence
of associated oral complications: A split-mouth cross-
sectional study. Quintessence Int 2012;43(9):747-52.
16. Kapferer I, Beier US, Jank S, Persson RG. Randomized
controlled trial: Lip piercing: The impact of material
on microbiological findings. Pediatr Dent 2013;35(1):
E23-8.
17. Kapferer I, Beier US, Persson RG. Tongue piercing: The
effect of material on microbiological findings. J Adolesc
Health 2011;49(1):76-83.
18. Kloppenburg G, Maessen J. Streptococcus endocarditis
after tongue piercing. J Heart Valve Dis 2007;16(3):
328-30.
19. Martinello R, Cooney E. Cerebellar brain abscess asso-
ciated with tongue piercing. Clin Infect Dis 2003;36(2):
32-4.
20. Maspero C, Farronato G, Giannini L, Kairyte L, Pisani
L, Galbiati G. The complication of oral piercing and the
role of dentist in their prevention: A literature review.
Stomatologija 2014;16(3):118-24.
21. Vieira EP, Ribeiro AL, Pinheiro Jde J, Alves Sde M. Oral
piercings: Immediate and late complications. J Oral
Maxillofac Surg 2011;69(12):3032-7.
22. Vilchez-Perez MA, Fuster-Torres MA, Figueiredo R,
Valmaseda-Castellon E, Gay-Escoda C. Periodontal health
and lateral lower lip piercings: A split-mouth cross-
sectional study. J Clin Periodontol 2009;36(7):558-63.

Policy on Prevention of Sports-Related Orofacial
Injuries
Latest Revision
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the prevalence of sports-related orofacial injuries
in our nation’s youth and the need for prevention. This
policy is intended to educate dental professionals, health care
providers, and educational and athletic personnel on the
prevention of sports-related orofacial injuries.
Methods
This policy was developed by the Clinical Affairs Committee,
adopted in 1991, and revised by the Council on Clinical
Affairs. This document is a revision of the previous version,
revised in 2013. The revision of this policy is based upon a
review of current dental and medical literature related to
orofacial injuries, including their prevention. Database searches
were performed using the terms: sports injuries, injury preven-
tion, dental injuries, orofacial injuries. Seventy-seven references
were chosen from this method and from references within
selected articles. The policies, recommendations, and listed
references of the Academy for Sports Dentistry (ASD) and
the International Association of Dental Traumatology were
consulted as valuable resources in preparation of this document.
Background
The tremendous popularity of organized youth sports and
the high level of competitiveness have resulted in a signifi-
cant number of dental and facial injuries.1,2 From 1990-
2003, there was an average of 22,000 dental injuries annually
in children less than 18 years of age.3 This was approximately
31.6 dental injuries per 100,000 children and adolescents. In
2007, it was reported that approximately 46 million youths
in the United States (U.S.) were involved in some form of
sports over the past decade.4 It has been estimated that 30
million children in the U.S. participate in organized sport
programs.5 All sporting activities have an associated risk of
orofacial injuries due to falls, collisions, contact with hard
surfaces, and contact from sports-related equipment. A
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
and maxillofacial surgery department found 31.8 percent of
injuries in children occurred during sports activities.7 Children
ages 17 years and younger represented 80.6 percent of the
ORAL HEALTH POLICIES: SPORTS-RELATED OROFACIAL INJURIES
How to Cite: American Academy of Pediatric Dentistry. Policy on
prevention of sports-related orofacial injuries. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:121-6.
total (sport and not-sport related) dental injuries that pre-
sented that presented to U.S. emergency rooms from
1990-2003.3 In all age groups, males were more likely to
have dental injuries than females.3
It has been demonstrated that dental and facial injuries
can be reduced significantly by introducing mandatory pro-
tective equipment.8,9 Currently in the U.S., high school football,
lacrosse, and ice hockey require protective equipment.10
Popular sports such as baseball, basketball, soccer, softball,
wrestling, volleyball, and gymnastics lag far behind in injury
protection for girls and boys. Baseball and basketball have
been shown to have the highest incidence of sports-related
dental injuries in children seven to 17 years of age.1 More
specifically, baseball accounted for the most dental injuries
within the seven to 12 year old age group, while basketball
was the most frequent sport associated with dental injuries in
the 13 to 17 year age group.3 Youths participating in leisure
activities such as skateboarding, inline or roller skating, and
bicycling also benefit from appropriate protective equip-
ment.11-14 A large national survey confirmed the bicycle as
the most common consumer sports product related to dental
injuries in children, followed by playground equipment, other
riding equipment (skates, inline skates), and trampolines.3
The use of the trampoline provides specialized training for
certain sports. However, when used recreationally, a signifi-
cant number of head and neck injuries occurs, with head
injuries most commonly a result of falls.15 The American
Academy of Pediatrics (AAP) recommends practitioners advise
patients and their families against recreational trampoline use
and discuss that current safety measures have not decreased
injury rates significantly.15 The AAP also states that practi-
tioners “should only endorse use of trampolines as part of a
structured training program with appropriate coaching, super-
vision, and safety measures in place”.15
Studies of dental and orofacial athletic injuries are reported
throughout the medical and dental literature.16-19 Injury rates
vary greatly depending on the size of the sample, the sample’s
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
Pediatric Dentistry. ASD: Academy of Sports Dentistry. ASTM:
American Society for Testing and Materials. U.S.: United States.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 121
ORAL HEALTH POLICIES: SPORTS-RELATED OROFACIAL INJURIES
geographic location, the ages of the participants, and the spe-
cific sports involved in the study.16-20 Rates of traumatic dental
injuries also differ in regards to the athlete’s level of competi-
tion; less-professional athletes exhibit a higher prevalence of
sports-related injuries.18 Most of the current data regarding
injuries comes from the National High School Sports-Related
Injury Surveillance Study and captures information such as
exposure (competition vs. practice), the injury, details of the
event, and type of protective equipment used.21 Data from this
source found that in 2016-2017 school year, of the 699,441
injuries reported during competition, 223,623 (32 percent)
occurred to the head/face; another 91,410 occurred during
practice.21 A similar study using this database followed athletes
from 2008-2014 and found the rate of dental injuries in
competition was three times higher than in practice.21 For the
majority of these reported injuries, the athlete was not wearing
a mouthguard.20 Review of this database found the highest
rates of dental injuries in high school athletes occurred in
girls’ field hockey and boys’ basketball.20 Although the statistics
vary, many studies reported that dental and orofacial injuries
occurred regularly and concluded that participation in sports
carries a considerable risk of injury.7,12,17,18
Consequences of orofacial trauma for children and their
families are substantial because of potential for pain, psycho-
logical effects, and economic implications. Children with
untreated trauma to permanent teeth exhibit greater impacts
on their daily living than those without any traumatic
injury.22,23 The yearly costs of all injuries, including orofacial
injuries, sustained by young athletes have been estimated to
be 500 million dollars24 and as high as 1.8 billion dollars.5
Significant costs can accrue over a patient’s lifetime for
restorative, endodontic, prosthodontic, implant, or surgical
treatment(s) resulting from dentoalveolar trauma. It has been
suggested that the lifetime cost of an avulsed tooth in a
teenage athlete can reach $20,000, exceeding the maximum
benefits for most insurance companies.25 Traumatic dental
injuries have additional indirect costs that include children’s
hours lost from school and parents’ hours lost from work,
consequences that disproportionately burden lower income,
minority, and non-insured children.26-29
The majority of sport-related dental and orofacial injuries
affect the upper lip, maxilla, and maxillary incisors, with
50 to 90 percent of dental injuries involving the maxillary
incisors.16,17,25,30 The most common injuries in order of inci-
dence are lacerations, crown fractures, and avulsions.7 Crown
fractures are the most common injury to permanent teeth,31,32
followed by subluxations and avulsions.32 While use of a
mouthguard can protect the upper incisors, it may not protect
against soft tissue injuries. However, studies have shown that
even with a mouthguard in place, dentoalveolar injuries still
can occur.33
Identifying patients who participate in sports and recrea-
tional activities allows the healthcare provider to recommend
and implement preventive protocols for individuals at risk for
orofacial injuries. In 2000, a predictive index was developed
122 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
to identify the risk factors involved in various sports.34 This
index is based upon a defined set of risk factors that predict
the chance of injury including demographic information (age,
gender, dental occlusion), protective equipment (type/usage),
velocity and intensity of the sport, level of activity and expo-
sure time, level of coaching and type of sports organization,
whether the player is a focus of attention in a contact or non-
contact sport, history of previous sports-related injury, and
the situation (practice vs. game).34 Behavioral risk factors
(e.g., hyperactivity) also have been associated significantly with
injuries affecting the face and/or teeth.35,36
While this predictive index looked at contact versus non-
contact sport as a factor, non-contact sports can carry signifi-
cant risk. For example, basketball is one of the sports with the
highest incidence of dental injury, but these injuries usually
involve player-player contact whereas greater than 87 percent
of all dental injuries sustained by baseball, softball, and field
hockey players are due to player-object contact.20
The frequency of dental trauma is significantly higher for
children with increased overjet (greater than six millimeters) and
inadequate lip coverage.37,38 A dental professional may be able
to modify these risk factors. Initiating preventive orthodontic
treatment in early- to middle-mixed dentition of patients with
an overjet greater than three millimeters has the potential to
reduce the severity of traumatic injuries to permanent incisors.37
Although some sports-related traumatic injuries are un-
avoidable, most can be prevented.39-41 Helmets, facemasks, and
mouthguards have been shown to reduce both the frequency
and severity of dental and orofacial trauma.39 While facemasks
may not significantly reduce the risk of orofacial trauma due
to player-player contact, they might have a significant effect
with player-object contact.9 The protective and positive results
of wearing a mouthguard have been demonstrated in nu-
merous epidemiological surveys and tests.18,42-46 However, few
sports have regulations that require their use. The National
Federation of State High School Associations mandates
mouthguards only for football, ice hockey, lacrosse, and
field hockey and for wrestlers wearing braces.10 Several states
have attempted to increase the number of sports which
mandate mouthguard use, with various degrees of success and
acceptance. Four states (Maine, Massachusetts, Minnesota,
and New Hampshire) have been successful in increasing the
number of sports requiring mouthguard use to include sports
such as soccer, wrestling, and basketball.41,47,48 It is likely that
the mandated mouthguard rule has not expanded to other
sports due to complaints by athletes, parents, and coaches that
mouthguards interfere with how the game is played and the
athletes’ enjoyment.47,49 Regardless of the relatively limited use
of mouthguards in sports, the American Dental Associations
and International Academy of Sports Dentistry currently rec-
ommend the use of mouthguards in 29 sports or activities.50
Initially used by professional boxers, the mouthguard has
been used as a protective device since the early 1900s.6,17,51 The
mouthguard, also referred to as a gumshield or mouth protec-
tor, is defined as a “resilient device or appliance placed inside

the mouth to reduce oral injuries, particularly to teeth and
surrounding structures.”52 The mouthguard was constructed to
“protect the lips and intraoral tissues from bruising and
laceration, to protect the teeth from crown fractures, root
fractures, luxations, and avulsions, to protect the jaw from
fracture and dislocations, and to provide support for eden-
tulous space.”53 The mouthguard helps to prevent fractures
and dislocations of teeth by providing cushioning from the
blow and redistributing shock during forceful impacts and
decreases the likelihood of jaw fracture by a similar mecha-
nism and also by stabilizing the mandible.54 The mouthguard
acts as a buffer between the soft and hard dento-oral structures
to prevent soft tissue injuries by separating the teeth from the
tissues.54 Recent data suggests that a properly fitted mouth-
guard of 3.0 millimeter thickness might reduce the incidence
of concussion injuries from a blow to the jaw by positioning
the jaw to absorb the impact forces which, without it, would
be transmitted through the skull base to the brain.55
The American Society for Testing and Materials (ASTM)
classifies mouthguards by three categories56:
1. Type I – Custom-fabricated mouthguards are produced
on a dental model of the patient’s mouth by either the
vacuum-forming or heat-pressure lamination technique.39
The ASTM recommends that for maximum protection,
cushioning, and retention, the mouthguard should cover
all teeth in at least one arch, customarily the maxillary
arch, less the third molar.56 A mandibular mouthguard is
recommended for individuals with a Class III malocclu-
sion. The custom-fabricated type is superior in retention,
protection, and comfort.39,54,57-60 When this type is not
available, the mouth-formed mouthguard is preferable to
the stock or preformed mouthguard.60-63
2. Type II – Mouth-formed, also known as boil-and-bite,
mouthguards are made from a thermoplastic material
adapted to the mouth by finger, tongue, and biting
pressure after immersing the appliance in hot water.52
Available commercially at department and sporting-goods
stores as well as online, these are the most commonly used
among athletes but vary greatly in protection, retention,
comfort, and cost.39,42
3. Type III – Stock mouthguards are purchased over-the-
counter. They are designed for use without any modifi-
cation and must be held in place by clenching the teeth
together to provide a protective benefit.45 Clenching a
stock mouthguard in place can interfere with breathing
and speaking and, for this reason, stock mouthguards
are considered by many to be less protective.50 Despite
these shortcomings, the stock mouthguard could be the
only option possible for patients with particular clinical
presentations (e.g., use of orthodontic brackets and
appliances, periods of rapidly changing occlusion during
mixed dentition).42,60,64
The ASD “recommends the use of a properly fitted mouth-
guard. It encourages the use of a custom fabricated mouthguard
ORAL HEALTH POLICIES: SPORTS-RELATED OROFACIAL INJURIES
made over a dental cast and delivered under the supervision
of a dentist. The ASD strongly supports and encourages a
mandate for use of a properly-fitted mouthguard in all
collision and contact sports.” 65 During fabrication of the
mouthguard, it is recommended to establish proper anterior
occlusion of the maxillary and mandibular arches as this
will prevent or reduce injury by better absorbing and dis-
tributing the force of impact.65 The practitioner also should
consider the patient’s vertical dimension of occlusion, personal
comfort, and breathing ability. 63 By providing cushioning
between the maxilla and mandible, mouthguards also may
reduce the incidence or severity of condylar displacement
injuries as well as the potential for concussions.55,66
Due to the continual shifting of teeth in orthodontic
therapy, the exfoliation of primary teeth, and the eruption of
permanent teeth, a custom-fabricated mouthguard may not
fit the young athlete soon after the impression is obtained.67
Several block-out methods used in both the dental operatory
and laboratory may incorporate space to accommodate for
future tooth movement and dental development. 67 By anti-
cipating required space changes, a custom fabricated mouth-
guard may be made to endure several sports seasons.67
Parents play an important role in the acquisition of a
mouthguard for young athletes. In a 2004 national fee survey,
custom mouthguards ranged from $60 to $285.54.68 In a
study to determine the acceptance of the three types of
mouthguards by seven- and eight-year-old children playing
soccer, only 24 percent of surveyed parents were willing to pay
$25 for a custom mouthguard.68 Thus, cost may be a barrier.68
However, a more likely barrier may be that children do not
accept mouthguard use easily. In a study of children receiving
mouthguards at no cost, 29 percent never wore the mouth-
guard, 32 percent wore it occasionally, 15.9 percent wore it
initially but quit wearing it after one month, and only 23.2
percent wore the mouthguard when needed.69
Attitudes of officials, coaches, parents, and players about
wearing mouthguards influence their usage.49 Although coaches
are perceived as the individuals with the greatest impact on
whether or not players wear mouthguards, parents view them-
selves as equally responsible for maintaining mouthguard
use.49,70 However, surveys of parents regarding the indications
for mouthguard usage reveal a lack of complete understanding
of the benefits of mouthguard use.70 Compared to other forms
of protective equipment, mouthguard use received only
moderate parental support in youth soccer programs. 71
A 2009 survey commissioned by the American Association
of Orthodontists reported that 67 percent of parents stated
their children do not wear a mouthguard during organized
sports.72 The survey also found that 84 percent do not wear
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’
speech as a potential hindrance to mouthguard compliance,
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 123
ORAL HEALTH POLICIES: SPORTS-RELATED OROFACIAL INJURIES
the ASD recommends that a properly-fitted mouthguard
should provide for adequate speech commiserate with the
playing status of the athlete. 76 Given the multiple reasons
for lack of compliance in wearing mouthguards, the dental
profession needs to influence and educate all stakeholders
about the risk of sports-related orofacial injuries and avail-
able preventive strategies.56,61,77 Routine dental visits can be
an opportunity to initiate patient/parent education and make
appropriate recommendations for use of a properly-fitted
athletic mouthguard.
Policy statement
The AAPD encourages:
• dentists to play an active role in educating the public
in the use of protective equipment for the prevention
of orofacial injuries during sporting and recreational
activities.
• continuation of preventive practices instituted in youth,
high school, and college football, lacrosse, field hockey,
ice hockey, and wrestling (for wrestlers wearing braces).
• an ASTM-certified face protector be required for youth
participating in baseball and softball activities.
• mandating the use of properly-fitted mouthguards in
other organized sporting activities that carry risk of oro-
facial injury.
• coaches/administrators of organized sports to consult
a dentist with expertise in orofacial injuries prior to
initiating practices for a sporting season for recommen-
dations for immediate management of sports-related
injuries (e.g., avulsed teeth).
• continuation of research in development of a comfort-
able, efficacious, and cost-effective sports mouthguard
to facilitate more widespread use of this proven protective
device.
• dentists of all specialties, including pediatric and general
dentists, to provide education to parents and patients
regarding prevention of orofacial injuries as part of the
anticipatory guidance discussed during dental visits.
• dentists to prescribe, fabricate, or provide referral for
mouthguard protection for patients at increased risk
for orofacial trauma.
• third-party payors to realize the benefits of mouthguards
for the prevention and protection from orofacial sports-
related injuries and, furthermore, to improve access to
these services.
• pediatric dentists to partner with other dentists and child
health professionals, school administrators, legislators,
and community sports organizations to promote the
broader use of mouthguards.
• pediatric dental departments to teach dental students
the fabrication of custom-fitting mouthguards.
124 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
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46. Takeda T, Ishigami K, Mishima O, et al. Easy fabrication
of a new type of mouthguard incorporating a hard insert
and space and offering improved shock absorption ability.
Dent Traumatol 2011;27(6):489-95.
47. Mills SC. Mandatory mouthguard rules for high school
athletes in the United States. Gen Dent 2015;63(6):
35-40.
48. Kumamoto D. Establishing a mouthguard program in
your community. Gen Dent 2000;48:160-4.
49. Gardiner D, Ranalli DN. Attitudinal factors influencing
mouthguard utilization. Dent Clin North Am 2000;44
(1):53-65.
50. American Dental Association. The importance of using
mouthguards: Tips for keeping your smile safe. J Am
Dent Assoc 2004;135(7):1061.
51. Mayer C. Tooth protectors for boxers. Oral Hyg 1930;
20:298-9.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 125
ORAL HEALTH POLICIES: SPORTS-RELATED OROFACIAL INJURIES
52. Newsome P, Tran D, Cooke M. The role of the mouth-
guard in the prevention of sports-related dental injuries:
A review. Int J Paediatr Dent 2001;11(6):396-404.
53. Biasca N, Wirth S, Tegner Y. The avoidability of head
and neck injuries in ice hockey: A historical review. Br
J Sports Med 2002;36(6):410-27.
54. Deogade SC, Dube G, Sumathi K, Dube P, Katare U,
Katare D. Sports dentistry and mouthguards. Brit J Med
Med Res 2016;11(6):1-10.
55. Winters J, DeMont R. Role of mouthguards in reducing
mild traumatic brain injury/concussion incidence in high
school athletes. Gen Dent 2014;62(3):34-8.
56. American Society for Testing and Materials. ASTM F697-
16. Standard practice for care and use of athletic mouth
protectors. West Conshohocken, Pa.: 2016. Available at:
“https://www.astm.org/Standards/F697.htm”. Accessed
June 30, 2018.
57. McClelland C, Kinirons M, Geary L. A preliminary study
of patient comfort associated with customised mouth-
guards. Br J Sports Med 1999;33(3):186-9.
58. Warnet L, Greasley A. Transient forces generated by
projectiles on variable quality mouthguards monitored
by instrumented impact testing. Br J Sports Med 2001;
35(4):257-62.
59. Greasley A, Imlach G, Karet B. Application of a standard
test to the in vitro performance of mouthguards. Br J
Sports Med 1998;32(1):17-9.
60. Duddy FA, Weissman J, Lee RA Sr, Paranipe A, Johnson
JD, Cohenca N. Influence of different types of mouth-
guards on strength and performance of collegiate
athletes: A controlled-randomized trial. Dent Traumatol
2012;28(4):263-7.
61. Patrick DG, van Noort R, Found MS. Scale of protec-
tion and the various types of sports mouthguard. Br J
Sports Med 2005;39(5):278-81.
62. Bureau of Dental Health Education and Bureau of
Economic Research and Statistics. Evaluation of mouth
protectors used by high school football players. J Am
Dent Assoc 1964;68(3):430-42.
63. DeYoung AK, Robinson E, Godwin WC. Comparing
comfort and wearability: Custom-made vs. self-adapted
mouthguards. J Am Dent Assoc 1994;125(8):1112-8.
64. Ranalli DN. Prevention of craniofacial injuries in
football. Dent Clin North Am 1991;35(4):627-45.
65. Academy for Sports Dentistry. Position statement: A
properly fitted mouthguard 2010. Available at: “http://
www.academyforsportsdentistry.org/index.php?option=
com_content&view=article&id=51:position-statements
&catid=20:site-content&Itemid=111”. Accessed June
30, 2018.
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66. Waliko T, Bir C, Godwin W, King A. Relationship between
temporomandibular joint dynamics and mouthguards:
Feasibility of a test method. Dent Traumatol 2004;20(5):
255-60.
67. Croll T, Castaldi CR. Custom sports mouthguard
modified for orthodontic patients and children in the
transitional dentition. Pediatr Dent 2004;26(5):417-20.
68. Walker J. Parents plus: Getting mouthguards into kids’
mouths. J Pediatr Dent Care 2005;11(2):39-40.
69. Matalon V, Brin I, Moskovitz M, Ram D. Compliance
of children and youngsters in the use of mouthguards.
Dental Traumatol 2008;24(4):462-7.
70. Diab N, Mourino A. Parental attitudes toward mouth-
guards. Pediatr Dent 1997;19(8):455-60.
71. Khodaee M, Fetters MD, Gorenflo DW. Football (soccer)
safety equipment use and parental attitudes toward safety
equipment in a community youth sports program. Res
Sports Med 2011;19(2):129-43.
72. American Dental Association. Play it safe: Prevent facial
injuries with simple sports safety precautions. April
2013. Available at: “https://www.ada.org/en/press-room/
news-releases/2013-archive/april/play-it-safe-prevent-
facial-injuries-with-simple-s”. Accessed June 30, 2018.
73. Walker J, Jakobsen J, Brown S. Attitudes concerning
mouthguard use in 7- to 8-year-old children. J Dent
Child 2002;69(2):207-11.
74. Raaii F, Vaidya N, Vaidya K, et al. Patterns of mouth-
guard utilization among atom and pee wee minor ice
hockey players: A pilot study. Clin J Sport Med 2011;
21(4):320-4.
75. Gawlak D, Mańka-Malara K, Kamiński T, Łuniewska
M, Mierzwińska-Nastalska E. Comparative evaluation
of custom and standard boil and bite (self-adapted)
mouthguards and their effect on the functioning of the
oral cavity. Dent Traumatol 2016;32(5):416-20.
76. Academy for Sports Dentistry. Position statement:
Mouthguard mandates. 2010. Available at: “https://asd.
memberclicks.net/position-statement”. Accessed June 30,
2018.
77. Woodmansey K. Athletic mouth guards prevent orofacial
injuries: A review. Gen Dent 1999;47(1):64-9.

Policy on the Use of Dental Bleaching for Child
and Adolescent Patients
Latest Revision
2019
Purpose
The American Academy of Pediatric Dentistry recognizes that
the desire for dental whitening by pediatric and adolescent
patients has increased. This policy is intended to help pro-
fessionals and patients make informed decisions about the
indications, efficacy, and safety of internal and external bleach-
ing of primary and young permanent teeth and incorporate
such care into a comprehensive treatment plan.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2004. This document is an update from the
last revision in 2014. This revision included a new literature
®
search of the PubMed /MEDLINE database using the terms:
dental bleaching, dental whitening, and tooth bleaching;
fields: all; limits: within the last 10 years, humans, English,
clinical trials, and birth through age 18. Over 350 articles
were selected and reviewed. Additional information was ob-
tained from reviewing references within selected articles.
Background
The desire for improved dental esthetics has fueled innovations
in dental materials. Patients, parents, and the news media
request information on dental whitening for children and
adolescents with increasing frequency. In addition, increased
demand for bleaching materials and services has affected
both the variety and availability of dental bleaching products
on the market.
Discoloration of teeth is classified by etiology. 1 Clinical
indications for internal or external dental whitening for
individual teeth may include discoloration resulting from a
traumatic injury (i.e., calcific metamorphosis, darkening with
devitalization), irregularities in enamel coloration of a perma-
nent tooth due to trauma or infection of the related primary
tooth, or intrinsic discoloration/staining (e.g., fluorosis, tetra-
cycline staining). 2-7 Teeth staining from metals (e.g., iron
supplements) or consumption of tea, coffee, soft drinks,
alcohol, and certain foods is extrinsic and easier to treat
compared to intrinsic factors whether congenital or acquired.
Severe discolorations may be best treated with microabrasion
and subsequent bleaching to achieve desirable results.8
Due to the difference in the thickness of enamel of primary
and permanent teeth, tooth coloration within a dental arch
ORAL HEALTH POLICIES: USE OF DENTAL BLEACHING
How to Cite: American Academy of Pediatric Dentistry. Policy on
the use of dental bleaching for child and adolescent patients.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:127-30.
may vary significantly during the mixed dentition. Full arch
cosmetic bleaching during this developmental stage, however,
would result in mismatched dental appearance once the child
is in the permanent dentition. Adolescents present with
unique dental needs, and the impact of tooth discoloration on
an adolescent’s self-image could be considered an indication
for bleaching.8 Tooth whitening has been successful in adoles-
cent patients using typical bleaching agents, 8 but research is
lacking on the effects of bleaching on the primary dentition.
Dental whitening may be accomplished by using either
professional or at-home bleaching modalities. Advantages of
in-office whitening or whitening products dispensed and
monitored by a dental professional include:
• an initial professional examination to help identify causes
of discoloration and clinical concerns with treatment
(e.g., existing restorations, side effects).
• professional control and soft-tissue protection.
• patient compliance.
• rapid results.
• immediate attention to teeth sensitivity and other adverse
effects.
The pretreatment professional assessment helps identify
pulpal pathology that may be associated with a single discol-
ored tooth. This examination also identifies restorations that
are faulty or could be affected by the bleaching process and
the associated costs for replacing such restorations to maximize
esthetic results.8-12 By using photographs and/or a shade guide,
the dentist can document the effectiveness of treatment. In
addition to providing in-office bleaching procedures, a dentist
may fabricate custom trays for at-home use of a bleaching
product. Custom trays ensure intimate fit and fewer adverse
gingival effects.13 Over-the-counter products for at-home use
include bleaching gels, whitening strips, brush-on agents,
toothpaste, mints, chewing gum, and mouth rinse. Their main
advantages include patient convenience and lower associated
costs.
Peroxide-containing whiteners or bleaching agents improve
the appearance by changing the tooth’s intrinsic color. The
professional-use products usually range from 10 percent car-
bamide peroxide (equivalent to about three percent hydrogen
peroxide) to 38 percent carbamide peroxide (equivalent to
approximately 13 percent hydrogen peroxide). In-office
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 127
ORAL HEALTH POLICIES: USE OF DENTAL BLEACHING
bleaching products require isolation with a rubber dam or a
protective gel to shield the gingival soft tissues. Home-use
bleaching products contain lower concentrations of hydrogen
peroxide or carbamide peroxide.2-4,14 Efficacy and long-term
outcomes of home whitening products will vary according to
the concentration of peroxide used and the severity of the
initial tooth discoloration.15-18 Many whitening toothpastes con-
tain polishing or chemical agents to improve tooth appearance
by removing extrinsic stains through gentle polishing, chem-
ically chelating, or other nonbleaching action.10,19 Carbamide
peroxide is the most commonly used active ingredient in
dentist-dispensed tooth-bleaching products for home-use.10,20
Side effects from bleaching vital and nonvital teeth have
been documented. It should be noted that most of the research
on bleaching has been performed on adult patients, with only
a small amount of published bleaching research using child or
adolescent patients.2,4,8,14,17,21-24 The more common side effects
associated with bleaching vital teeth are tooth sensitivity and
tissue irritation. Tooth sensitivity associated with vital bleach-
ing may be due to permeation of enamel and dentin by hydro-
gen peroxide and a subsequent mild, transient inflammatory
response.25-27 Hydrogen peroxide is a highly reactive substance
which can cause damage to oral hard and soft tissues when
used at high concentrations and an extended period of time.28,29
Between eight and 66 percent of patients experience post-
bleaching sensitivity, most often during the early stages of
treatment.7,10,14,17,21,24 Overtreatment has been shown to harm
tooth structure, which is of particular concern when bleaching
products are used excessively by overzealous teens and young
adults.29-31 Tissue irritation, in most cases, results from an ill-
fitting tray rather than the bleaching agents and resolves once
a more accurately fitted tray is used.32 Both sensitivity and tissue
irritation usually are temporary and cease with the discontinu-
ance of treatment.6,7,14,17,19,21,24,33,34 Additional risks may include
erosion, mineral degradation, pulpal damage, and increased
marginal leakage of existing restorations.14,35 When used
correctly, however, teeth bleaching has been proven to be safe
and causes no irreversible tooth structure damage.29
Internal bleaching for non-vital endodontically treated teeth
in young patients can be performed in the same way as for
adults.29 The more common side effect from internal bleaching
of nonvital teeth is external root resorption.36-39 With external
bleaching of nonvital teeth, the most common side effect is
increased marginal leakage of an existing restoration.3,40-44 One of
the degradation byproducts of hydrogen peroxide or carbamide
peroxide results in a hydroxyl-free radical. This byproduct
has been associated with periodontal tissue damage and root
resorption. Due to the concern of the hydroxyl free radical
damage45-47 and the potential side effects of dental bleaching,
minimizing exposure at the lowest effective concentration of
hydrogen peroxide or carbamide peroxide is recommended.
Providers should use caution when bleaching primary anterior
teeth, as the underlying permanent teeth are in jeopardy of
developmental disturbance from intramedullary inflammatory
changes.29,48
128 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Of growing concern is the preponderance of non-dental
professionals offering teeth whitening services to the public.49
Tooth whitening is defined as any process to whiten, lighten,
or bleach teeth.49 Teeth-whitening kiosks and beauty salons
and retail stores are providing whitening services and dis-
pensing teeth whitening agents.19,50 Dental organizations have
supported state regulations that restrict the practice of pro-
viding bleaching services to only dentists or other qualified
dental staff under the direct supervision of a dentist.49-51 The
use of over-the-counter whitening products remains exempt
from such regulation. Legislation defining the scope of practice
by non-dentists offering whitening treatment varies from state
to state and should be examined when these services are being
provided.50-52
Policy statement
Teeth whitening procedures that have been shown to be safe
may be beneficial for children and adolescents. Although the
use of whitening agents can improve dental esthetics and en-
hance a person’s self-esteem, proper treatment planning with
objectives should be conducted prior to engaging in any
bleaching protocol. Use of whitening agents should follow
the safety and efficacy standards as defined by clinical research
and best practice. Bleaching by young patients should be
supervised by an adult and under the guidance of a dentist.
The American Academy of Pediatric Dentistry encourages:
• the judicious use of bleaching for vital and nonvital teeth.
• patients to consult their dentists to determine appro-
priate methods for and the timing of dental whitening
within the context of an individualized, comprehensive,
and sequenced treatment plan.
• dental professionals and consumers to consider side effects
when contemplating dental bleaching for child and
adolescent patients.
• further research of dental whitening agents in children.
The American Academy of Pediatric Dentistry discourages
full-arch cosmetic bleaching for patients in the mixed denti-
tion and primary dentition.
References
1. Pinto MM, Leal de Godoy CH, Bortoletto CC, et al.
Tooth whitening with hydrogen peroxide in adolescents:
Study protocol for a randomized controlled trial. Trials
2014;15:395.
2. Zekonis R, Matis BA, Cochran MA, Al Shetri SE, Eckert
GJ, Carlson TJ. Clinical evaluation of in-office and at-
home bleaching treatments. Oper Dent 2003;28(2):114-21.
3. Abbott P, Heah SY. Internal bleaching of teeth: An
analysis of 255 teeth. Aust Dent J 2009;54(4):326-33.
4. Matis BA, Wang Y, Jiang T, Eckert GJ. Extended at-home
bleaching of tetracycline-stained teeth with different
concentrations of carbamide peroxide. Quintessence Int
2002;33(9):645-55.

5. Kugel G, Gerlach RW, Aboushala A, Ferreira S, Magnuson
B. Long-term use of 6.5% hydrogen peroxide bleaching
strips on tetracycline stain: A clinical study. Compend
Cont Educ Dent 2011;32(8):50-6.
6. Bizhang M, Muller M, Phark JH, Barker ML, Gerlach
RW. Clinical trial of long-term color stability of hydro-
gen peroxide strips and sodium percarbonate film. Am
J Dent 2007;20(Spec No A):23A-27A.
7. Donly KJ, Gerlach RW. Clinical trials on the use of
whitening strips in children and adolescents. Gen Dent
2002;50(3):242-5.
8. Donly KJ. The adolescent patient: Special whitening
challenges. Compend Contin Educ Dent 2003;24(4A):
390-6.
9. Lima DA, DeAlexandre RS, Martins AC, AGuiar FH,
Ambrosano GM, Lovadino JR. Effect of curing lights
and bleaching agents on physical properties of a hybrid
composite resin. J Esthet Restor Dent 2008;20(4):
266-73.
10. Bolay S, Cakir FY, Gurgan S. Effects of toothbrush-
ing with fluoride abrasive and whitening dentifrices on
both unbleached and bleached human enamel surface
in terms of roughtness and hardness: An in vitro study.
J Contemp Dent Pract 2012;13(5):584-9.
11. Metz MJ, Cochran MA, Batis BA, Gonzalez C, Platt JA,
Pund MR. Clincal evaluation of 15% carbamide peroxide
on the surface microhardness and shear bond strength
of human enamel. Oper Dent 2007;32(5):427-36.
12. Mullins JM, Kao EC, Martin CA, Gunel E, Ngan P.
Tooth whitening effects on bracket bond strength in
vivo. Angle Orthod 2009;79(4):777-83.
13. Aushcill TM, Schneider-Del Savio T, Hellwig E, Ar-
weiler NB. Randomized clinical trial of the efficacy,
tolerability, and long-term color stability of two bleaching
techniques: 18 month follow up. Quintessence Int 2012;
43(8):683-94.
14. Dawson PF, Sarif Mo, Smith AB, Brunton PA. A clinical
study comparing the efficacy and sensitivity of home vs
combined whitening. Oper Dent 2011;36(5):460-6.
15. Demarco FF, Meireles SS, Masotti AS. Over the counter
whitening agents: A concise review. Braz Oral Res 2009;
23(Sec Iss 1):64-70.
16. Francci C, Marson FC, Briso ALF, Gomes MN. Dental
bleaching–Current concepts and techniques. Rev Assoc
Paul Cir Dent 2010;64(1):78-89.
17. Donly KJ, Segura A, Sasa I, Perez E, Anastasia MK, Farrell
S. A controlled clinical trial to evaluate the safety and
whitening efficacy of a 9.5% hydrogen peroxide high-
adhesion whitening strip in a teen population. Am J
Dent 2010;23(5):292-6.
18. Ermis RB, Uzer CE, Yildiz G, Yazkan B. Effect of tooth
discolouration severity on the efficacy and colour stabil-
ity of two different trayless at-home bleaching systems.
J Dent Res Dent Clin Dent Prospects 2018;12(2):
120-7.
ORAL HEALTH POLICIES: USE OF DENTAL BLEACHING
19. American Dental Association Council on Scientific Affairs.
Tooth whitening/bleaching: Treatment considerations
for dentists and their patients; September 2009, Revised
November 2010. Available at: “https://www.ada.org/~/
media/ADA/About%20the%20ADA/Files/ada_house_of_
delegates_whitening_report.ashx effectiveness”. Accessed
June 30, 2019.
20. Walsh LJ. Safety issues relating to the use of hydrogen
peroxide in dentistry. Aust Dent 2000;45(4):257-60.
21. Donly KJ, Donly AS, Baharloo L, et al. Tooth whitening
in children. Compend Contin Educ Dent 2002;23(1A):
22-28; quiz 49.
22. Bacaksiz A, Tulunoglu O, Tulunoglu I. Efficacy and
stability of two in-office bleaching agents in adolescents:
12 months follow-up. J Clin Pediatr Dent 2016;40(4):
269-73.
23. Giachetti L, Bertini F, Bambi C, Nieri M, Scaminaci
Russo D. A randomized clinical trial comparing at-home
and in-office tooth whitening techniques: A nine-month
follow up. J Am Dent Assoc 2010;141(11):1357-64.
24. Donly KJ, Segura A, Henson T, Barker ML, Gerlach
RW. Randomized controlled trial of professional at-home
tooth whitening in teenagers. Gen Dent 2007;55(7):69-74.
25. Bowles WH, Ugwuneri Z. Pulp chamber penetration by
hydrogen peroxide following vital bleaching procedures.
J Endo 1987;13(8):375-7.
26. Cooper JS, Bokmeyer TJ, Bowles WH. Penetration of
the pulp chamber penetration by carbamide peroxide
beaching agents. J Endo 1992;18(7):315-7.
27. Moncada G, Sepulveda D, Elphick K, et al. Effects of light
activation, agent concentration, and tooth thickness on
dental sensitivity after bleaching. Oper Dent 2013;38(5):
467-476.
28. Haywood VB, Heymann HO. Nightguard vital bleach-
ing. Quintessence Int 1991;22(7):515-23.
29. Croll T, Donly K. Tooth bleaching in children and teens.
J Esthet Restor Dent 2014;26(3):147-150.
30. Goldberg M, Grootveld M. Lynch E. Undesirable and
adverse effects of tooth-whitening products: A review.
Clin Oral Investig 2010;14(1):1-10.
31. Lee SS, Zhang W, Lee DH, Li Y. Tooth whitening in
children and adolescents: A literature review. Pediatr
Dent 2005;27(5):362-8.
32. Haywood VB. Nightguard vital bleaching: Current con-
cepts and research. J Am Dent Assoc 1997;127(suppl):
19S-25S.
33. Matis BA, Cochran MA, Eckert G, Carlson TJ. The
efficacy and safety of a 10 percent carbamide peroxide
bleaching gel. Quintessence Int 1998;29(9):555-63.
34. Da Costa JB, McPharlin R, Paravina RD, Ferracane JL.
Comparison of at-home and in-office tooth whitening
using a novel shade guide. Oper Dent 2010;35(4):381-8.
35. Carey CM. Tooth whitening: What we now know. J Evid
Based Dent Pract 2014;14(Suppl):70-6.
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ORAL HEALTH POLICIES: USE OF DENTAL BLEACHING
36. Heithersay GS. Invasive cervical resorption following
trauma. Aust Endod J 1999;25(2):79-85.
37. Heithersay GS. Invasive cervical resorption: An analysis
of potential predisposing factors. Quintessence Int 1999;
30(2):83-95.
38. Heithersay GS. Treatment of invasive cervical resorption:
An analysis of results using topical application of trichlor-
acetic acid, curettage, and restoration. Quintessence Int
1999;30(2):96-110.
39. Attin T, Paqué F, Ajam F, Lennon AM. Review of the
current status of tooth whitening with the walking bleach
technique. Int Endod J 2003;36(5):313-29.
40. Teixeira EC, Hara AT, Turssi CP, Serra MC. Effect of
non-vital tooth bleaching on microleakage of coronal
access restorations. J Oral Rehabil 2003;30(11):1123-7.
41. Ferrari R, Attin T, Wegehaupt FJ, Stawarczyk B, Taubock
TT. The effects of internal tooth bleaching regimens on
composite-to-composite bond strength. J Am Dent Assoc
2012;143(12):1324-31.
42. Shinohara MS, Rodrigues JA, Pimenta LA. In vitro
microleakage of composite restorations after nonvital
bleaching. Quintessence Int 2001;32(5):413-7.
43. Sharma DS, Sharma S, Natu SM, Chandra S. An in vitro
evaluation of radicular penetration of hydrogen peroxide
from bleaching agents during intra-coronal tooth bleach-
ing with an insight of biologic response. J Clin Pediatr
Dent 2011;35(3):289-94.
44. Palo RM, Valera MC, Camargo SE, et al. Peroxide
penetration from the pulp chamber to the external root
surface after internal bleaching. Am J Dent 2010;23(3):
171-4.
45. Firat E, Ercan E, Gurgan S, Yucel OO, Cakir FY, Berker
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.
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46. Anderson DG, Chiego DJ Jr, Clickman GN, McCauley
LK. A clinical assessment of the effects of 10 percent
carbamide peroxide gel on human pulp tissue. J Endod
1999;25(4):247-50.
47. Kinomoto Y, Carnes DL Jr, Ebisu S. Cytotoxicity of
intracanal bleaching agents on periodontal ligament cells
in vitro. J Endod 2001;27(9):574-7.
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primary incisors: A clinical and histological study. J Dent
Child 1987;54(6):401-22.
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aspx”. Accessed March 25, 2019.
50. Otto M. Understanding the legal battles over teeth-
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25, 2019.

Policy on the Use of Lasers for Pediatric Dental
Patients
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the judicious use of lasers as a beneficial instrument
in providing dental restorative and soft tissue procedures for
infants, children, and adolescents, including those with
special health care needs. This policy is intended to support
safe and evidence-based use of lasers through a review of
the fundamentals, types, diagnostic and clinical applications,
benefits, and limitations of laser use in pediatric dentistry.
Methods
This policy was developed by the Council on Clinical
Affairs, adopted in 2013 1, and last revised in 2017 2. The
revision is based on a review of current dental and medical
literature related to the use of lasers. This document included
database searches using the terms: laser dentistry, dental lasers,
laser pediatric dentistry, laser soft tissue treatments, and
laser restorative dentistry. Articles were evaluated by title and/
or abstract and relevance to pediatric dental care. Expert
and/or consensus opinion by experienced researchers and
clinicians also was considered.
Background
Medicine began integrating lasers for soft tissue procedures
in the mid-1970s. Oral and maxillofacial surgeons incorpo-
rated the carbon dioxide (CO2) laser into practice for removal
of oral lesions in the 1980s. 3 The first laser specifically for
dental use was a neodymium:yttrium-aluminum-garnet
(Nd:YAG) laser, developed in 1987 and approved by the
United States Food and Drug Administration in 1990.4 Since
then, laser technology has advanced significantly. Currently,
lasers used in dentistry include Nd:YAG, argon, erbium,
(erbium, chromium:yttrium-scandium-gallium-garnet
[Er,Cr:YSGG] and erbium:yttrium-aluminum-garnet
[Er:YAG]), diode, and two CO 2 wavelengths. The use of
lasers contributes to many areas of dentistry including perio-
dontics5, pediatrics5, endodontics, oral surgery5, restorative
dentistry, dental hygiene, cosmetic dental whitening, and pain
management.6-10
Laser basics
While a detailed description of how lasers work is beyond
the scope of this document, the basics of laser physics are
ORAL HEALTH POLICIES: USE OF LASERS
How to Cite: American Academy of Pediatric Dentistry. Policy on
the use of lasers for pediatric dental patients. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:131-4.
important to understand prior to selecting a laser for dental
treatment. The term laser is an acronym for light amplification
by stimulated emission of radiation. Within a laser, an active
medium (e.g., erbium crystal, CO2 gas, a semiconductor) is
stimulated to produce photons of energy that are delivered in
a beam of unique wavelength measured in nanometers.10 The
wavelength of a dental laser is the determining factor of the
level to which the laser energy is absorbed by the intended
tissue. 10,11 Target tissues differ in their affinity for specific
wavelengths of laser energy depending on the presence of the
chromophore or the laser-absorbing elements of the tissue.10-12
Oral hard and soft tissues have a distinct affinity for absorb-
ing laser energy of a specific wavelength.10,11 For this reason,
selecting a specific laser unit depends on the target tissue the
practitioner wishes to treat.
The primary effect of a laser within target tissues is photo-
thermal, meaning the laser energy is transformed into heat.10
When the temperature of the target tissue containing water
is raised above 100 degrees Celsius, vaporization of the water
occurs, resulting in soft tissue ablation.10,11 Since soft tissue is
made up of a high percentage of water, excision of soft tissue
initiates at this temperature. Dental hard tissue is composed
of hydroxyapatite, mineral, and water. Erbium lasers do not
ablate hard tissues directly, but vaporization of the water com-
ponent causes the resulting steam to expand and then disperses
the encompassing material into small particles, a process
known as spallation.11,12 The 9300 nanometer (nm) CO2 wave-
length targets absorption within the water component, as well
as the phosphate and hydrogen phosphate anions of the
hydroxyapatite mineral molecule and is, therefore, capable of
ablating enamel and dentin.7,11
Laser operating parameters such as power, frequency,
emission mode, thermal relaxation time, and air and water
coolant used affect the clinical abilities of a laser. 10,11 Addi-
tionally, the delivery system of laser unit as well as the tissue
concentration of the chromophore greatly influence the
laser-tissue interactions.7,10
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CO2: Carbon dioxide.
Er,Cr:YSGG: Erbium, chromium:yttrium-scandium-gallium-garnet.
Er:YAG: Erbium:yttrium-aluminum-garnet. Nd:YAG: Neodymium-
yttrium-aluminum-garnet. nm: nanometer. PBM: Photobiomodulating.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 131
ORAL HEALTH POLICIES: USE OF LASERS
Clinical applications of the lasers commonly used in
pediatric dentistry are listed in the Table.
Laser safety
Adherence to safe practices is a duty of every practitioner,
but identification of a laser safety officer for a clinical facility
can maximize safe and effective laser operations. This person
would provide all necessary information, inspect and maintain
the laser and its accessories, and ensure that all safety pro-
cedures are implemented. 10 Because reflected or scattered
laser beams may be hazardous to unprotected skin or eyes,
wearing wavelength-specific protective eyewear is required
by the dental team, patient, and observers at all times during
laser use.10 Laser plume results from the aerosol byproducts
of laser-tissue interaction and may contain particulate organic
and inorganic matter (e.g., viruses, toxic gases, chemicals)
which may be infectious or carcinogenic.10
When using dental lasers, adherence to infection control
protocol, including wearing a 0.1 micron (um) filtration mask,
and utilization of high-speed suction are imperative.10 Sparks
from lasers can contribute to patient fire in the presence of
an oxidizer-enriched atmosphere and combustible agents (e.g.,
dry gauze, throat pack, paper, cotton products; hair; petroleum-
based lubricants; alcohol-based products; rubber dam and
nitrous mask).13-16 Safe laser practices reduce the risk of fire.13
Providing soft tissue treatment of viral lesions in immuno-
compromised patients has the risk of disease transmission from
laser-generated aerosol.17,18 Palliative pharmacological thera-
pies may be more acceptable and appropriate in this group of
patients in order to prevent viral transmission.18 Many states
have well-defined laser safety regulations, and information can
be obtained from state boards.
Benefits of lasers in pediatric dentistry
One of the benefits of laser use in pediatric dentistry is the
selective and precise interaction with diseased tissues.10 Less
thermal necrosis of adjacent tissues is produced with lasers
than with electrosurgical instruments. 10 During soft tissue
procedures, hemostasis can be obtained without the need for
sutures in most cases.5,10,11 This may allow wound healing to
occur more rapidly with less post-operative discomfort and a
reduced need for analgesics.5,9-12 Little to no local anesthesia is
required for most soft-tissue treatments.5,9-12 Reduced operator
chair time has been observed when soft tissue procedures have
been completed using lasers.5,9 Lasers demonstrate decontami-
nating and bacteriocidal properties on tissues, requiring less
prescribing of antibiotics post-operatively.5,9,11,12
Laser therapeutics can occur without a photothermal event,
and these effects are known as photobiomodulating (PBM) or
low-level laser effects.6 PBM therapy has been used in children
for prevention and treatment of oral mucositis associated with
immunosuppressive therapy (chemotherapy, radiation, and
transplants).19-22 PMB may reduce postsurgical or traumatic
oral pain6 and pain during cavity preparation.23 Laser ther-
apy (PBM as well as application of erbium and CO 2 laser
132 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
energy24,25) can provide relief from the pain and inflammation
associated with aphthous ulcers and herpetic lesions without
pharmacological intervention5,9,26,27; however, more studies are
needed to establish the laser type and therapeutic parameters
(e.g., applied energy, wavelength, power outlet) recommended
for children.25
Nd:YAG, erbium, and 9300 nm CO 2 lasers have been
shown to have an analgesic effect on hard tissues, reducing or
eliminating the use of local anesthesia during tooth prepara-
tions.7,12,28-32 The mechanism for laser analgesia is not known;
however, proposed explanations include that the photo-
acoustic effect of laser energy acts within the gate control
pathway blocking pain sensations, direct and indirect in-
fluences of laser energy on nerves and nociceptors, and
modifications of the sodium/potassium pump systems
inhibiting nerve transmission.7,33 During restorative procedures.
conventional dental handpieces produce noise and vibrations
which have been postulated as stimulating discomfort, pain,
and anxiety for the pediatric patient.12,23,29,34 The non-contact
of lasers with hard tissue eliminates the vibratory effects of
the conventional high-speed handpiece and may reduce
anxiety related to rotary instruments.35
Lasers can remove caries effectively with minimal involve-
ment of surrounding tooth structure because caries-affected
tissue has a higher water content than healthy tissue.7,10
Disadvantages of lasers in pediatric dentistry
Laser use in pediatric dentistry has some disadvantages. Since
different wavelengths are necessary for various soft and hard
tissue procedures, the practitioner may need more than one
laser.10 Laser use requires additional training and education for
the various clinical applications and types of lasers.9,10,29,30
High start-up costs are required to purchase the equipment,
implement the technology, and invest in the required educa-
tion and training.9,10 Laser manufacturers provide training on
their own units, but most laser education is obtained through
continuing education courses. Few dental schools and grad-
uate programs currently provide comprehensive laser education.
Most dental instruments are both side- and end-cutting; lasers
are exclusively end-cutting, and lasers are unable to ablate
metallic restorations.7,10 Cavity preparations are slower to make
with a laser than with a highspeed handpiece.7 Modifications
in clinical technique along with additional preparation with
handpieces may be required to finish tooth preparations.10,29
Policy statement
The AAPD:
• recognizes the use of lasers as an alternative and com-
plementary method of providing soft and hard tissue
dental procedures for infants, children, adolescents,
and persons with special health care needs.
• advocates the dental professional receive additional
didactic and experiential education and training on
the use of lasers before applying this technology on
pediatric patients.
 ORAL HEALTH POLICIES: USE OF LASERS

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 screening7,10
Diode 810 - 980 nm 1. Soft tissue ablation – gingival contouring for esthetic purposes, frenectomy, gingivectomy,
operculectomy, biopsy5,10
2. Photobiomodulation – proliferation of fibroblasts and enhancing the healing of oral lesions
(mucositis, aphthous ulcers, herpetic lesions) or surgical wounds6,25
3. Periodontal procedures – laser bacterial reduction, elimination of necrotic epithelial tissue
during regenerative periodontal surgeries36
4. Enamel whitening8
Er, Cr:YSGG* 2,780 nm 1. Hard tissue procedures – enamel etching, caries removal and cavity preparation in enamel
and dentin5,7,10
2. Osseous tissue procedures – bone ablation5,10
3. Soft tissue procedures – incision, excision, vaporization, coagulation and hemostasis; gin-
gival contouring for esthetic purposes, frenectomy, gingivectomy, operculectomy, biopsy5,10
4. Endodontic therapy – pulp cap, pulpotomy, pulpectomy, root canal preparation37
5. Periodontal procedures – laser bacterial reduction, elimination of necrotic epithelial tissue
during regenerative periodontal surgeries36
6. Treatment of oral ulcerative lesions24
Er:YAG** 2,940 nm 1. Hard tissue procedures – caries removal and cavity preparation in enamel and dentin5,7,10
2. Endodontic therapy – root canal preparation37
CO2† 9,300 nm 1. Hard tissue procedures – caries removal and cavity preparation in enamel and dentin11
2. Osseous tissue procedures – bone ablation
3. Soft tissue procedures – gingival contouring for esthetic purposes, frenectomy, gingivec-
tomy, operculectomy, biopsy5,10
CO2 10,600 nm 1. Soft tissue procedures – gingival contouring for esthetic purposes, frenectomy, gingivectomy
biopsy5,10,37
2. Treatment of oral ulcerative lesions25,37
3. Periodontal procedures – elimination of necrotic epithelial tissue during regenerative
periodontal surgeries37

* Er, Cr:YSGG – erbium, chromium, yttrium, scandium, gallium, garnet. ** Er:YAG – erbium, yttrium, aluminium, garnet. † CO2: Carbon dioxide.
‡ nm – nanometer.

• encourages dental professionals to research, implement,
and utilize the appropriate laser specific and optimal
for the indicated procedure. Understanding the tech-
nology and clinical implications is necessary before
practitioners utilize lasers in patient care.
• encourages additional research regarding the safety,
efficacy, and application of lasers for dental care for
pediatric patients.
• supports patient, visitor, and staff safety through iden-
tification of a laser safety officer, supplementation of
infection control practices, and use of wavelength-
specific protective eyewear when a dental facility
employs laser technology.
References
1. American Academy of Pediatric Dentistry. Policy on
use of lasers for pediatric dental patients. Pediatr Dent
2013;35(special issue):75-7.
2. American Academy of Pediatric Dentistry. Policy on
use of lasers for pediatric dental patients. Pediatr Dent
2017;39(6):93-5.
3. Frame JW. Carbon dioxide laser surgery for benign oral
lesions. Br Dent J 1985;158(4):125-8.
4. Myers TD, Myers ED, Stone RM. First soft tissue study
utilizing a pulsed Nd:YAG dental laser. Northwest Dent
1989;68(2):14-7.
5. Boj JR, Poirer C, Hernandez M, Espassa E, Espanya A.
Review: Laser soft tissue treatments for paediatric dental
patients. Eur Arch Paediatr Dent 2011;12(2):100-5.
6. Fornaini C, Arany P, Rocca J, Merigo E. Photobiomodu-
lation in pediatric dentistry: A current state-of-the-art.
Photomed Laser Surg 2019;37(12):798-813.
7. Parker S. Lasers in restorative dentistry. In: Convisar RA,
ed. Principles and Practice of Laser Dentistry. 2nd ed.
St. Louis, Mo.: Elsevier Mosby; 2016:162-77.
References continued on the next page.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 133

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8. Suresh S, Navit S, Khan S, et al. Effect of diode laser
office bleaching on mineral content and surface topo-
graphy of enamel surface: An SEM study. Int J Clin Ped
Dent 2020;13(5):480-5.
9. Olivi G, Genovese MD, Caprioglio C. Evidence-based
dentistry on laser paediatric dentistry: Review and out-
look. Eur J Paediatr Dent 2009;10(1):29-40.
10. Coluzzi DJ, Convissar RA, Roshkind DM. Laser funda-
mentals. In: Convissar RA, ed. Principles and Practice of
Laser Dentistry. 2nd ed. St. Louis, Mo.: Elsevier Mosby;
2016:12-26.
11. Parker S, Cronshaw M, Anagnostaki E, Mylona V, Lynch
E, Grootveld M. Current concepts of laser-oral tissue
interaction. Dent J (Basel) 2020;8(3):61. Available at:
“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC75
58496/”. Accessed May 31, 2022.
12. Martens LC. Laser physics and review of laser applications
in dentistry for children. Eur Arch Paediatr Dent 2011;
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13. American Academy of Pediatric Dentistry. Policy on pa-
tient safety. The Reference Manual of Pediatric Dentistry.
Chicago, Ill: American Academy of Pediatric Dentistry;
2022:176-80.
14. Chen JW. Fire during deep sedation and general
anesthesia-urban myth or real nightmare? Pediatr Dent
Today 2019;LIV(6):32. Available at: “https://www.
pediatricdentistrytoday.org/2019/November/LIV/6/
news/article/1304/”. Accessed March 11, 2022.
15. Bosack R, BruleyM, VanCleave A, Weaver J. Patient fire
during dental care: A case report and call for safety. J
Am Dent Assoc 2016;147(8):661-7.
16. Weaver JM. Prevention of fire in the dental chair. Anesth
Prog 2012;59(3):105-6.
17. Parker S. Laser regulation and safety in general dental
practice. Br Dent J 2007;202(9):523-32.
18. Garden JM, O’Bannon MK, Bakus AD, Olson C. Viral
disease transmitted by laser-generated plume (aerosol).
Arch Dermatol 2002;138(10):1303-7.
19. American Academy of Pediatric Dentistry. Dental
management of pediatric patients receiving immuno-
suppressive therapy and/or head and neck radiation. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
The American Academy of Pediatric Dentistry; 2022:
507-16.
20. Elad S, Cheng KKF, Lalla RV, et al; Mucositis Guidelines
Leadership Group of the Multinational Association of
Supportive Care in Cancer and International Society of
Oral Oncology (MASCC/ISOO). MASCC/ISOO clini-
cal practice guidelines for the management of mucositis
secondary to cancer therapy. Cancer 2020;126(19):
4423-31.
21. Miranda-Silva W, Gomes-Silva W, Zadik Y, et al. Mucositis
Study Group of the Multinational Association of Sup-
portive Care in Cancer/International Society for Oral
Oncology (MASCC/ISOO). MASCC/ISOO clinical
practice guidelines for the management of mucositis:
Sub-analysis of current interventions for the management
of oral mucositis in pediatric cancer patients. Support
Care Cancer 2021;29(7):3539-62.
134 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
22. Zadik Y, Arany P R, Fregnani ER, et al. Systematic review
of photobiomodulation for the management of oral
mucositis in cancer patients and clinical practice guide-
lines. Supp Care in Cancer 2019;27(10):3969-83.
23. Tanboga I, Eren F, Altinok B, Peker S, Ertugral F. The
effect of low level laser therapy on pain during dental
tooth-cavity preparation in children. Eur Arch Paediatr
Dent 2011;12(2):93-5.
24. Yilmaz HG, Albaba MR, Caygur A, Cengiz E, Boke-
Karacaoglu F, Tumer H. Treatment of recurrent aphthous
stomatitis with Er,CR:YSGG laser irradiation: A random-
ized controlled split mouth clinical study. J Photochem
Photobiol B 2017;170:1-5.
25. Suter VGA, Sjolund S, Bornstein MM. Effect of laser on
pain relief and wound healing of recurrent aphthous
stomatitis: A systematic review. Lasers Med Sci 2017;32
(4):954-63.
26. Green J, Weiss A, Stern A. Lasers and radiofrequency
devices in dentistry. Dent Clin North Am 2011;55(3):
585-97.
27. Bardellini E, Veneri F, Amadori F, Conti G, Majorana
A. Photobiomodulation therapy for the management of
recurrent aphthous stomatitis in children: Clinical
effectiveness and parental satisfaction. Med Oral Patol
Oral Circ Bucal 2020;25(4):e549-e53.
28. Caprioglio C, Olivi G, Genovese MD. Pediatric laser
dentistry. Part 1: General introduction. Eur J Paediatr
Dent 2017;18(1):80-2.
29. Olivi G, Genovese MD. Laser restorative dentistry in
children and adolescents. Eur Arch Paediatr Dent 2011;
12(2):68-78.
30. van As G. Erbium lasers in dentistry. Dent Clin North
Am 2004;48(4):1017-59.
31. Matsumoto K, Hossain M, Hossain MM, Kawano H,
Kimura Y. Clinical assessment of Er,Cr:YSGG laser
applications for caries removal and cavity preparation in
children. Med Laser Appl 2002;20(1):17-21.
32. DenBesten PK, White JM, Pelino JEP, Furnish G, Silveira
A, Parkins FM. The safety and effectiveness of an Er:YAG
laser for caries removal and cavity preparation in children.
Med Laser Appl 2001;16(3):215-22.
33. Poli R, Parker S, Anagnostaki E, Mylona V, Lynch E,
Grootveld M. Laser analgesia associated with restorative
dental care: A systematic review of the rationale, techniques,
and energy dose considerations. Dent J 2020;8(4):128.
Available at: “https://www.ncbi.nlm.nih.gov/pmcarticles
/PMC7712922/”. Accessed May 31, 2022.
34. Takamori K, Furukama H, Morikawa Y, Katayama T,
Watanabe S. Basic study on vibrations during tooth
preparations caused by highspeed drilling and Er:YAG
laser irradiation. Lasers Surg Med 2003;32(1):25-31.
35. Merigo E, Fornaini C, Clini F, Fontana M, Cella L, Oppici
A. Er:YAG laser dentistry in special needs patients. Laser
Therapy 2015;24(3):189-93.
36. Low S. Lasers in surgical periodontics. In: Convissar RA,
ed. Principles and Practice of Laser Dentistry. 2nd ed. St.
Louis Mo.: Elsevier Mosby; 2016:51-66.
37. Nazemisalman B, Farsadeghi M, Sokhansanj M. Types
of lasers and their applications in pediatric dentistry: A
review. J Lasers Med Sci 2015;6(3):96-101.

Policy on Obstructive Sleep Apnea (OSA )
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that obstructive sleep apnea (OSA) occurs in the
pediatric population. Undiagnosed or untreated OSA is asso-
ciated with cardiovascular complications, impaired growth
(including failure to thrive), learning problems, and behavioral
problems.1 In order to reduce such complications, AAPD
encourages healthcare professionals to routinely screen their
patients for increased risk for OSA and to facilitate medical
referral when indicated.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2016.2 This revision is based on a review of
current dental and medical literature pertaining to obstructive
sleep apnea including a search with PubMed /MEDLINE®
using the terms: sleep apnea AND dentistry, obstructive sleep
apnea AND dentistry, obstructive sleep apnea AND attention-
deficit hyperactivity disorder (ADHD), sleep disordered
breathing; fields: all; limits: within the last ten years, humans,
all children zero to 18 years, English, clinical trials, and
literature reviews. The search returned 283 articles. When data
did not appear sufficient or were inconclusive, policies were
based upon expert and/or consensus opinion by experience
researchers and clinicians.
Background
OSA is a disorder of breathing characterized by episodes of
complete or partial upper airway obstruction during sleep,
often resulting in gas exchange abnormalities and arousals
that cause disrupted sleep.1,3 OSA affects approximately 25
million people in the United States and is a common form
of sleep-disordered breathing.4 The presentation, diagnostic
criteria, course, and complications of OSA differ significantly
between adults and children.1 Pediatric OSA differs from
adult OSA due to several developmental, physiological, and
maturational factors related to respiration and sleep param-
eters.5 The condition exists in one to five percent of children
and can occur at any age but may be most common in
children ages two to seven.6-8 In prepubertal children, the
disease occurs equally among boys and girls; in adolescents,
data suggest the prevalence may be higher in males.1 Adult
and pediatric OSA and sleep-related hypoventilation disorders
are defined by different criteria.1 Adult criteria for OSA may
be used for patients aged 13-18 years.1 Early diagnosis and
ORAL HEALTH POLICIES: SLEEP APNEA
How to Cite: American Academy of Pediatric Dentistry. Policy on
obstructive sleep apnea (OSA). The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:135-8.
treatment of OSA may decrease morbidity and improve
quality of life; however, diagnosis frequently is delayed.3,9
The pathophysiology underlying upper airway narrowing
during sleep is multifactorial.1,19 Obstructive sleep apnea occurs
when the pharyngeal dilating muscles relax, causing the airway
to narrow on inspiration. This, in turn, may lower oxygen
and increase carbon dioxide levels in the blood. Decreased
end-expiratory lung volume, failing ventilatory drive, respira-
tory arousal threshold, muscle responsiveness, and unstable
ventilatory control (high loop gain) also may contribute to
airway narrowing.1,10 Mechanisms of apnea/hypopnea termi-
nation are controversial.1 Respiratory events may resolve with
augmentation of the upper airway muscle tone from chemical
stimuli (low partial pressure of oxygen [PaO2], high partial
pressure of carbon dioxide [PaCO2]), mechanical stimuli from
changes in lung volume (upper airway mechanoreceptors),
or change of sleep state (arousal) at either the cortical or sub-
cortical level.1 Arousals related to obstructive events cause
sleep fragmentation which is believed to be responsible for
excessive daytime sleepiness in older children or adolescents
and hyperactivity, behavioral problems, and impaired acad-
emic performance in younger children.1 For this reason,
children with untreated OSA may be inappropriately diagnosed
as having ADHD.11
OSA differs from central sleep apnea (CSA). CSA is less
common and occurs when the brain fails to transmit signals
to the muscles of respiration.11 The most common conditions
associated with CSA include neurological or neurosurgical
conditions (e.g., Arnold-Chiari malformation, brain tumor),
genetic conditions (e.g., Down syndrome, Prader-Willi syn-
drome, achondroplasia), congestive heart failure, stroke,
high altitude, and use of certain medications (e.g., narcotics,
benzodiazepines, barbiturates).1 Premature infants also may be
predisposed to CSA.1
Symptoms of OSA include:1,3
• excessive daytime sleepiness.
• loud snoring three or more nights per week.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ADHD: Attention-
deficit hyperactivity disorder. CPAP: Continuous positive airway
pressure. CSA: Central sleep apnea. MADs: Mandibular advance-
ment devices. OSA: Obstructive sleep apnea. RPE: Rapid maxillary/
palatal expansion.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 135
ORAL HEALTH POLICIES: SLEEP APNEA
• episodes of breathing cessation witnessed by another
person.
• abrupt awakenings accompanied by shortness of breath.
• awakening with dry mouth or sore throat.
• morning headache.
• difficulty staying asleep.
• unusual sleep positions (seat or neck hyperextended).
• attention problems.
• mouth breathing.
• diaphoresis.
• restlessness.
• frequent awakenings.
Signs of untreated sleep apnea in school-aged children may
include nocturnal enuresis (bed wetting), poor school perfor-
mance, aggressive behavior, or developmental delay.3,12 Rare
sequelae of untreated OSA include brain damage, seizures,
coma, and cardiac complications.1,3,13,14 Children with OSA
also may experience impaired growth.3,15
Etiology of pediatric OSA
In most children who are otherwise healthy, narrowing of the
upper airway is due primarily to adenotonsillar hypertrophy.1
However, pediatric OSA may be related to inadequate airway
size, inadequate neuromuscular tone of the airway muscles, or
both.16 Patients with certain anatomic anomalies, craniofacial
anomalies, neuromuscular diseases, or hypotonia are at in-
creased risk for development of obstructive sleep apnea.17
Anatomic anomalies may include hypertrophic tonsils and
adenoids, macroglossia, choanal atresia, respiratory tissue
thickening (e.g., caused by disease such as mucopolysaccha-
ridosis), or obesity.18 Neuromuscular disorders with a compo-
nent of hypotonia (e.g., cerebral palsy, myotonic dystrophies,
other myopathies) predispose children to OSA.3,18 Exposure to
environmental tobacco smoke also has been associated with
OSA.3,19
Children with craniofacial differences (e.g., craniosynostotic
syndromes, achondroplasia, Pierre Robin sequence, cleft lip
and palate) have an increased risk of having OSA because of
modified craniofacial morphology.18,20 Midface deficiency, with
or without micrognathia, may predispose some children to
OSA.20 Certain surgical procedures (e.g., pharyngeal flaps to
correct velopharyngeal insufficiency) also may contribute to OSA.1
Screening and diagnosis of OSA
Pediatric dentists are in a unique position to be able to
identify patients at greatest risk.21 Adenotonsillar hypertrophy9
and obesity22 are major risk factors for OSA in otherwise
healthy children. With a history and careful clinical examina-
tion at each dental visit, pediatric dentists may identify signs
and symptoms that may raise a concern for OSA. Assessment
of tonsillar hypertrophy and percentage of airway obstruction
by supine Mallampati classification23 or the Friedman tongue
position (FTP)24 may be performed as part of the routine
intraoral examination.
136 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Validated screening tools are available for adult obstructive
sleep apnea (e.g., STOP-BANG, STOP, Berlin questionnaire,
Epworth sleepiness scale)25; however, questionnaires for the
pediatric population (e.g., PSQ, OSA-18) are not sensitive
enough to detect presence or severity of OSA26. Nonetheless,
the inclusion of sleep questions on the health history form
may further help identify patients at risk. Such questions
might include:
• does your child snore loudly when sleeping?
• does your child have trouble breathing while sleeping?
• does your child stop breathing during sleep?
• does your child occasionally wet the bed at night?
• is your child hard to wake up in the morning?
• does your child complain of headaches in the morning?
• does your child tend to breathe through his/her
mouth during the day?
• have you or the teacher commented your child appears
sleepy during the day?
• does your child fall asleep quickly?
If a patient is suspected of being at risk for OSA, a referral
to a medical specialist (e.g., otolaryngologist, pulmonologist,
sleep medicine physician) allows for further assessment in-
cluding polysomnography (sleep study) to either confirm or
deny the diagnosis.27 The American Academy of Pediatrics
recommends polysomnography be performed in children/
adolescents with snoring and signs/symptoms of OSA.3 The
threshold for the diagnosis of OSA based on the apnea
hypopnea index (AHI) is lower in children than in adults.1 A
positive diagnosis of OSA made by a sleep physician would in-
volve the presence of signs/symptoms concurrent with at least
one predominantly obstructive respiratory event, mixed apnea,
or hypopnea per hour of sleep or a pattern of obstructive
hypoventilation with hypercapnia for at least 25 percent of
total sleep time during the polysomnography.1
Treatment of OSA
Treatment for OSA may be accomplished with either non-
surgical or surgical options, depending on its severity and
etiology. Nonsurgical options include treatment of nasal
allergies28, continuous positive airway pressure (CPAP)29,
weight reduction, and changes in sleep position.3 Some studies
have advocated the use of nonsurgical dental interventions;
however, these reports were based on small sample sizes and
lack control groups.19 Rapid maxillary expansion (RME) used
to normalize maxillary transverse deficiencies and mandibular
advancement devices (MADs) for Class II malocclusion cor-
rection are examples of orthodontic therapy that may be
useful for managing OSA. Cumulative evidence to date on
the use of rapid maxillary/palatal expansion consists of small
uncontrolled studies with a relatively short follow-up period.30
MADs are an alternative to CPAP to treat OSA in adult
patients31; however, they are not routinely used in growing
children32. As functional intraoral appliances alter the position
and/or growth of the maxilla or mandible, a complete

orthodontic assessment including records should be completed
prior to initiating appliance therapy.20 Through consultation
with the physician, the dentist can determine if adjunctive
options (e.g., RPE, orthodontia) are advised as part of a multi-
disciplinary treatment effort.20 When an intraoral appliance
is used for OSA, reassessment of symptoms throughout
therapy helps determine if the treatment is beneficial.3 The
most common surgical option for treatment of OSA is
adenotonsillectomy.33 Other surgical options include uvulo-
palatopharyngoplasty, ablation, revision of previous posterior
pharyngeal flap surgery, maxillomandibular advancement,
distraction osteogenesis, or tracheostomy.34,35
Complications of untreated OSA
In addition to the comorbidities listed previously (e.g., cardio-
vascular problems, impaired growth, learning problems,
behavioral problems), untreated OSA in combination with
insulin resistance and obesity in a child sets the stage for heart
disease and endocrinopathies.
Pediatric dentists who perform sedation and surgical pro-
cedures in patients with OSA should be aware that these
patients are more likely to experience perioperative and post-
operative breathing complications.36 Performing an airway
assessment in conjunction with the caregiver, especially when
considering sedation or general anesthesia, may help identify
patients at increased risk for OSA or peri-/post-operative
breathing complications. These individuals may benefit from
referral to a medical professional for further evaluation,
diagnosis, and management.
Policy statement
Recognizing that there may be consequences of untreated
OSA, the AAPD encourages health care professionals to:
• screen patients for sleep-related breathing disorders
such as OSA and primary snoring.
• assess the tonsillar pillar area for hypertrophy.
• assess tongue positioning as it may contribute to
obstruction.
• recognize obesity may contribute to OSA.
• recognize craniofacial anomalies may be associated
with OSA.
• refer to an appropriate medical provider (e.g., otolar-
yngologist, sleep medicine physician, pulmonologist)
for diagnosis and treatment of any patient suspected
of having OSA.
• consider nonsurgical intraoral appliances only after
a complete orthodontic/craniofacial assessment of
the patient’s growth and development as part of a
multidisciplinary approach.
References
1. American Academy of Sleep Medicine. International
Classification of Sleep Disorders, 3rd ed. Darien, Ill.:
American Academy of Sleep Medicine; 2014:63-8.
ORAL HEALTH POLICIES: SLEEP APNEA
2. American Academy of Pediatric Dentistry. Policy on
obstructive sleep apnea. Pediatr Dent 2016;38(special
issue):87-9.
3. American Academy of Pediatrics. Clinical practice guide-
line on the diagnosis and management of childhood
obstructive sleep apnea syndrome. Pediatrics 2012;130
(3):576-684.
4. American Academy of Sleep Medicine. Rising prevalence
of sleep apnea in U.S. threatens public health. 2014.
Available at: “https://aasm.org/rising-prevalence-of-sleep
-apnea-in-u-s-threatens-public-health/”. Accessed June 24,
2021.
5. Alsubie HS, BaHammam AS. Obstructive sleep apnoea:
Children are not little adults. Paediatr Respir Rev 2017;
21:72-9.
6. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and
management of childhood obstructive sleep apnea syn-
drome. Pediatrics 2012;130(3):576-84.
7. Lumeng JC, Chervin RD. Epidemiology of pediatric
obstructive sleep apnea. Proc Am Thorac Soc 2008;5(2):
242-52.
8. Bixler EO, Vgontzas AN, Lin HM, et al. Sleep disordered
breathing in children in a general population sample:
Prevalence and risk factors. Sleep 2009;32(6):731-6.
9. Marcus CL, Moore RH, Rosen CL, et al. A randomized
trial of adenotonsillectomy for childhood sleep apnea.
N Engl J Med 2013;368(25):2366-76.
10. Eckert DJ, White DP, Jordan AS. Defining phenotypic
causes of OSA. Am J Respir Crit Care Med 2013;188
(8):996-1004.
11. McLaren AT, Bin-Hasan S, Narang I. Diagnosis, man-
agement, and pathophysiology of central sleep apnea in
children. Paediatr Respir Rev 2019;30:49-57.
12. Lal C, Strange C, Bachman D. Neurocognitive impairment
in obstructive sleep apnea. Chest 2012;141(6):1601-10.
13. Tzeng NS, Chung CH, Chang HA, et al. Obstructive
sleep apnea in children and adolescents and the risk of
major cardiovascular events: A nationwide cohort study
in Taiwan. J Clin Sleep Med 2019;15(2):275-83.
14. Padmanabhan V, Kavitha PR, Hedge AM. Sleep dis-
ordered breathing in children—A review and the role of
the pediatric dentist. J Clin Ped Dent 2010;35(1):15-21.
15. Park DY, Choik JH, Young S, et al. Correlations between
pediatric obstructive sleep apnea and longitudinal growth.
Int J Pediatr Otorhinolaryngol 2018;106:41-5.
16. Quo SD, Pliska BT, Huynh Y. Oropharyngeal growth
and skeletal malformations. In: Kryger MH, Roth T,
Dement WC, eds. Principles and Practice of Sleep
Medicine. 6th ed. Kindle Edition. Philadelphia, Pa.:
Elsevier Health Sciences; 2017:(Kindle Location 121964).
17. ElMallah M, Bailey E, Trivedi M, et al. Pediatric obstruc-
tive sleep apnea in high-risk populations: Clinical
implications. Pediatric Ann 2017;46(9):366-9.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 137
ORAL HEALTH POLICIES: SLEEP APNEA
18. Stark TR, Pozo-Alonso M, Daniels R, Camacho M.
Pediatric considerations for dental sleep medicine. Sleep
Med Clin 2018;13(4):531-48.
19. Jara SM, Benke JR, Lin SY, Ishman SL. The association
between smoke and sleep disordered breathing in
children: A systematic review. Laryngoscope 2015;125
(1):241-7.
20. Behrents RG, Shelgikar AV, Conley RS, et al. Obstructive
sleep apnea and orthodontics: An American Association
of Orthodontists white paper. Am J Orthod Dentofacial
Orthop 2019;156(1):13-28.
21. Paglia L. Respiratory sleep disorders in children and the
role of the paediatric dentist. Eur J Paediatr Dent 2019;
20(1):5.
22. Andersen IG, Holm JC, Homøe P. Obstructive sleep
apnea in obese children and adolescents, treatment
methods and outcome of treatment – A systematic review.
Int J Pediatr Otorhinolaryngol 2016;87:190-7.
23. Kumar HVM, Schroeder JW, Sheldon SH. Mallampati
score and pediatric obstructive sleep apnea. J Clin Sleep
Med 2014;10(9):985-90.
24. Friedman M, Hamilton C, Samuelson C, Lundgren M,
Pott T. Diagnostic value of the Friedman tongue position
and Mallampati classification for obstructive sleep apnea:
A meta-analysis. Otolaryngol Head Neck Surg 2013;148
(4):540-7.
25. Chiu HY, Chen PY, Chuang LP, et al. Diagnostic accu-
racy of the Berlin questionnaire, STOP-BANG, STOP,
and Epworth sleepiness scale in detecting obstructive
sleep apnea: A bivariate meta-analysis. Sleep Med Rev
2017;36:57-70.
26. Øverland B, Berdal H, Akre H. Obstructive sleep apnea
in 2-6 year old children referred for adenotonsillectomy.
Eur Arch Otorhinolaryngol 2019;276(7):2097-104.
27. Berry RB, Quan SF, Abreau AR, et al. for the American
Academy of Sleep Medicine. The AASM Manual for the
Scoring of Sleep and Associated Events: Rules, Terminol-
ogy, and Technical Specifications. Version 2.6. Darien,
Ill.: American Academy of Sleep Medicine; 2020:62-5.
28. Liming BJ, Ryan M, Mack D, Ahmad I, Camacho M.
Montelukast and nasal corticosteroids to treat pediatric
obstructive sleep apnea: A systematic review and meta-
analysis. Otolaryngol Head Neck Surg 2019;160(4):
594-602.
138 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
29. Perriol MP, Jullian-Desayes I, Joyeux-Faure M, et al.
Long-term adherence to ambulatory initiated continuous
positive airway pressure in non-syndromic OSA children.
Sleep Breath 2019;23(2):575-8.
30. Camacho M, Chang ET, Song SA, et al. Rapid maxillary
expansion for pediatric obstructive sleep apnea: A system-
atic review and meta-analysis. Laryngoscope 2017;127(7):
1712-9.
31. Ramar K, Dort LC, Katz SG, et al. Clinical practice guide-
line for the treatment of obstructive sleep apnea and
snoring with oral appliance therapy: An update for 2015
an American Academy of Sleep Medicine and American
Academy of Dental Sleep Medicine clinical practice
guideline. J Clin Sleep Med 2015;11(7):773-827.
32. Yanyan M, Min Y, Xuemei G. Mandibular advancement
appliances for the treatment of obstructive sleep apnea
in children: A systematic review and meta-analysis. Sleep
Med 2019;60:145-51.
33. Venekamp RP, Hearne BJ, Chandrasekharan D, Blackshaw
H, Lim J, Schilder AG. Tonsillectomy or adenotonsil-
lectomy versus nonsurgical management for obstructive
sleep-disordered breathing in children. Cochrane Database
Syst Rev 2015;14(10):CD011165.
34. Noller MW, Guilleminault C, Gouveia CJ, et al. Mandibu-
lar advancement for pediatric obstructive sleep apnea: A
systematic review and meta-analysis. J Craniomaxillofac
Surg 2018;46(8):1296-302.
35. Ehsan Z, Ishman SL. Pediatric obstructive sleep apnea.
Otolaryngol Clin North Am 2016;49(6):1449-64.
36. American Society of Anesthesiologists Task Force on
Perioperative Management of Patients with Obstructive
Sleep Apnea. Practice guidelines for the perioperative
management of patients with obstructive sleep apnea:
An updated report by the American Society of Anesthe-
siologists Task Force on Perioperative Management of
Patients with Obstructive Sleep Apnea. Anesthesia 2014;
120(2):268-86.

Policy on Pediatric Dental Pain Management
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that children vary greatly in their cognitive and
emotional development, medical conditions, and responses to
pain and interventions. This policy is not intended to provide
clinical recommendations, which can be found in AAPD’s best
practice on pain management 1; rather, the purpose of this
document is to support efforts to prevent or alleviate pediatric
pain and complications from pain medications. Infants, chil-
dren, adolescents, and those with special health care needs can
and do experience pain; dental-related pain in most patients
can be prevented or substantially relieved. The AAPD further
recognizes many therapeutics are available to treat pain with
varying regimens. Recent concerns have developed about
toxicities associated with codeine and the adverse effects of
opioid analgesics.
Methods
This policy was developed by the Council on Clinical Affairs,
adopted in 20122, and last revised in 20173. This document is
an update of the previous version and is based on a review of
current dental and medical literature pertaining to pediatric
®
pain management including a search with PubMed /MEDLINE
using the terms: pediatric dental pain management, pediatric
pain management, pediatric postoperative pain management,
pediatric analgesic overdose; fields: all; limits: within the last
ten years, humans, all children zero to 18 years, English,
clinical trials, and literature reviews. The search returned 8,031
articles. When data did not appear sufficient or were incon-
clusive, information included in this policy was based upon
expert and/or consensus opinion by experienced researchers
and clinicians.
Background
Pain assessment is an integral component of the dental history
and comprehensive evaluation. A detailed pain assessment
helps the dentist to derive a clinical diagnosis, develop a
prioritized treatment plan, and better estimate analgesic require-
ments for the patient.4 Assessment of pain indicates the need
for intervention and appropriateness of treatment.4 Assess-
ment of pediatric pain may significantly improve the patient’s
comfort and quality of life.5 Research suggests that undertreat-
ment of pediatric pain can amplify future pain experience.6
Effective pain management is important in both the short and
the long-term.4 Children with an established dental home have
better access for acute and chronic orofacial pain management.
ORAL HEALTH POLICIES: PAIN MANAGEMENT
How to Cite: American Academy of Pediatric Dentistry. Policy on
pediatric dental pain management. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:139-41.
A dental home provides comprehensive care which can assess
and manage acute and chronic oral pain and infection.7
Pain management may range from nonpharmacologic
modalities to pharmacological treatment. Nonpharmacologic
therapy includes maintaining a calm environment, encourag-
ing deep breathing, and employing guided imagery, distraction,
play therapy, hypnotherapy, virtual reality, and other (e.g.,
acupuncture, transcutaneous nerve stimulation) techniques.1,8
Pharmacologic therapy may consist of administration of topical
and local anesthesia, analgesic medications, and/or mild,
moderate, or deep sedation regimens.8,9 Analgesic selection
depends on the individual patient, the extent of treatment, the
duration of the procedure, psychological factors, and the pa-
tient’s medical history.10 If moderate to severe postoperative
pain is considered likely, administering an analgesic on a
regular schedule for 36 to 48 hours helps to maintain a stable
plasma levels of the agent and decreases risk for breakthrough
pain.11,12
Many therapeutics are available for the prevention of pain.
Acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs), such as ibuprofen, are considered first line agents
in the treatment of acute mild to moderate postoperative
pain. 10 Alternating administration of ibuprofen and
acetaminophen is another strategy for pain management in
children and may allow lower doses of each individual medica-
tion to be used.11,13,14 Many analgesics have multiple modali-
ties of administration, such as oral, rectal, or intravenous, to
accommodate a wide patient population.15 Consideration of
these modalities may be pertinent when treating patients in
different environments such as an office-based outpatient
setting versus in the hospital.
Certain analgesics are contraindicated in the pediatric
population due to concerns for toxicity and adverse reactions.
NSAIDs may prolong bleeding time and exacerbate kidney
or liver impairment, and acetaminophen overuse may be
associated with hepatotoxicy.10,16 Aspirin-containing analgesics
are contraindicated for pediatric pain management in most
situations because, if administered during a viral illness, the
potential exists for a serious condition known as Reye syn-
drome, a condition that causes swelling of the liver and brain.15
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. FDA: U.S. Food and
Drug Administration. NSAIDs: Nonsteroidal anti-inflammatory
drugs.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 139
ORAL HEALTH POLICIES: PAIN MANAGEMENT
Although opioid analgesics can be effective for moderate to
severe postoperative pain, there are potential adverse effects
(e.g., nausea, emesis, constipation, sedation, respiratory depres-
sion) and diversion. 13,17,18 From 2006 to 2018, the opioid
dispensing rate for the pediatric population steadily decreased.19
Persistent opioid use among children and adolescents is a
major concern and represents an important pathway to opioid
misuse.20 A 2013 systematic review found a combination of
acetaminophen and ibuprofen provided effective analgesia
without the adverse side effects associated with opioids; the
combination of acetaminophen and ibuprofen was shown
to be more effective in combination than either medication
alone.14 In 2017, the United States Food and Drug Adminis-
tration (FDA) issued a warning to restrict the use of codeine
and tramadol in children and breastfeeding mothers.21
Policy statement
The AAPD recognizes that pediatric dental patients may
experience pain as a direct result of their oral condition or sec-
ondary to invasive dental procedures. Inadequate pain control
has the potential for significant physical and psychological
consequences, including altering future pain experiences for
these children. Furthermore, pharmacologic agents used in
pediatric pain management have potential for toxicity and
adverse reactions, with narcotics at risk for diversion to unin-
tended recipients. Therefore, the AAPD encourages:
• healthcare professionals to emphasize preventive oral
health practices and to implement safe and effective
pre-, intra-, and post-operative approaches to minimize
the patient’s risk for pain.
• healthcare practitioners to follow evidence-based recom-
mendations regarding analgesic use by pediatric patients
to minimize untoward reactions and potential for
substance misuse.
• additional research to determine safe and effective
treatment modalities for acute pain.
References
1. American Academy of Pediatric Dentistry. Pain manage-
ment in infants, children, adolescents, and individuals
with special health care needs. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:392-400.
2. American Academy of Pediatric Dentistry. Policy on pedi-
atric pain management. Pediatr Dent 2012;34(special
issue):74-5.
3. American Academy of Pediatric Dentistry. Policy on
acute pediatric dental pain management. Pediatr Dent
2017;39(6):99-101.
4. De Leeuw R, Klasser G. American Academy of Orofacial
Pain: Guidelines for Assessment, Diagnosis and Manage-
ment. 6th ed. Hanover, Ill.: Quintessence Publishing;
2018:26-49.
140 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
5. Zielinksi J, Morawska-Kochman M, Zatonski T. Pain
assessment and management in children in the postoper-
ative period: A review of the most common postoperative
pain assessment tools, new diagnostic methods and the
latest guidelines for postoperative pain therapy in
children. Adv Clin Exp Med 2020;29(3):365-74.
6. Cramton R, Gruchala NE. Managing procedural pain in
pediatric patients. Curr Opin Pediatr 2012;24(4):530-8.
7. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:21-2.
8. Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B.
Pediatric clinical practice guidelines for acute procedural
pain: A systematic review. Pediatr 2014;133(3):500-15.
9. American Academy of Pediatric Dentistry. Use of local
anesthesia for pediatric dental patients. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:347-52
10. Laskarides C. Update on analgesic medication for adult
and pediatric dental patients. Dent Clin North Am 2016;
60(2):347-66.
11. Chou R, Gordon DB, de Leon-Cassola OA, et al. Guide-
lines on the management of postoperative pain. Manage-
ment of postoperative pain: A clinical practice guideline
from the American Pain Society, American Society of
Regional Anesthesia and Pain Medicine, American Society
of Anesthesiologists’ Committee on Regional Anesthesia,
Executive Committee, and Administrative Counsel. J Pain
2016;17(2):131-57.
12. Sutters KA, Miaskowsk C, Holdridge-Zeuner D, et al.
A randomized clinical trial of the efficacy of scheduled
dosing of acetaminophen and hydrocodone for the
management of postoperative pain in children after
tonsillectomy. Clin J Pain 2010;26(2):95-103.
13. Liu C, Ulualp SO. Outcomes of an alternating ibuprofen
and acetaminophen regimen for pain relief after tonsillec-
tomy in children. Ann Otol Rhinol Laryngol 2015;124
(10):777-81.
14. Moore PA, Hersh EV. Combining ibuprofen and ace-
taminophen for acute pain management after third-molar
extractions. J Am Dental Assoc 2013;144(8):898-908.
15. Ruest C, Anderson A. Management of acute pediatric
pain in the emergency department. Curr Opin Pediatr
2016;28(3):298-304.
16. U.S. Food and Drug Administration. Drug Safety
Communication: Prescription acetaminophen products
to be limited to 325 mg per dosage unit; boxed warning
will highlight potential for severe liver failure. Available
at:”https://www.fda.gov/drugs/drug-safety-and-availability/
fda-drug-safety-communication-prescription-acetamino-
phen-products-be-limited-325-mg-dosage-unit”. Accessed
March 15, 2022.

17. Jutkiewicz EM, Traynor JR. Opioid analgesics. Section
II: Neuropharmacology. In: Brunton LL, Knollmann BC.
eds. Goodman & Gilman’s: The Pharmacological Basis of
Therapeutics. 14th ed. New York City, New York: McGraw
Hill; 2023.
18. Dionne R, Moore PA. Opioid prescribing in dentistry:
Keys for safe and proper usage. Contin Educ Dent 2016;
37(1):29-32; quiz 34.
19. Renny MH, Yin SY, Jen V, Hadland SE, Cerda M. Tem-
poral trends in opioid prescribing practices in children,
adolescents, and younger teens in the US from 2006 to
2018. JAMA Pediatrics 2021;175(10):1043-52.
ORAL HEALTH POLICIES: PAIN MANAGEMENT
20. Harbaugh CM, Lee JS, Hu HM, et al. Persistent opioid
uses among pediatric patients after surgery. Pediatrics
2018;141(1):e20172349.
21. U.S. Food and Drug Administration. Drug Safety Com-
munication: FDA restricts use of prescription codeine
pain and cough medicines and tramadol pain medicines
in children; recommends against use in breastfeeding
women. Available at: “https://www.fda.gov/Drugs/Drug
Safety/ucm549679.htm”. Accessed March 15, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 141
ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE
Policy on Minimizing Occupational Health Hazards
Associated with Nitrous Oxide
Latest Revision
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that exposure to ambient nitrous oxide (N2O) may
be an occupational health hazard for dental personnel and
encourages practitioners to take all precautions to minimize
associated risks.
Methods
This policy was developed by the Clinical Affairs Committee,
adopted in 1987, and revised by the Council on Clinical
Affairs. This document is a revision of the previous version,
revised in 2013. The update used electronic database and hand
searches of articles in the medical and dental literature using
the following parameters: terms: nitrous oxide, occupational
exposure, AND dentistry; fields: all; limits: within the last 10
years, English. Additionally, guidelines and recommendations
from the National Institute for Occupational Safety and Health
(NIOSH) were reviewed.1-2 Expert opinions and best current
practices were relied upon when sufficient scientific data were
not available.
Background
Effects of occupational exposure to ambient N2O are uncer-
tain, especially since the introduction of methods to scavenge
N2O and ventilate operatories.3 As of 2008, there were no
definitive studies linking general health problems and
reproductive difficulties among dental personnel to chronic
exposure to scavenged ambient N2O.3 A maximum safe level
of ambient N2O in the dental environment has not been
determined.4-6
Reduction of ambient N2O through system maintenance,
scavenging, ventilation, use of the minimal effective dose, and
patient management is important to maintaining the lowest
practical levels in the dental environment.1,2,7 Frequent and
regular inspection and maintenance of the N2O delivery
system, together with the use of a scavenging system, can re-
duce ambient N2O significantly.8 Using a well-fitted mask
and an appropriate suction strength via the scavenging system
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
of waste nitrous oxide.10,11 The combined use of the double
mask system and scavenging systems with a high evacuation
flow rate have been demonstrated to decrease occupational
142 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
minimizing occupational health hazards associated with nitrous
oxide. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:142-3.
exposure to nitrous.12 NIOSH has recommended that the
exhaust ventilation of N2O from the patient’s mask be main-
tained at an air flow rate of 45 liters per minute and vented
outside the building away from fresh air intakes.1,5 However,
scavenging at this rate has been shown to reduce the level
of psychosedation achieved with N2O inhalation.13 Where
possible, outdoor air should be used for dental operatory
ventilation.1,14 Supply and exhaust vents should be well
separated to allow good mixing and prevent short-circuiting.1
Female dental staff frequently (i.e., three or more days a week)
exposed to nitrous oxide have been found to have no elevated
risk of spontaneous abortion in offices using appropriate
scavenging systems.15,16
Patient selection is an important consideration in reducing
ambient N2O levels.7 Patients who are unwilling or unable to
tolerate the nasal hood and those with medical conditions
(e.g., obstructive respiratory diseases, emotional disturbances,
drug dependencies) that contraindicate the use of N2O should
be managed by other behavior guidance techniques.7 In the
dental environment, patient behaviors such as talking, crying,
and moving have been shown to result in significant increases
in baseline ambient N2O levels despite the use of the mask-
type scavenging systems.17,18 Utilization of titrated nitrous
concentration levels in relation to procedure difficulty should
be considered. Nitrous can be discontinued once adequate
anesthesia is achieved,19 or decreased levels can be maintained
during easier procedures and increased for stimulating
procedures.5
The use of scavenging systems alone cannot lower the
ambient N2O levels to the recommended standards.8,17,20 Use
of supplemental measures, such as high-volume dental suction
placed in proximity to the dental operative site, has been
shown to reduce ambient N2O levels significantly.17,21 Diligent
use of the above practices in the pediatric dental environment
has allowed for the reduction of ambient N2O to the levels
recommended by NIOSH.21,22 Measurement of N2O levels
in the dental operatory can be helpful in determining the type
and extent of remediation necessary to decrease occupational
exposure.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. N2O: Nitrous oxide.
NIOSH: National Institute for Occupational Safety and Health.

Policy statement
The AAPD encourages dentists and dental auxiliaries to
maintain the lowest practical levels of N2O in the dental en-
vironment while using N2O. Adherence to the recommenda-
tions below can help minimize occupational exposure to N2O.
• Educate dental personnel on minimizaing occupational
exposure to and potential abuse of nitrous oxide.
• Use scavenging systems that remove N2O during
patient’s exhalation.
• Ensure that exhaust systems adequately vent scavenged
air and gases to the outside of the building and away
from fresh air intake vents.
• Use, where possible, outdoor air for dental operatory
ventilation.
• Implement careful, regular inspection and mainte-
nance of the nitrous oxide/oxygen delivery equipment.
• Carefully consider patient selection criteria (i.e., indi-
cations and contraindications) prior to administering
N2O.
• Select a properly-fitted mask size for each patient.
• During administration, visually monitor the patient
and titrate the flow/percentage to the minimal effec-
tive dose of N2O.
• Encourage patients to minimize talking and mouth
breathing during N2O administration.
• Use high volume dental suction when possible during
N2O administration.
• Administer 100 percent oxygen to the patient for at
least five minutes after terminating nitrous oxide use
to replace the N2O in the gas delivery system.
References
1. National Institute of Occupational Safety and Health.
Control of nitrous oxide in dental operatories. Appl
Occup Environ Hyg 1999;14(4):218-20.
2. National Institute of Occupational Safety and Health.
Controlling exposures of nitrous oxide during anesthetic
administration. Cincinnati, Ohio: National Institute of
Occupational Safety and Health; 1994. DHHS/NIOSH
Publication No. 94-100.
3. Sanders RD, Weimann J, Maze M. Biologic effects of
nitrous oxide. Anesthesiology 2008;109(4):707-22.
4. Howard WR. Nitrous oxide in the dental environment:
Assessing the risk and reducing the exposure. J Am Dent
Assoc 1997;128(3):356-60.
5. American Dental Association Council on Scientific
Affairs, American Dental Association Council on Dental
Practice. Nitrous oxide in the dental office. J Am Dent
Assoc 1997;128(3):364-5.
6. Donaldson D, Meechan JG. The hazards of chronic ex-
posure to nitrous oxide: An update. Br Dent J 1995;178
(3):95-100.
7. American Academy of Pediatric Dentistry. Use of nitrous
oxide for pediatric dental patients. Pediatr Dent 2018;40
(6):281-6.
8. Rademaker AM, McGlothlin JD, Moenning E, Bagnoli
M, Carlson G, Griffin C. Evaluation of two nitrous
oxide scavenging systems using infrared thermography to
visualize and control emissions. J Am Dent Assoc 2009;
140(2):190-9.
ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE
9. Crouch KG, Johnston OE. Nitrous oxide control in the
dental operatory: Auxiliary exhaust and mask leakage,
design, and scavenging flow rate as factors. Am Ind Hyg
Assoc J 1996;57(3):272-8.
10. Chrysikopoulou A, Matheson P, Miles M, Shey Z, Houpt
M. Effectiveness of two nitrous oxide scavenging nasal
hoods during routine pediatric dental treatment. Ped
Dent 2006;28(3):242-7.
11. Freilich MM, Alexander L, Sandor GKB, Judd P. Effec-
tiveness of 2 scavenger mask systems for reducing expo-
sure to nitrous oxide in a hospital-based pediatric dental
clinic: A pilot study. J Can Dent Assoc 2007;73(7):
615-615d. Available at: “http://www.cda-adc.ca/jcda/vol
-73/issue-7/615.pdf ”. Accessed October 1, 2018.
12. Messeri A, Amore E, Dugheri S, et al. Occupational expo-
sure to nitrous oxide during procedural pain control in
children: A comparison of different inhalation techniques
and scavaging systems. Pediatr Anaesth 2016;26(1):
919-25.
13. Primosch R, McLellan M, Jerrell G, Venezie R. Effect of
scavenging on the psychomotor and cognitive function
of subjects sedated with nitrous oxide and oxygen in-
halation. Pediatr Dent 1997;19(8):480-3.
14. Centers for Disease Control and Prevention. Control of
nitrous oxide in dental operatories. 2014. Available at:
“https://www.cdc.gov/niosh/docs/hazardcontrol/hc3.
html”. Accessed May 31, 2018.
15. Rowland AS, Baird DD, Shore DL, et al. Reduced
fertility among women employed as dental assistants
exposed to high levels of nitrous oxide. N Engl J Med
1992;327(14):993-7.
16. Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz
DA, Wilcox AJ. Nitrous oxide and spontaneous abortion
in female dental assistants. Am J Epidemiol 1995;141
(6):531-7.
17. Henry RJ, Primosch RE, Courts FJ. The effects of various
dental procedures and patient behaviors upon nitrous
oxide scavenger effectiveness. Pediatr Dent 1992;14(1):
19-25.
18. Crouch KG, McGlothin JD, Johnston OE. A long-term
study of the development of N2O controls at a pediatric
dental facility. Am Ind Hyg Assoc J 2000;61(5):753-6.
19. Guelmann M, Brackett R, Beavers N, Primosch RE.
Effect of continuous versus interrupted administration of
nitrous oxide-oxygen inhalation on behavior of anxious
pediatric dental patients: A pilot study. J Clin Pediatr
Dent 2012;37(1):77-82.
20. Gilchrist F, Whitters CJ, Cairns AM, Simpson M, Hosey
MT. Exposure to nitrous oxide in a paediatric dental
unit. Int J Paediatr Dent 2007;17(2):116-22.
21. Henry RJ, Borganelli GN. High-volume aspiration as a
supplemental scavenging method for reducing ambient
nitrous oxide levels in the operatory: A laboratory study.
Int J Paediatr Dent 1995;5(2):157-61.
22. Borganelli GN, Primosch RE, Henry RJ. Operatory
ventilation and scavenger evacuation rate influence on
ambient nitrous oxide levels. J Dent Res 1993;72(9):
1275-8.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 143
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
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
advocates hospitalization and equal access to operating room
facilities, when indicated, for oral care of infants, children,
adolescents, and individuals with special health care needs. The
AAPD recognizes that barriers to hospital oral care for patients
who require treatment in that setting need to be addressed.
Methods
This policy was developed by the Dental Care Committee,
adopted in 19891, and last revised by the Council of
®
Clinical Affairs in 20152. A PubMed /MEDLINE search was
performed using the terms: access for dental/oral care in hos-
pitals, operating room access for dental/oral care, and access
to hospital dentistry; fields: all; limits: within the last 10
years, humans, English, birth through age 18. Additionally,
websites for the American Medical Association, American Den-
tal Association (ADA), AAPD, American Dental Association
Commission on Dental Accreditation, and Centers for Disease
Control and Prevention were reviewed.
Background
Pediatric dentists treat patients who present special challenges
related to their age, behavior, medical status, developmental
disabilities, or special needs. Caries, periodontal diseases, and
other oral conditions, if left untreated, can lead to pain, infec-
tion, and loss of function.3-5 These undesirable outcomes can
adversely affect learning, communication, nutrition, and other
activities necessary for normal growth and development.5-8
Many medical (e.g., hematological, oncological) conditions
are exacerbated by the presence of oral maladies and disease.
To address these challenges and to provide the treatment needs
effectively, pediatric dentists have developed and employ a
variety of management techniques, including accessing anes-
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
may only be able to receive their dental treatment safely in a
hospital setting. Hospital dentistry is an integral part of the
curriculum of all accredited advanced pediatric dental training
144 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
hospitalization and operating room access for oral care of infants,
children, adolescents, and Individuals with special health care needs.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:144-5.
programs. Pediatric dentists are, by virtue of training and ex-
perience, qualified to recognize the indications for such an
approach and to render such care.10,11
Pediatric dentists occasionally have experienced difficulty
in gaining an equal opportunity to schedule operating room
time, postponement/delay of non-emergency oral care, and
economic credentialing. Economic credentialing (i.e., the use
of economic criteria not related to quality of care or profes-
sional competency) to determine qualifications for granting/
renewing an individual’s clinical staff membership or privileges
should be opposed.12 The AAPD and the ADA urge hospital
insurance carriers to include hospitalization benefits for dental
treatment in both private and public insurance programs so
the resources of a hospital are available to patients whose
condition – in the judgment of the dentist – warrants treatment
in the operating room.13,14
Hospital governing boards and medical staffs are interested
in improving the quality and efficiency of patient care. Deci-
sions regarding hospital privileges should be based upon the
training, experience, and demonstrated competence of candi-
dates, taking into consideration the availability of facilities
and the overall medical needs of the community, the hospital,
and especially the patients. Privileges should not be based on
numbers of patients admitted to the facility or the patient’s
economic or insurance status.15
Policy statement
The AAPD shall work with all concerned medical and dental
colleagues and organizations to remove barriers to hospital and
operating room access for oral care for patients best treated in
those settings. The AAPD affirms that hospitals or outpatient
settings providing surgical treatment should not discriminate
against pediatric dental patients requiring care under general
anesthesia. Such patients and their care providers need access
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ADA: American
Dental Association.

to these facilities. The dental patient, as with any other
patient, should have the right to be seen in a timely manner.
Evidence has demonstrated dental treatment under general
anesthesia in the operating room is a necessity, as well as an
important component of comprehensive care, to assure opti-
mal health for many, especially those considered high risk.16-18
References
1. American Academy of Pediatric Dentistry Dental Care
Committee. Hospitalization for dental care of infants
and children. May, 1989. Orlando, Fla.: American
Academy of Pediatric Dentistry; 1989.
2. American Academy of Pediatric Dentistry. Hospitali-
zation and operating room access for oral care of infants,
children, adolescents, and persons with special health care
needs. Pediatr Dent 2015;37(special issue):88-9.
3. Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes
and parental satisfaction following dental rehabilitation
under general anesthesia. Pediatr Dent 2001;23(5):
419-23.
4. American Academy of Pediatric Dentistry. Definition
of dental neglect. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:16.
5. Low W, Tan S, Schwartz S. The effect of severe caries on
the quality of life in young children. Pediatr Dent 1999;
21(6):325-6.
6. Edelstein B, Yoder K. The child in context of the fam-
ily, community and society. In: Dean JA, ed. McDonald
and Avery’s Dentistry for the Child and Adolescent. 10th
ed. St. Louis, Mo: Elsevier; 2016:645-62.
7. Thomas CW, Primosch RE. Changes in incremental
weight and well-being of children with rampant caries
following complete dental rehabilitation. Pediatr Dent
2002;24(2):109-13.
8. American Academy of Pediatric Dentistry. Definition of
dental disability. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:17.
9. Velan E, Sheller B. Providing dental treatment for chil-
dren in a hospital setting. Dent Clin North Am 2013;
57(1):163-73.
ORAL HEALTH POLICIES: HOSPITALIZATION AND OPERATING ROOM ACCESS
10. American Dental Association Commission on Dental
Accreditation. Accreditation standards for advanced spe-
cialty education programs in pediatric dentistry: Hospital
dentistry. Chicago, Ill.: American Dental Association;
2018:31-3.
11. Forsyth AR, Seminario AL, Scott J, Berg J, Ivanova I, Lee
H. General anesthesia time for pediatric dental cases.
Pediatr Dent 2012;34(5):129-35.
12. American Medical Association. Policy H-230.975 Econo-
mic credentialing. 2017. American Medical Association
PolicyFinder. Available at: “https://policysearch.ama-assn.
org/policyfinder/detail/230.975?uri=%2FAMADoc%2FH
OD.xml-0-1606.xml”. Accessed August 6, 2020.
13. American Academy of Pediatric Dentistry. Policy on
model dental benefits for infants, children, adolescents,
and individuals with special health care needs. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2020:131-4.
14. American Dental Association. Economic credentialing
(Trans.1993:692). Hospitals. In: Current Policies.
Adopted 1954-2019. Chicago, Ill.: American Dental
Association; 2019:120. Available at: “http://www.ada.
org/~/media/ADA/Member%20Center/Members/current
_policies.pdf ”. Accessed August 6, 2020.
15. American Medical Association. Code of Medical Ethics
Opinion 9.5.2. Staff privileges. Ethics. American Medical
Association. November 14, 2016. Available at: “https://
www.ama-assn.org/delivering-care/ethics/staff-privileges”.
Accessed August 6, 2020.
16. Chi DL, Momany ET, Neff J, et al. Impact of chronic
condition status and severity on dental utilization for
Iowa Medicaid-enrolled children. Pediatr Anes 2010;20
(9):856-65.
17. Chang J, Patton LL, Kim HY. Impact of dental treatment
under general anesthesia on the oral health-related quality
of life of adolescents and adults with special needs. Eur
J Oral Sci 2014;122(6):363-71.
18. Park JS, Anthonappa RP, Yawary R, King NM, Martens
LC. Oral health-related quality of life changes in children
following dental treatment under general anesthesia: A
meta-analysis. Clin Oral Investig 2018;22(8):2809-18.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 145
ORAL HEALTH POLICIES: HOSPITAL STAFF MEMBERSHIP
Policy on Hospital Staff Membership
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry recognizes that
dentists have an opportunity to play a significant role
within a hospital. Staff membership is necessary to provide
comprehensive, consultative, and/or emergency dental services
for infants, children, adolescents, and persons with special
health care needs within the hospital setting.
Methods
This policy was developed by the Hospital Guidelines for
Pediatric Dentistry Ad Hoc Committee and adopted in 1977.1
This document by the Council on Clinical Affairs is a
revision of the previous version2, last revised in 2015. The
update included an electronic search using the terms: hospital
medical staff and Joint Commission, AND dentistry; fields:
all; limits: within the last 10 years, humans, English.
Background
Pediatric dentists contribute in multiple ways as members of
the hospital staff. Most commonly, the pediatric dentist can
provide comprehensive oral health care services to patients
within an operating room setting. Additionally, the pediatric
dentist can provide consultative and emergency services.3
Team (e.g., cleft lip/palate, hemophilia) evaluations of patients
often require dental input, and certain medical protocols
(e.g., hematopoietic cell transplantation) require an oral
examination. Beyond patient services, a pediatric dentist may
participate within the hospital’s organizational structure
through committee memberships of either clinical or admin-
istrative purpose. A pediatric dentist can partner with medical
colleagues in self-development through hospital-sponsored
continuing medical education.
Pediatric dentists seeking hospital staff membership must
contact the medical staff office at an area hospital. Board
certification or candidacy routinely is required for hospital
staff membership. Following a credentialing process and
appointment to a medical staff, a pediatric dentist must
accept and fulfill certain responsibilities. Among them are
patient care within the limits of approved clinical privileges,
possible participation in emergency department on-call ro-
tations, timely completion of medical records, and compliance
with the rules and regulations of the medical/dental staff and
the policies and procedures of the hospital.
Although hospitals and medical/dental staffs have some
individual latitude, the standards for all hospital services are
146 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
hospital staff membership. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:146-7.
issued by healthcare accreditation organizations such as The
Joint Commission.4 Standards for dental services are integrated
intimately and inseparably within the overall hospital
organizational structure and, therefore, are stringently subject
to the standards established by these commissions.
As per the American Medical Association’s Code of Medical
Ethics, “the purpose of medical staff privileging is to improve
the quality and efficiency of patient care in the hospital”,
while selection should be based on a candidate’s training,
experience, competence, availability, and the overall medical
needs of the community. 5 Select organizations associate a
dentist’s economic performance and other monetary param-
eters with their ability to establish privileges. Facilities may
employ economic credentialing (i.e., using economic criteria
not related to quality of care or professional competency) to
protect their financial interests. The use of economic creden-
tialing to determine qualifications for granting/renewing an
individual’s clinical staff membership or privilege is strongly
opposed by the American Medical Association.6 Economic
credentialing may present in a variety of forms such as pro-
viding individuals with contract exclusivity, profiling practice
habits, or identifying potential conflicts of interest. Objective
credentialing decisions should always be guided by concern
for the welfare and best interest of the patient.
Policy statement
The American Academy of Pediatric Dentistry:
• encourages the participation of pediatric dentists on
hospital medical/dental staffs. Beyond having the
capability to provide valuable services to patients,
the pediatric dentist can be an effective, contributing
member to the hospital through consultative services,
educational opportunities, leadership initiatives, and
committee membership.
• recognizes the American Dental Association as a cor-
porate member of The Joint Commission and further
recognizes the standards for hospital governance, as
established by The Joint Commission.
• encourages hospital member pediatric dentists to
maintain strict adherence to the rules and regulations
of the medical/dental staff and the policies and
procedures of the hospital.
• is opposed to the use of economic credentialing to
determine qualifications for granting/renewing a
practitioner’s clinical staff membership or privileges.

References
1. American Academy of Pedodontics. Hospital guidelines
for pediatric dentistry. Chicago, Ill.: American Academy
of Pedodontics; 1977.
2. American Academy of Pediatric Dentistry. Policy on
hospital staff membership. Pediatr Dent 2015;37(special
issue):90-1.
3. Weddell JA, Jones JE. Hospital dental services for chil-
dren and the use of general anesthesia. In: Dean JA,
ed. McDonald and Avery’s Dentistry for the Child and
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: HOSPITAL STAFF MEMBERSHIP
5. American Medical Association. Staff privileges. American
Medical Association Code of Medical Ethics Opinion
9.5.2. November 14, 2016. Available at: “https://www.
ama-assn.org/delivering-care/ethics/staff-privileges”.
Accessed August 6, 2020.
6. American Medical Association. Policy H-230.975 Eco-
nomic credentialing. 2017. American Medical Association
PolicyFinder. Available at: “https://policysearch.ama-assn.
org/policyfinder/detail/230.975?uri=%2FAMADoc%2FH
OD.xml-0-1606.xml”. Accessed August 6, 2020.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 147
ORAL HEALTH POLICIES: MODEL DENTAL BENEFITS
Policy on Model Dental Benefits for Infants,
Children, Adolescents, and Individuals with
Special Health Care Needs
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD) believes
that all infants, children, adolescents, and individuals with
special health care needs must have access to comprehensive
preventive and therapeutic oral health care benefits that
contribute to their optimal health and well-being. This policy
is intended to assist policy makers, third-party payors, and
consumer groups/benefits purchasers to make informed deci-
sions about the appropriateness of oral health care services for
these patient populations.
Methods
This policy was developed by the Council on Dental Benefit
Programs and Council on Clinical Affairs, adopted in 20081,
and last revised in 20172. This policy is based upon a review
of the AAPD’s oral health policies, best practices, and clinical
practice guidelines as well as clinical practice guidelines that
have been developed by other professional organizations and
endorsed by the AAPD.
Background
The AAPD advocates optimal oral health and health care for
all infants, children, adolescents, and individuals with special
health care needs, regardless of race, ethnicity, religion, sexual
or gender identity, medical status, disability, family structure,
or financial circumstances.3 Oral diseases are progressive and
cumulative; ignoring oral health problems can lead to needless
pain and suffering, infection, loss of function, increased health
care costs, and lifelong consequences in educational, social,
and occupational environments. A dental benefit plan should
be actuarially sound and fiscally capable of delivering plan
benefits without suppressing utilization rates or the delivery
of services. When a benefits plan, whether for a commercial
or government program, is not actuarially sound and ade-
quately underwritten, access and appropriate care under the
plan are placed at risk. When oral health care is not accessible,
the health implications, effects on quality of life, and societal
costs are enormous.4 The AAPD’s oral health policies, best
practices, and clinical guidelines5 encourage the highest possible
level of care to children and patients with special health care
148 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
model dental benefits for infants, children, adolescents, and indi-
viduals with special health care needs. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:148-51.
needs. The AAPD also sponsors a national symposium each
year on pediatric oral health care. Those sources as well as
clinical practice guidelines from other organizations with rec-
ognized professional expertise and stature6-13, serve as the basis
for the recommendations below. Such recommendations ideally
are evidence based but, in the absence of conclusive evidence,
may rely on expert opinion and clinical observations.
Policy statement
The AAPD encourages all policy makers and third-party pay-
ors to consult the AAPD in the development of benefit plans
that best serve the oral health interests of infants, children,
adolescents, and individuals with special health care needs.
These model services are predicated on establishment of a
dental home, defined as the ongoing relationship between the
dentist (i.e., the primary oral health care provider) and the
patient, inclusive of all aspects of oral health care, starting
no later than 12 months of age.14
Value of services is an important consideration, and the
AAPD encourages all stakeholders to recognize that a least
expensive treatment is not necessarily the most beneficial or
cost-effective plan in the long term for the patient’s oral
health.
The following services are essential components in health
benefit plans.5
A. Preventive services:
1. initial and periodic orofacial examination, including
medical, dental, and social histories, furnished in accord-
ance with the attached periodicity schedule or when
oral screenings by other health care providers indicate a
risk of caries or other dental or oral disease.
2. education for the patient and the patient’s family on
measures that promote oral health as part of initial and
periodic well-child assessment.
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

3. age-appropriate anticipatory guidance and counseling on
nonnutritive habits, injury prevention, intraoral/perioral
piercing, human papilloma virus, and tobacco use/
substance abuse.
4. application of topical fluoride at a frequency based upon
caries risk factors.
5. prescription of a high-concentration fluoridated tooth-
paste for patients over six years old who are at moderate
to high caries risk.
6. prescription of dietary fluoride supplement13 based upon
a child’s age and caries risk as well as fluoride level of
the water supply or supplies and other sources of dietary
fluoride.
7. application of pit and fissure sealants on primary and
permanent teeth based on caries risk factors, not patient
age.15
8. dental prophylactic services at a frequency based on caries
and periodontal risk factors.
B. Diagnostic procedures consistent with guidelines developed
by organizations with recognized professional expertise and
stature, including radiographs in accordance with recommen-
dations by the American Academy of Oral and Maxillofacial
Radiology, United States (U.S.) Food and Drug Adminis-
tration, and the American Dental Association. 8,9 When
necessary and appropriate, teledentistry for orofacial evaluation
may be used.
C. Restorative and endodontic services to relieve pain, resolve
infection, restore teeth, and maintain dental function and oral
health. This would include interim therapeutic restorations,
a beneficial provisional technique in contemporary pediatric
restorative dentistry.
D. Orthodontic services including space maintenance and
services to diagnose, prevent, intercept, and treat malocclu-
sions, including management of children with cleft lip/palate,
congenital or developmental defects, and obstructive sleep
apnea (OSA). These services include, but are not limited to,
obturators, initial appliance construction, and replacement of
appliances as the child grows.17
E. Dental and oral surgery including sedation/general
anesthesia and related medical services performed in an office,
hospital, or ambulatory surgical care setting.
F. Periodontal services to manage gingivitis, periodontitis, and
other periodontal diseases or conditions in children.
G. Prosthodontic services, including implants with restorations
to restore oral function as well as maxillofacial prosthetics/
prosthodontics as recommended/supported by a craniofacial
team.17,18
ORAL HEALTH POLICIES: MODEL DENTAL BENEFITS
H. Diagnostic and therapeutic services related to the acute and
long-term management of orofacial trauma. When the injury
involves a primary tooth, benefits should cover complications
for the developing succedaneous tooth. When the injury in-
volves a permanent tooth, benefits should cover long-term
complications to the involved and adjacent or opposing teeth
including cosmetic/esthetic treatment that could impact social
health.
I. Drug prescription for preventive services, relief of pain, or
treatment of infection or other conditions within the dentist’s
scope of practice.
J. Medically-necessary services for preventive and therapeutic
care in patients with medical, physical, or behavioral condi-
tions. These services include, but are not limited to, the care
of hospitalized patients, sedation, and general anesthesia in
outpatient or inpatient hospital facilities.
K. Behavior guidance services necessary for the provision of
optimal therapeutic and preventive oral care to patients with
medical, physical, or behavioral conditions. These services
may include both pharmacologic and nonpharmacologic
management techniques.
L. Consultative services provided by a pediatric dentist when
requested by a general practitioner or another dental specialist
or medical care provider.
References
1. American Academy of Pediatric Dentistry. Policy on model
dental benefits for infants, children, adolescents, and in-
dividuals with special health care needs. Pediatr Dent
2008;30(suppl):71-3.
2. American Academy of Pediatric Dentistry. Policy on
model dental benefits for infants, children, adolescents,
and individuals with special health care needs. Pediatr
Dent 2017;39(6):108-11.
3. American Academy of Pediatric Dentistry. Policy on care
for vulnerable populations in a dental setting. The Refer-
ence Manual of Pediatric Dentistry. Chicago, Ill.: Amer-
ican Academy of Pediatric Dentistry; 2022:34-40.
4. National Institutes of Health. Oral Health in America:
Advances and Challenges. Bethesda, Md.: U.S. Depart-
ment of Health and Human Services, National Institutes
of Health, National Institute of Dental and Craniofacial
Research, 2021. Available at:“https://www.nidcr.nih.
gov/sites/default/files/2021-12/Oral-Health-in-America-
Advances-and-Challenges.pdf ”. Accessed March 11,
2022.
5. American Academy of Pediatric Dentistry. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:1-640.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 149
ORAL HEALTH POLICIES: MODEL DENTAL BENEFITS
6. American Association of Endodontists. Guide to Clinical
Endodontics. 6th ed. Chicago, Ill.: American Association
of Endodontists; Updated 2019. Available at: “https://
www.aae.org/specialty/clinical-resources/guide-clinical-
endodontics/”. Accessed March 11, 2022.
7. Caton JG, Armitage G, Berglundh T, et al. A new clas-
sification scheme for periodontal and peri-implant diseases
and conditions – Introduction and key changes from the
1999 classification. J Clin Periodontol 2018;45(Suppl
20):S1-S8. Available at: “https://onlinelibrary.wiley.com/
doi/10.1111/jcpe.12935”. Accessed March 13, 2022.
8. American Dental Association, U.S. Department of Health
and Human Services. Recommendations for Patient
Selection and Limiting Radiation Exposure. Revised:
2012. Available at: “http://www.ada.org/~/media/ADA/
Publications/ADA%20News/Files/Dental_Radiographic
_Examinations_2012.pdf?la=en”. Accessed March 11,
2022.
9. Carter L, Geist J, Scarfe WC, et al. American Academy
of Oral and Maxillofacial Radiology executive opinion
statement on performing and interpreting diagnostic cone
beam computed tomography. Oral Surg Oral Med Oral
Pathol Oral Radiol 2008;106(4):561-2.
10. American Cleft Palate-Craniofacial Association. Param-
eters for Evaluation and Treatment of Patients with Cleft
Lip/Palate or Other Craniofacial Differences. Revised
ed, January, 2018. Cleft Palate Craniofac J 2018;55(1):
137-56. Available at: “https://journals.sagepub.com/doi/
pdf/10.1177/1055665617739564”. Accessed March 13,
2022.
11. National Foundation for Ectodermal Dysplasias. Param-
eters of Oral Health Care for Individuals Affected by
Ectodermal Dysplasias. National Foundation for Ecto-
dermal Dysplasias. Mascoutah, Ill.; 2nd Revision 2015.
Available at: “https://www.nfed.org/learn/library/
parameters-dental-health-care/”. Accessed March 11, 2022.
150 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
12. Rozier RG, Adair S, Graham F, et al. Evidence-based
clinical recommendations on the prescription of dietary
fluoride supplements for caries prevention: A report of
the American Dental Association Council on Scientific
Affairs. J Am Dent Assoc 2010;141(12):1480-9.
13. Clark MB, Slayton RL; Section on Oral Health. Fluoride
use in caries prevention in the primary care setting.
Pediatrics 2014;134(3):626-33.
14. American Academy of Pediatric Dentistry. Definition of
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:15.
15. Crall JJ, Donly KJ. Dental sealants guidelines develop-
ment 2002-2014. Pediatr Dent 2015;37(2):111-5.
16. Wright JT, Crall JJ, Fontana M, et al. Evidence-based
clinical practice guideline for the use of pit and fissure
sealants. American Academy of Pediatric Dentistry,
American Dental Association. Pediatric Dent 2016;38(5):
E120-36.
17. Reisberg DJ. Dental and prosthodontic care for pa-
tients with cleft or craniofacial conditions. Cleft Palate
Craniofac J 2000;37(6):534-7.
18. Wermker K, Jung S, Joos U, Kleinheinz J. Dental implants
in cleft lip, alveolus, and palate patients: A systematic
review. Int J Oral Maxillofac Implants 2014;29(2):
384-90.
 ORAL HEALTH POLICIES: MODEL DENTAL BENEFITS

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
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 151

ORAL HEALTH POLICIES: REIMBURSEMENT FOR MANAGEMENT OF SHCN
Policy on Third-Party Reimbursement for
Management of Patients with Special Health Care
Needs
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that, because of improvements in medical care, the
number of patients with special health care needs (SHCN)
will continue to grow. Many of the formerly acute and fatal
diagnoses have become chronic and manageable conditions.
Patients with SHCN require a dental team with special
knowledge and skills and additional staff time to coordinate
care and accommodate the patient’s unique circumstances. An
increased appointment length often is necessary in order to
treat the patient in a safe, effective, and high-quality manner.
Such customized services have not been reimbursed by third-
party payors. AAPD advocates reimbursement for measures
that are necessary to manage the patient’s unique
healthcare needs within the dental home.
Methods
This policy, originally developed by the Council on Clinical
Affairs and adopted in 20171, is a review of current dental and
medical literature, sources of recognized professional expertise
related to medical and dental reimbursement, and industry
publications. An electronic search was conducted using the
®
PubMed /MEDLINE database with the terms: special health
care needs AND access to care, special health care needs AND
reimbursement, disease management AND managed care, dis-
ease management AND insurance, disease management AND
reimbursement; fields: all; limits: within the last 20 years,
humans, English, birth through age 99. The search yielded
1229 articles. Papers for review were chosen from this list and
from the references within selected articles.
Background
In 2017-2018, approximately 18.5 percent (13.6 million) of
United States (U.S.) children had SHCN, and one in four
households (24.8 percent) had one or more children with
SHCN.2 The AAPD defines special health care needs as “any
physical, developmental, mental, sensory, behavioral, cognitive,
or emotional impairment or limiting condition that requires
medical management, health care intervention, and/or use
of specialized services or programs.”3 The 2001 National Survey
152 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
third-party reimbursement for management of patients with
special health care needs. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:152-5.
of Children with Special Health Care Needs determined that
dental care was among the largest unmet needs 4, a finding
that has remained consistent for nearly two decades.2,5-7 The
specific category of dental care for children with SHCN has
been reviewed and compared with healthy children.6,8 Children
with SHCN have been shown to receive preventive care at
equal or greater rates than children without SHCN. 7,8
However, parents of children with SHCN are more likely to
report unmet dental care needs in their children compared
with unaffected children.8,9
Patients with SHCN face both disparities and barriers to
oral health care.10-12 Disparities refer to differences in health
status that result from discrimination, lack of access, or
systematic exclusion from services.12,13 Barriers may be either
environmental/system-centered or non-environmental. 12
Environmental barriers to obtaining oral health care include
difficulties finding a dental office close to home that accepts
the patient’s dental insurance and is able to accommodate
the patient’s unique needs, in addition to the rising costs of
healthcare. 12 Non-environmental factors center around the
patient. They may include patient anxiety, oral defensiveness,
and inability to tolerate dental treatment in an office setting.12
Additionally, the patient’s medical condition may complicate
dental treatment, or the patient may have medical health
care needs which are more urgent than dental care needs.12
Patients with SHCN, particularly those with developmen-
tal disabilities, complex health care issues, behavioral issues,
and dental fears, may require more provider time.14 Many
dentists are unwilling to treat individuals with SHCN due to
lack of familiarity with the medical conditions, the additional
time required to obtain a medical history or consultations and
render treatment, inadequate training to treat patients with
SHCN, poor reimbursement, and lack of knowledge about
available resources.8,15-18 Pediatric dentists have the necessary
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CDT: Current Dental
Terminology. CPT: Current Procedural Terminology. SHCN: Special
health care needs. U.S.: United States.

expertise and provide a disproportionate amount of care to
individuals with SHCN; however, the number and distribution
of U.S. pediatric dentists cannot adequately address the treat-
ment needs of this population.10,11 The AAPD has successfully
advocated for federal Title VII funding to train more pediatric
dentists through the expansion and creation of new pediatric
dental residency positions and programs, most of which focus
on providing care to children with SHCN.19 However, there
has been little to no progress towards improving reimburse-
ment by third-party payors for the additional time required to
provide dental care for individuals with SHCN.20
Lack of insurance coverage, high out-of-pocket expense, and
high deductibles have been cited as common financial barriers
that disproportionately burden families of patients with SHCN
when seeking medically-necessary oral health care.12,20-24 Elimi-
nating or reducing these barriers can be expected to result in
lasting positive effects on the oral health of patients with
SHCN.25 To that point, low Medicaid reimbursement and a
shortage of general dentists qualified or willing to treat patients
with SHCN have been identified as the main barriers to tran-
sitioning to adult-centered dental care.20 Conversely, access to
private insurance has been shown to facilitate the transition
to adult-centered dental care for individuals with SHCN.20
Patients with significant medical complexity require longer
face-to-face appointments to review a thorough history, as well
as additional non-face-to-face time for medical consultations,
documentation, and care coordination.26-28 Currently, a medi-
cal model exists that accounts for either complexity in medical
decision making or the increased time above the usual amount
of time a practitioner requires to treat a non-complex pa-
tient.28-30 In the medical model, if the additional time that is
spent is for counseling or coordination of care, primary care
providers are allowed to bill for evaluation and management
([E/M]; Current Procedural Terminology [CPT] codes 99201-
99215) based on time.26,30 In doing this, providers need to
document the following information:
• total time of the visit,
• time or percent of the visit spent in counseling/coordi-
nation of care, and
• nature of the counseling/coordination of care.
Discussions with patients regarding referrals to other pro-
viders and ordering and reviewing of tests/laboratory results
meet the time criteria for medical billing.30 Care coordination
offers the possibility of improving quality and controlling
costs for patients with complex conditions.31 Adequate re-
imbursement for the care coordination code (Current Dental
Terminology [CDT] code D9992) 32 will more accurately
identify patients with special health care needs and help
alleviate financial losses to dentists caring for individuals
with SHCN.23
Many patients with special needs can be treated in the tra-
ditional clinical setting without the increased medical risk
or additional cost of general anesthesia, but the provision of
this care may require additional time and involve the use of
ORAL HEALTH POLICIES: REIMBURSEMENT FOR MANAGEMENT OF SHCN
additional personnel or use of advanced behavior management
techniques. When physicians are faced with similar circum-
stances, they are able to use the prolonged service codes (CPT
codes 99354 and 99356). 30 In order to qualify for billing
either code, the physician or other qualified healthcare profes-
sional must provide at least one hour of face-to-face patient
contact, either outpatient or inpatient respectively, beyond the
usual evaluation and management service. CPT codes 99355
and 99357 may be used if the prolonged service is increased
by an additional 30-minute increment.30 The CDT behavior
management code 9920 is most similar to the prolonged
service code. Reimbursement for the behavior management
code may result in reduced referrals for costly general anesthesia
services and facilitate the delivery of medically-necessary
oral health care in the dental setting to which these patients
are entitled.23
Payment reform that allows implementation and reim-
bursement of codes such as CDT code 9920 could allow
the dental home to follow an important trend of the medical
home. 23 Care coordination activities could change from
mostly being reactive to episodic needs of patients to being
more systematically proactive and comprehensive 33 thereby
reducing hospitalizations and avoiding emergency department
visits. 31 As the number of patients with SHCN increases,
demands and expertise required for management and care
coordination also increase. 20 The dental care paradigm for
managing patients with SHCN is changing. 34 Treatment in
isolation is no longer possible, and a team approach is often
necessary. 34 Practitioners may need to communicate with
primary care physicians, medical specialists, occupational
therapists, behavioral health providers, and social workers to
effectively care for individuals with SCHN. 34 Combining
dental services with separate procedures requiring sedation or
general anesthesia (e.g., medical imaging, adenotonsillectomy,
myringotomy) is an example of providing collaborative
healthcare for patients with SHCN.35
Policy statement
The AAPD recognizes that the population of people with
special health care needs is increasing and that additional
time and skills are necessary to provide optimal care to those
individuals in a dental home setting. Care coordination activities
for patients with SHCN that are more systematically proactive,
rather than reactive, and allow for comprehensive manage-
ment could reduce hospitalizations and avoid emergency
department visits. Furthermore, reimbursement for the use of
additional personnel or advanced behavior management tech-
niques could reduce the need for costly general anesthesia and
facilitate the delivery of medically-necessary oral health care
to which these patients are entitled. Therefore, the AAPD
advocates that third-party payors and managed care organi-
zations review their capitation policies to provide adequate
reimbursement for care coordination (CDT code D9992) and
behavior management (CDT code D9920).
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 153
ORAL HEALTH POLICIES: REIMBURSEMENT FOR MANAGEMENT OF SHCN
References
1. American Academy of Pediatric Dentistry. Policy on third-
party reimbursement for management of patients with
special health care needs. Pediatr Dent 2017;39(special
issue):112-4.
2. U.S. Department of Health Resources and Services
Administration’s Maternal and Child Health Bureau.
Children with Special Health Care Needs. National
Survey of Children’s Health Data Brief | July 2020.
Available at: “https://mchb.hrsa.gov/sites/default/files/
mchb/Data/NSCH/nsch-cshcn-data-brief.pdf ”. Accessed
June 22, 2021.
3. American Academy of Pediatric Dentistry. Definition
of special health care needs. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2020:19.
4. U.S. Department of Health and Human Service, Health
Resources and Service Administration, Maternal and
Child Health Bureau. The National Survey of Children
with Special Health Care Needs Chartbook 2001.
Rockville, Md.: U.S. Department of Health and Human
Service; 2004. Available at: “https://mchb.hrsa.gov/chscn/
pages/toc.htm”. Accessed March 6, 2021.
5. U.S. Department of Health and Human Service, Health
Resources and Service Administration, Maternal and
Child Health Bureau. The National Survey of Children
with Special Health Care Needs Chartbook 2005-2006
Summary Tables. Rockville, Md.: U.S. Department of
Health and Human Service; 2008. Available at: “https://
www.cdc.gov/nchs/data/slaits/summary_tables_nscshcn
_0506.pdf ”. Accessed March 6, 2021.
6. U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and
Child Health Bureau. The National Survey of Children
with Special Health Care Needs Chartbook 2009–2010.
Rockville, Maryland: U.S. Department of Health and
Human Services, 2013. Available at: “https://mchb.hrsa.
gov/sites/default/files/mchb/Data/NSCH/nscshcn0910
-chartbook-jun2013.pdf ”. Accessed March 16, 2021.
7. Lebrun-Harris LA, Canto MT, Vodicka P. Preventive oral
health care use and oral health status among US children:
2016 National Survey of Children’s Health. J Am Dent
Assoc 2019;150(4):246-58.
8. Lewis CW. Dental care and children with special health
care needs: A population-based perspective. Acad Pediatrics
2009;9(6):420-6.
9. Sannicandro T, Parish SL, Son E, Powell RM. Health
care changes for children with special health care needs.
Matern Child Health J 2017;21(3):524-30.
10. Kerins C, Casamassimo PS, Ciesla D, Lee Y, Seale NS. A
preliminary analysis of the US dental health care system’s
capacity to treat children with special health care needs.
Pediatr Dent 2011;33(2):107-12.
154 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
11. Norwood KW, Slayton RL, Council on Children with
Disabilities Section on Oral Health. Oral health care
for children with developmental disabilities. Pediatrics
2013;131(3):614-9.
12. Nelson LP, Getzin A, Graham D, et al. Unmet dental needs
and barriers to care for children with significant special
health care needs. Pediatr Dent 2011;33(1):29-36.
13. Webb JR. Overview of disability. In: Nelson TM, Webb
JR, eds. Dental Care for Children with Special Needs.
Cham, Switzerland: Springer; 2019:51-2.
14. Mattson G, Kuo DZ, AAP Committee on Psychosocial
Aspects of Child and Family Health, AAP Council on
Children with Disabilities. Psychosocial factors in chil-
dren and youth with special health care needs and their
families. Pediatrics 2019;143(1):E20183171.
15. Shakespeare T, Iezzoni LI, Groce NE. Disability and the
training of health professionals. Lancet 2009;374(9704):
1815-6.
16. Casamassimo PS, Seale NS, Ruehs K. General dentists’
perceptions of educational and treatment issues affecting
access to care for children with special health care needs.
J Dent Educ 2004;68(1):23-8.
17. Edelstein BL. Conceptual frameworks for understanding
system capacity in the care of people with special health
care needs. Pediatr Dent 2007;29(2):108-16.
18. Ferguson FS, Berentsen B, Richardson PS. Dentists’ will-
ingness to provide care for patients with developmental
disabilities. Spec Care Dentist 1991;11(6):234-7.
19. Ng MW, Glassman P, Crall J. The impact of Title VII
on general and pediatric dental education and training.
Acad Med 2008;83(11):1039-48.
20. Bayarsaikhan Z, Cruz S, Neff J, Chi DL. Transitioning
from pediatric dental care to adult care for adolescents
with special needs: Dentist perspectives (Part Two).
Pediatr Dent 2015;37(5):447-51.
21. Bachman SS, Comeau M, Long TF. Statement of the
problem: Health reform, value-based purchasing, alternative
payment strategies, and children and youth with special
health care needs. Pediatrics 2017;139(Suppl 2):S89-98.
22. Rouleau T, Harrington A, Brennan M, et al. Receipt of
dental care and barriers encountered by persons with dis-
abilities. Spec Care Dentist 2011;31(2):63-7.
23. Crall JJ. Improving oral health for individuals with special
health care needs. Pediatr Dent 2007;29(2):98-104.
24. Kastner T, American Academy of Pediatrics Committee
on Children With Disabilities. Managed care and children
with special healthcare needs. Clinical Report—Guidance
for the clinician in rendering pediatric care. Pediatrics
2004;114(12):1696-8.
25. Paschal AM, Wilroy JD, Hawley SR. Unmet needs for
dental care in children with special health care needs.
Prev Med Rep 2015;3:62-7.
26. Cohen E, Kuo DZ, Srivastava R. Children with medical
complexity: An emerging population for clinical and
research initiatives. Pediatrics 2011;127(3):529-38.

27. Mount JK, Massanari RM, Teachman J. Patient care
complexity as perceived by primary care physicians. Fam
Syst Health 2015;33(2):137-45.
28. Dorlan B, American Academy of Pediatrics Division of
Health Care Finance. Codes developed for non-face-
to-face-services. American Academy of Pediatrics AAP
News Coding Corner, March 6, 2019. Available at:
“https://www.aappublications.org/news/2019/03/06/
coding030619”. Accessed June 22, 2021.
29. 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 March 6, 2021
30. American Medical Association. Current Procedural
Terminology Professional Edition: CPT: 2020. Chicago,
Ill.: American Medical Association; 2019.
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31. Goodell S, Bodenheimer T, Berry-Millet R. The Synthesis
Project. Care management of patients with complex
health care needs. Policy Brief No. 19. Robert Wood
Johnson Foundation. 2009. Available at: “http://www.
rwjf.org/en/library/research/2009/12/care-management-of
-patients-with-complex-health-care-needs.html”. Accessed
March 6, 2021.
32. American Dental Association. CDT 2020: Dental Pro-
cedure Codes. Chicago, Ill.: American Dental Association;
2020.
33. Van Cleave J, Boudreau AA, McAllister J, Cooley WC,
Maxwell A, Kuhlthau K. Care coordination over time
in medical homes for children with special health care
needs. Pediatrics 2015;35(6):1018-26.
34. Nelson TM, Webb JR. Shifting the dental care paradigm
for CSHCN. In: Dental Care for Children with Special
Needs. Cham, Switzerland: Springer; 2019:651-61.
35. Syed F, Uffman JC, Tumin D, Flaitz CM, Tobias JD,
Raman VT. A study on the efficacy and safety of com-
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Clin Cosmet Investig Dent 2018;10:45-9.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 155
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO SEDATION / GA
Policy on Third-Party Reimbursement of Medical
Fees Related to Sedation/ General Anesthesia for
Delivery of Oral Health Care Services
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD) wants
to ensure that all children have access to the full range of oral
health delivery systems. It advocates that if sedation or general
anesthesia and related facility fees are payable benefits of a
healthcare plan, these same benefits shall apply for the deliv-
ery of oral health services.
Methods
This policy was developed by the Dental Care Committee,
adopted in 19891, and last revised by the Council of Clinical
Affairs in 20162. This document is based on a review of the
current dental literature related to guidelines for sedation and
general anesthesia, as well as issues pertaining to medically-
necessary oral health care. The update included a PubMed /
MEDLINE search using the terms: general anesthesia/sedation
® and poorly-defined criteria.12-14 While states or third-party
costs, general anesthesia/sedation reimbursement, general
anesthesia/sedation insurance coverage, general anesthesia and
medically necessary dental care, and general anesthesia/oral
health-related quality of life and limit: within the last 10 years,
as well as relevant articles from dental and medical literature.
The search returned 300 articles. Relevant policies and best
practices of the AAPD and the American Dental Association
(ADA) are included. Additionally, expert opinions and best
current practices were relied upon when clinical evidence was
not available.
Background
For some infants, children, adolescents, and persons with special
health care needs, treatment under sedation/general anesthesia
in a hospital, outpatient facility, or dental office or clinic repre-
sents the optimal method to deliver necessary oral health care.3-5
The patient’s age, dental treatment needs, limited abilities,
medical conditions, or acute situational anxiety may preclude
the patient from being treated in a traditional outpatient set-
ting.5-10 These patients may be denied access to oral health care
when insurance companies refuse to provide reimbursement for
sedation/general anesthesia and related facility services. When
oral health care is not accessible, the health implications, effects
on quality of life, and societal costs are enormous.11
156 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
third-party reimbursement of medical fees related to sedation/
general anesthesia for delivery of oral health care services. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:156-9.
Dental care is medically necessary to prevent and eliminate
orofacial disease, infection, and pain, to restore the form and
function of the dentition, and to correct facial disfiguration or
dysfunction. Medically necessary care includes all supportive
health care services that, in the judgment of the attending
dentist, are necessary for the provision of optimal quality thera-
peutic and preventive oral care.3 Some medical insurance plans
may not view dental care and adjunctive services requiring
hospital/anesthesia related fees as medically necessary. Although
medical policies often provide reimbursement for sedation/
general anesthesia and facility fees related to myringotomy for a
three-year-old child, these benefits may be denied when related
to treatment of dental disease or infection for the same patient.
This determination at times appears to be based on inconsistent
payors may require prior authorization for such procedures in
an effort to control healthcare expenditures, this can be a
time-consuming burden for practitioners. By establishing well-
defined criteria (e.g., patient’s age, treatment requirements,
behavior, and medically-compromising condition; failed
attempts at in-office treatment) and a streamlined preauthori-
zation process, the dental practitioner is provided an opportunity
to justify the need for anesthesia services and all parties can
be assured of transparency, access to the full range of services
available through a patient’s benefits plan, and improved
timeliness of treatment and reimbursement.
Delays in care can result in needless pain and suffering,
infection, loss of function, and increased health care costs.
Additionally, indiscriminate prescription of antibiotics for in-
fections contributes to antibiotic resistance, and chronic use
of acetaminophen for pain control can lead to hepatotoxicity.
Less-effective management of these patients may result in a
higher disease burden for the patient (i.e., more teeth requir-
ing treatment and more invasive treatment needs)15 as well as
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ACA: Affordable
Care Act. ADA: American Dental Association. ECC: Early childhood
caries. QOL: Quality of life.

the patient’s avoidance of oral health professionals in the future
and increased likelihood of seeking care in the emergency de-
partment7. Furthermore, this could also place an increased
demand on practitioners, emergency departments, and hospi-
tals to treat patients with urgent and emergent dental needs.
In the event the insurer denies the preauthorization or claim
citing lack of medical necessity, an appeals process to allow the
practitioner to advocate on the patient’s behalf through peer-
to-peer conferences is essential.
Some patients may have dental developmental disorders
such as dentinogenesis imperfecta, osteogenesis imperfecta, or
molar-incisor hypoplasia which require extensive dental treat-
ment that may exceed the capability of the patient to be treat-
ed in the normal clinic setting. Dental rehabilitation of early
childhood caries (ECC) has shown a significant improvement
in oral health-related quality of life (QOL) in children.6,16-26
Children undergoing comprehensive dental treatment under
general anesthesia exhibited improvement in several areas such
as sleeping, eating, and pain.6,17-20 Parents reported their children
to have a better perceived QOL one to four weeks following
dental rehabilitation under general anesthesia.21 Such treatment
also has been reported to have a positive impact on the family’s
quality of life.16
ADA Resolution 1989-546 states that insurance compa-
nies should not deny benefits that otherwise would be payable
“solely on the basis of the professional degree and licensure of
the dentist or physician providing treatment, if that treatment
is provided by a legally qualified dentist or physician oper-
ating within the scope of his or her training and licensure”.27
Recently, the ADA adopted Resolution 3-H (2021) which
addressed anesthesia coverage under health plans. It “supports
the position that all health plans, including those governed by
the Employee Retirement Income Security Act, should be re-
quired to cover general anesthesia and/or hospital or outpatient
surgical facility charges incurred by covered persons who receive
dental treatment under anesthesia, due to a documented
complexity, behavioral, physical, mental or medical reason as
determined by the treating dentist(s) and/or physician.”28
A majority of states have enacted legislation requiring medi-
cal insurers to reimburse for hospital charges associated with
provision of dental care for children in the operating room.7
Such legislation has resulted in increased access to care, with
more children receiving services in an operating room setting
after enactment of legislation.6 However, this increased access
has recently come in jeopardy due to multiple factors includ-
ing the implementation of the Essential Health Benefits
package under the Affordable Care Act (ACA).7,29 While most
ACA plans included “oral health” as a benefit, oral health was
not defined. States play a major role in determining the content
of their ACA plans, and fewer states included dental anesthesia
(15) than orthodontic care (32) as a benefit for children.29
Lower reimbursement of hospital facility and anesthesia fees
also has reduced access to dental care under general anesthesia.30
Per an analysis commissioned by the AAPD, no suitable
mechanism for billing rehabilitation services for Medicare or
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO SEDATION / GA
Medicaid beneficiaries having complex dental needs requiring
operating room access exists.31 Coding for dental procedures
is limited to a miscellaneous code (CPT 41899) which falls in
the Ambulatory Payment Class 5161. The mean reimbursement
nationally for this class was less than $250, which is grossly
insufficient as this rate does not cover the facility’s overhead,
equipment costs, or anesthesia services.31 Therefore, hospitals
may have financial incentive to provide operating room time
to surgeons whose cases are associated with higher reimburse-
ment levels. Hospital financial and staffing challenges including
those caused by the severe acute respiratory syndrome corona-
virus 2 (SARS-CoV-2)/coronavirus disease 2019 (COVID-19)
pandemic have limited patient care and severely decreased
hospital revenue.31-33 Due to these obstacles, dental cases re-
portedly have been delayed as long as six months to a year.30,31
Regardless of the insurer and hospital challenges, with dental
caries as the most common chronic disease of childhood, access
to dental care remains one of the most frequently cited unmet
needs.34 Less availability of the operating room for pediatric
dental patients has far reaching implications. Until this situa-
tion is rectified, third party payors may be faced with patients
seeking medically-necessary oral health care in more expensive
locations such as emergency departments.35-37
Policy statement
The AAPD encourages all policy makers and third-party pay-
ors to consult the AAPD in the development of benefit plans
that best serve the oral health interests of infants, children,
adolescents, and individuals with special health care needs.
The AAPD strongly believes that the treating dentist deter-
mines the medical necessity for sedation/general anesthesia3
consistent with accepted guidelines on sedation and general
anesthesia9.
The AAPD strongly encourages third-party payors to:
1. recognize that sedation or general anesthesia is necessary
to deliver compassionate, quality oral health care to some
infants, children, adolescents, and persons with special
health care needs.
2. include sedation, general anesthesia, and related facility
services as benefits of health insurance without discrim-
ination between the medical or dental nature of the
procedure.
3. end denial of reimbursement for sedation, general anes-
thesia, and facility costs related to the delivery of oral
health care.
4. regularly consult the AAPD and the ADA with respect
to the development of benefit plans that best serve the
oral health interests of infants, children, adolescents, and
patients with special care needs.38
The AAPD encourages all states to enact legislation that re-
quires third-party payors to reimburse for facility and sedation/
general anesthesia costs associated with providing oral health
care for children.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 157
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO SEDATION / GA
References
1. American Academy of Pediatric Dentistry. Policy on third-
party reimbursement of medical costs related to sedation/
general anesthesia. Orlando, Fla.: American Academy of
Pediatric Dentistry; May, 1989.
2. American Academy of Pediatric Dentistry. Definition of
medically-necessary care. Pediatr Dent 2016;38(special
issue):103-5.
3. American Academy of Pediatric Dentistry. Policy on
medically-necessary care. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:23-8.
4. American Academy of Pediatrics. Essential contractual
language for medical necessity for children. Pediatr 2013;
132(20):398-401.
5. Glassman P, Caputo A, Dougherty N, et al. Special Care
Dentistry Association consensus statement on sedation,
anesthesia, and alternative techniques for people with spe-
cial needs. Spec Care Dentist 2009;29(1):2-8, quiz 67-8.
6. White HR, Lee JY, Rozier RG. The effects of general anes-
thesia legislation on operating room visits by preschool
children undergoing dental treatment. Pediatr Dent 2008;
30(1):500-5.
7. American Academy of Pediatric Dentistry Oral Health
Policy and Research Center. Technical Report 2-2012: An
Essential Health Benefit: General Anesthesia for Treat-
ment of Early Childhood Caries. Available at: “http: //
www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf ”.
Accessed August 23, 2022.
8. Escanilla-Casal A, Aznar-Gómez M, Viaño JM, López-
Giménez A, Rivera-Baró A. Dental treatment under
general anesthesia in a group of patients with cerebral
palsy and a group of healthy pediatric patients. Med
Oral Patol Oral Cir Bucal 2014;19(5):e490-4.
9. Cote CJ, Wilson S. American Academy of Pediatric Den-
tistry, American Academy of Pediatrics. Guidelines for
monitoring and management of pediatric patients before,
during and after sedation for diagnostic and therapeutic
procedures. Pediatr Dent 2019;41(4):E26-E52.
10. American Academy of Pediatric Dentistry. Use of anes-
thesia providers in the administration of office-based deep
sedation/general anesthesia to the pediatric dental patient.
The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:
387-91.
11. National Institutes of Health. Oral Health in America:
Advances and Challenges. Bethesda, Md.: U.S. Depart-
ment of Health and Human Services, National Institutes
of Health, National Institute of Dental and Craniofacial
Research, 2021. Available at: “https://www.nidcr.nih.
gov/sites/default/files/2021-12/Oral-Health-in-America-
Advances-and-Challenges.pdf ”. Accessed March 8, 2022.
12. White BA. The costs and consequences of neglected
medically necessary oral care [review]. Spec Care Dentist
1995;15(5):180-6.
158 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
13. Cameron CA, Litch CS, Liggett M, Heimberg S. Na-
tional Alliance for Oral Health Consensus Conference
on Medically-Necessary Oral Health Care: Legal issues.
Spec Care Dentist 1995;15(5):192-200.
14. Crall J. Behavior management conference Panel II report
–Third party payor issues. Pediatr Dent 2004;26(2):
171-4.
15. Okuji DM, Lin J. Predicting negative outcomes while
awaiting dental treatment under general anesthesia. J
Dent Child 2021;88(1):3-10.
16. Jankauskiene B, Narbutaite J. Changes in oral health-
related quality of life among children following dental
treatment under general anaesthesia. A systematic review.
Stomatologija 2010;12(2):60-4.
17. Jankauskiene B, Virtanen JI, Kubilius R, Narbutaite J. Oral
health-related quality of life after dental general anaes-
thesia treatment among children: A follow-up study.
BMC Oral Health 2014;14(1):1-7.
18. Gaynor WN, Thomson WM. Changes in young children’s
OHRQoL after dental treatment under general anaes-
thesia. Int J Paediatr Dent 2012;22(4):258-64.
19. Yawary R, Anthonappa RP, Ekambaram M, McGrath C,
King NM. Changes in the oral health-related quality of
life in children following comprehensive oral rehabilita-
tion under general anaesthesia. Int J Paediatr Dent 2016;
26(5):322-9.
20. Baghdadi ZD. Children’s oral health-related quality of
life and associated factors: Midterm changes after dental
treatment under general anesthesia. J Clin Experimental
Dent 2015;7(1):e106.
21. Malden PE, Thomson WM, Jokovic A, Locker D. Changes
in parent-assessed oral health related quality of life
among young children following dental treatment under
general anaesthestic. Community Dent Oral Epidemiol
2008;36(2):108-17.
22. Cantekin K, Yildirim MD, Cantekin I. Assessing change
in quality of life and dental anxiety in young children
following dental rehabilitation under general anesthesia.
Pediatr Dent 2014;36(1):12E-17E.
23. Klaassen MA, Veerkamp JS, Hoogstraten J. Young chil-
dren’s oral health-related quality of life and dental fear
after treatment under general anaesthesia: A randomized
controlled trial. Eur J Oral Sci 2009;117(3):273-8.
24. Antunes LAA, Andrade MRTC, Leão ATT, Maia LC,
Luiz R. Change in the quality of life of children and
adolescents younger than 14 years old after oral health
interventions: A systematic review. Pediatr Dent 2013;35
(1):37-42.
25. Cunnion DT, Spiro A, Jones JA, et al. Pediatric oral
health-related quality of life improvement after treatment
of early childhood caries: A prospective multisite study. J
Dent Child 2010;77(1):4-11.

26. Lanlan L, Wang H, Han X. Oral health-related quality of
life in pediatric patient under general anesthesia: A pro-
spective study. Medicine 2017;96(2):e5596. Available at:
“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC526
6155/”. Accessed March 10, 2022.
27. American Dental Association. Benefits for services by
qualified practitioners (1989:546). In: ADA Current Poli-
cies Adopted 1954-2021. Chicago, Ill.: American Dental
Association; 2022:90.
28. American Dental Association. Anesthesia coverage under
health plans. In: ADA Current Policies Adopted 1954-
2021. Chicago, Ill.: American Dental Association; 2022:
106.
29. Grace AM, Noonan KG, Cheng TL, et al. The ACA’s
pediatric essential health benefit has resulted in a state-
by-state patchwork of coverage and exclusions. Health
Affairs 2014;33(12):2136-43.
30. Vo AT, Casamassimo PS, Peng J, Amini H, Litch CS,
Hammersmith K. Denial of operating room access for
pediatric dental treatment: A national survey. Pediatr
Dent 2021;43(1):33-41.
31. American Academy of Pediatric Dentistry, Pediatric Oral
Health Research and Policy Center. Keels MA, Vo A,
Casamassimo PS, Litch CS, Wright R, eds. Denial of
Access to Operating Room Time in Hospitals for Pediatric
Dental Care. Chicago, Ill.: American Academy of Pediat-
ric Dentistry; 2021. Available at: “https://www.aapd.org/
globalassets/media/advocacy/ord.pdf ”. Accessed July 7,
2022.
32. Berlin G, Bueno D, Gibler K, Schultz J. Cutting through
the COVID-19 surgical backlog. New York: McKinsey
and Company. October 2020. Available at: “https://www.
mckinsey.com/industries/healthcare-systems-and-services/
our-insights/cutting-through-the-covid-19-surgical-back-
log”. Accessed December 30, 2021.
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO SEDATION / GA
33. Best MJ, McFarland EG, Anderson GF, et al. The likely
economic impact of fewer elective surgical procedures on
U.S. hospitals during the COVID-19 pandemic. Surgery
2020;168(5):962-7.
34. Benjamin RM. Oral health: The silent epidemic. Pub
Health Rep 2010;125(2):158-9. Available at: “doi: 10.11
77/003335491012500202”. Accessed October 14, 2021.
35. Moron EM, Tomar S, Balzer J, Souza R. Hospital inpatient
admissions for nontraumatic dental conditions among
Florida adults, 2006 through 2016. J Am Dent Assoc
2019;150(6):514-21.
36. Owens PL, Manski RJ, Weissw AJ. Emergency depart-
ment visits involving dental conditions, 2018. HCUP
Statistical Brief #280. August 2021. Agency for Health-
care Research and Quality, Rockville, MD. Available at:
“www.HCUP-us.ahrq.gov/reports/statbriefs/sb280-Dental
-ED-Visits-2018.pdf ”. Accessed October 14, 2021.
37. Cohen LA, Magder LS, Manski RJ, Mullins CD. Hospital
admissions associate with nontraumatic dental emergencies
in a Medicaid population. Am J Emer Med 2003;21(7):
540-4.
38. American Academy of Pediatric Dentistry. Policy on
model dental benefits for infants, children, adolescents,
and individuals with special health care needs. The Refer-
ence Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:148-51.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 159
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO OROFACIAL DIFFERENCES
Policy on Third-Party Reimbursement for Oral
Health Care Services Related to Congenital and
Acquired Orofacial Differences
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD) values
the unique qualities of each person and the need to ensure
maximal health attainment for all, regardless of developmen-
tal anomalies or other special health care needs. Recognizing
that patients with craniofacial differences, referred to in this
document as anomalies, require oral health care as a direct
result of their craniofacial condition and that these services
are an integral part of the rehabilitative process,1 AAPD
advocates for the provision of comprehensive oral health care
throughout life. This document provides background
information to assist pediatric dentists to continue working
with and encouraging third-party payors to provide oral health
care benefits for individuals with craniofacial anomalies.
Methods
This policy was developed by the Clinical Affairs Committee,
adopted in 1996 2, and last revised by the Council of Clinical
Affairs in 2016 3. This update is based on review of current
dental and medical literature, including a search of the
®
PubMed /MEDLINE database using the terms: orofacial
anomalies and cleft OR cleft palate OR anondontia OR
oligodontia OR ectodermal dysplasia AND insurance OR
third-party OR reimbursement; fields: all; limits: within the
last 10 years, human, English. Papers for review were chosen
from the resultant list of articles and from the references within
selected articles. When data did not appear sufficient or were
inconclusive, policies were based upon expert or consensus
opinion by experienced researchers and clinicians.
Background
There exists a large and diverse group of congenital and
acquired orofacial anomalies that can have significant negative
functional, esthetic, and psychological effects on individuals
and impose a financial burden on their families.1,4-9 The oral
health care needs of these patients are unique, impact their
overall health, and necessitate special considerations.10 Patients
with craniofacial anomalies often require specialized oral
health care as a direct result of their condition to promote
160 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
third-party reimbursement for oral health care services related to
congenital and acquired orofacial differences. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:160-2.
normal function and development. These services are medically
necessary and an integral part of the rehabilitative process.1,11
Young children benefit from esthetic and functional restorative
techniques and readily adapt to appliances that replace miss-
ing teeth and improve function, appearance, and self-image.
During the period of facial and oral growth, appliances
require frequent adjustment and must be remade as the
individual grows.
These patients should not be denied coverage for initial
appliance construction or replacement of appliances as the
child grows. Unfortunately, third-party payors legally may
control the coverage of these services by limiting contractual
benefits. The distinction between congenital and acquired
anomalies involving the orofacial complex and those involving
other parts of the body seems arbitrary and unfair. For in-
stance, health care policies may provide reimbursement for
the necessary prosthesis required for a congenitally missing
extremity and its replacement as the individual grows but deny
benefits for the initial prosthesis and the necessary periodic
replacement for congenitally missing teeth. Third-party payors
frequently will refuse to pay for oral health services even when
they clearly are associated with the complete rehabilitation of
the craniofacial condition.12,13
Coverage for orthodontic services for individuals with oro-
facial anomalies or cleft palate is at the discretion of individual
state mandates,13,14 leaving room for states to exclude coverage
for crucial treatment. Private health insurance plans may
demand clear indications of medical necessity to improve
function15 and documented agreement among an interdisci-
plinary team16,17 while denying coverage for services deemed
elective or cosmetic in nature. Subjective and indiscriminate
denials by insurance companies hinder the ability of individuals
to obtain comprehensive and timely care that can significantly
improve their appearance, function, and quality of life.18,19
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

The Patient Protection and Affordable Care Act of 2010 20
“is silent on the features of what might constitute a fair and
acceptable medical necessity standard in qualified health
plans”21. Despite being included as one of the essential health
benefits in all qualified plans, federal regulations allow signi-
ficant flexibility to plans that include dental care, and these
services often are restricted.9,13,14,22 The restriction of these
benefits largely affects children with multiple chronic conditions
who have complex developmental needs and use specialty
care. 21 Additionally, limitations on allowable services and
reimbursement inequitably affect those with public health in-
surance, amplifying the vulnerability of those requiring complex
treatment.23 Clerical personnel and professional consultants
employed by third-party payors sometimes make benefit deter-
minations based on arbitrary distinction between medical versus
dental anomalies, ignoring important functional and medical
relationships. Recent legislation has been introduced to address
the disconnect between coverage for preliminary surgeries and
denials of corrective or follow-up procedures, including neces-
sary dental services.13,24 Evaluation and care provided for an
infant, child, or adolescent by a cleft lip/palate, orofacial,
or craniofacial anomalies team have been described as the
optimal way to coordinate and deliver complex services. 1,12
This approach may provide additional documentation to
facilitate medical necessity of dental rehabilitation.
Policy statement
The AAPD encourages all policy makers and third-party
payors to consult the AAPD in the development of benefit
plans that best serve the oral health interests of infants, chil-
dren, adolescents, and individuals with special health care
needs.
The AAPD strongly believes that the dentist providing
the oral health care for the patient determines the medical
indication and justification for treatment for patients with
congenital and acquired orofacial anomalies.
The AAPD encourages third-party payors to:
• recognize that congenital and acquired orofacial anom-
alies require care over the life-time of the patient.
• include oral health services related to these facial and
dental anomalies as benefits of health insurance without
discrimination between the medical and dental nature
of the defect. These services, optimally provided by the
craniofacial team, include, but are not limited to, initial
appliance construction, periodic examinations, and re-
placement of appliances.
• provide payable benefits for oral health services related
to these facial and dental anomalies.
References
1. American Cleft Palate-Craniofacial Association. Param-
eters for Evaluation and Treatment of Patients with Cleft
Lip/Palate or Other Craniofacial Differences. Revised ed.
Chapel Hill, N.C.: American Cleft Palate-Craniofacial
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO OROFACIAL DIFFERENCES
Association; January 2018:1-15. Available at: “https://
acpa-cpf.org/team-care/standardscat/parameters-of-care/”.
Accessed June 22, 2021.
2. American Academy of Pediatric Dentistry. Third-party
reimbursement of dental costs related to congenital oro-
facial anomalies and birth defects. Pediatr Dent 1996;18
(special issue):26.
3. American Academy of Pediatric Dentistry. Third-party
reimbursement for oral health care services related to
congenital and acquired orofacial anomalies. Pediatr Dent
2016;38(suppl issue):106-7.
4. Murdock S, Lee JY, Guckes A, Wright JT. A cost analysis
of dental treatment for ectodermal dysplasia. J Am Dent
Assoc 2005;136(9):1273-5.
5. National Foundation for Ectodermal Dysplasias. Param-
eters of Oral Health Care for Individuals Affected by
Ectodermal Dysplasias. 2nd revision. Mascoutah, Ill.:
National Foundation for Ectodermal Dysplasias. 2015.
Available at: “https://juyhw1n8m4a3a6yng24eww91-w
pengine.netdna-ssl.com/wp-content/uploads/2016/07/
NFEDParametersOfOralHealthCare.pdf ”. Accessed June
29, 2021.
6. Coffield KD, Phillips C, Brady M, Roberts MW, Strauss
RP, Wright JT. The psychosocial impact of developmen-
tal dental defects in people with hereditary amelogenesis
imperfecta. J Am Dent Assoc 2005;136(5):620-30.
7. Boulet SL, Grosse SD, Honein MA, Correa-Villaseñor A.
Children with orofacial clefts: Health-care use and costs
among a privately insured population. Public Health Rep
2009;124(3):447-53.
8. Long RE, Wilson-Genderson M, Grayson BH, Flores R,
Broder HL. Oral health-related quality of life and self-
rated speech in children with existing fistulas in mid-
childhood and adolescence. Cleft Palate Craniofac J 2016;
53(6):664-9.
9. Nidey N, Wehby GL. Barriers to health care for children
with orofacial clefts: A systematic literature review and
recommendations for research priorities. Oral Health
Dent Stud 2019;2(1):2.
10. American Academy of Pediatric Dentistry. Management
of dental patients with special health care needs. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2021:287-94.
11. American Academy of Pediatric Dentistry. Policy on
medically-necessary care. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2021:22-7.
12. Strauss RP. The organization and delivery of craniofacial
services: The state of the art. Cleft Palate Craniofac J
1999;36(3):189-95.
13. Pfeifauf, KD, Snyder-Warwick, A, Patel, KB. Proposed
federal bill to mandate insurance coverage for children
with congenital anomalies. Cleft Palate Craniofac J 2020;
57(6):770-2.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 161
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO OROFACIAL DIFFERENCES
14. Pfeifauf KD, Snyder-Warwick A, Skolnick GB, Naidoo
SD, Nissen RJ, Patel KB. Primer on state statutory man-
dates of third-party orthodontic coverage for cleft palate
and craniofacial care in the United States. Cleft Palate
Craniofac J 2018;55(3):466-9.
15. Premera. Orthodontic services for treatment of congenital
craniofacial anomalies. Premera Medical Policy. 9.02.500.
Available at: “https://www.premera.com/medicalpolicies
/9.02.500.pdf ”. Accessed May 22, 2021.
16. Hawaii Medical Services Association. Orthodontic treat-
ment of orofacial anomalies. Policy #MM.12.021.
Available at: “https://hmsa.com/portal/provider/MM.
12.021_Orthodontic_Treatment_of_Orofacial_Anomalies
_052617.pdf ”. Accessed May 22, 2021.
17. University Health Alliance. Orthodontic Services for
Orofacial Anomalies Payment Policy. 2015. Available at
“https://uhahealth.com/blog/new-medical-payment-policy-
orthodontic-services-for-orofacial-anomalies”. Accessed
May 21, 2021.
18. Abeleira MT, Pazos E, Ramos I, et al. Orthodontic treat-
ment for disabled children: A survey of parent’s attitudes
and overall satisfaction. BMC Oral Health 2014;14(98):
1-8.
162 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
19. Abeleira MT, Pazos E, Limeres J, Outumuro M, Diniz M,
Diz P. Fixed multibracket dental therapy has challenges
but can be successfully performed in young persons with
Down syndrome. Disabil Rehabil 2016;38(14):1391-6.
20. 111th U.S. Congress. Patient Protection and Affordable
Care Act. Public Law 111-148—March. 23, 2010. U.S.
Government Publishing Office. Available at: “https://
www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW
-111publ148.pdf ”. Accessed June 22, 2021.
21. American Academy of Pediatrics. Defining and deter-
mining medical necessity in Medicaid managed care.
Pediatrics 2014;134(3):516-22.
22. Wanchek T, Wehby G. State-mandated coverage of cleft
lip and cleft palate treatment. Cleft Palate Craniofac J
2020;57(6):773-7.
23. Broder HL, Wilson-Genderson M, Sischo L. Health dis-
parities among children with cleft. Am J Public Health
2012;102(5):828-30.
24. 116th Congress. Ensuring Lasting Smiles Act. H.R. 1379
– 2019-2020. Available at: “https://www.congress.gov/
bill/116th-congress/senate-bill/560”. Accessed June 22,
2021.

Policy on Third-Party Reimbursement of Fees
Related to Dental Sealants
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that the placement of sealants and their continued
maintenance are scientifically-sound and cost-effective tech-
niques for prevention of pit-and-fissure caries and to prevent
the progression of early noncavitated carious lesions.
Methods
This policy was developed by the Clinical Affairs Committee,
adopted in 19991, and last revised by the Council on Clinical
of Affairs in 20162. This update is based upon a review of
current dental and medical literature related to dental sealants.
The update used electronic database and hand searches of
articles using the terms: dental sealants AND insurance; fields:
all; limits: within the last 10 years, humans, English. Sixty-one
articles matched these criteria. Papers for review were chosen
from this list and from the references within selected articles.
Background
According to national estimates, the prevalence of dental caries
(untreated and treated) in primary or permanent teeth among
children ages two through 19 years was 45.8 percent for 2015-
2016.3 Data indicate that around 40 percent of children ages
two through eight years have experienced dental caries in their
primary teeth, with 44 percent of caries lesions in the pits and
fissures.4,5 Pit and fissure occlusal caries occurs disproportionate-
ly higher compared to smooth surface caries in the school-aged
population.6,7 Permanent first and second molars are especially
at increased risk as fluoride has less preventive effect on pits
and fissures than on smooth surfaces.6,7 Yet, any tooth, in-
cluding primary teeth and permanent teeth other than molars,
may benefit from sealant application due to fissure anatomy
and caries risk factors.6 Caries risk may increase due to changes
in patient habits, oral microflora, or physical condition, and
unsealed teeth subsequently might benefit from sealant appli-
cation.6 Placement of pit-and-fissure sealants significantly
reduces the percentage of incipient noncavitated caries lesions
that progress in children, adolescents, and young adults, com-
pared to unsealed teeth, for as long as five years after sealant
placement.8 When placed over existing caries, sealants lower
the number of viable bacteria by at least 100-fold and reduce
the number of lesions with any viable bacteria by 50 percent.9
Sealants provide secondary prevention by inhibiting or arrest-
ing the progression of pit-and-fissure caries.7
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO SEALANTS
How to Cite: American Academy of Pediatric Dentistry. Policy on
third-party reimbursement of fees related to dental sealants. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:163-4.
Current data show that, although initial sealant retention
rates are high, sealant loss does occur.7 Receiving periodic
evaluation of sealants for maintenance or replacement is in the
patient’s interest.10,11 Without recall and maintenance, sealant
failure will compound over time, leaving previously sealed
surfaces with a caries susceptibility equal to that of surfaces
that never were sealed.12 With appropriate follow-up care, the
success rate of sealants may be 80 to 90 percent, even after
a decade.5,11,13
Although sealants are safe and effective, they continue to
be underutilized.6,7,14 Sealants are particularly effective in
preventing pit-and-fissure caries. They provide cost savings if
placed on patients during periods of greatest risk by delaying
or avoiding invasive treatment and the destructive cycle of
dental caries.6,15-17 However, initial insurance coverage for
sealants often is denied based on the age of the patient, and
insurance coverage for repair or replacement may be
limited.18-20
Policy statement
The AAPD encourages all policy makers and third-party
payors to consult the AAPD in the development of benefit
plans that best serve the oral health interests of infants, chil-
dren, adolescents, and individuals with special health care
needs.
The AAPD advocates that the dentition periodically be
evaluated for developmental defects and deep pits and fissures
that may contribute to caries risk and that sealants be placed
on primary and permanent teeth judged to be at risk for
dental caries. AAPD encourages placement of dental sealants
on early (noncavitated/incipient) caries lesions to inhibit lesion
progression. Once sealants have been placed, they should
be evaluated for repair or replacement as part of a periodic
dental examination.
The AAPD encourages third-party payors to:
• recognize that dental sealants are scientifically-sound and
cost-effective techniques for primary or permanent teeth
at increased risk for caries and for early (noncavitated/
incipient) caries lesions.
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 163
ORAL HEALTH POLICIES: REIMBURSEMENT RELATED TO SEALANTS
• base third-party coverage for sealants on a patient’s caries
risk rather than age. Timing of the eruption of teeth can
vary widely. Furthermore, caries risk may increase at any
time during a patient’s life.
The AAPD shall continue to work with other dental or-
ganizations, the insurance industry, and consumer groups to
make the advantages of dental sealants understood and to
seek reimbursement for fees associated with their placement,
maintenance, and repair.
References
1. American Academy of Pediatric Dentistry. Policy on third
party reimbursement of costs related to dental sealants.
Pediatr Dent 1999;21(5):35.
2. American Academy of Pediatric Dentistry. Policy on third-
party reimbursement of fees related to dental sealants.
Pediatr Dent 2016;38(special issue):108-9.
3. Fleming E, Afful J. Prevalence of Total and Untreated
Dental Caries Among Youth: United States, 2015–2016.
NCHS Data Brief, no 307. Hyattsville, MD: National
Center for Health Statistics. 2018. Available at: “https://
www.cdc.gov/nchs/data/databriefs/db307.pdf ”. Accessed
June 18, 2021.
4. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental
caries and sealant prevalence in children and adolescents
in the United States, 2011-2012. NCHS Data Brief,
no. 191. Hyattsville, Md.: National Center for Health
Statistics; 2015. Available at: “https://www.cdc.gov/nchs/
data/databriefs/db191.pdf ”. Accessed June 18, 2021.
5. Tinanoff N, Coll JA, Dhar V, Maas WR, Chhibber S,
Zokaei L. Evidence-based update of pediatric dental
restorative procedures: Preventative strategies. J Clin
Pediatr Dent 2015;39(3):193-7.
6. Wright JT, Crall JJ, Fontana M, et al. Evidence-based
clinical practice guideline for the use of pit-and-fissure
sealants. American Academy of Pediatric Dentistry,
American Dental Association. Pediatr Dent 2016;38(5):
E120-E36.
7. Wright JT, Tampi MP, Graham L, et al. Sealants for pre-
venting and arresting pit-and-fissure occlusal caries in
primary and permanent molars: A systematic review of
randomized controlled trials. Pediatr Dent 2016;38(4):
282-94.
8. Griffin SO, Oong E, Kohn W, et al. The effectiveness of
sealants in managing caries lesions. J Dent Res 2008;87
(2):169-74.
164 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
9. Oong EM, Griffin SO, Kohn WG, Gooch BF, Caufield
PW. The effect of dental sealants on bacteria levels in
caries lesions: A review of the evidence. J Am Dent Assoc
2008;139(3):271-8.
10. Gooch B, Griffin S, Kolavic Gray S, et al. Preventing
dental caries through school-based sealant programs. J
Am Dent Assoc 2009;140(11):1356-65.
11. American Academy of Pediatric Dentistry. Periodicity
of examination, preventive dental services, anticipatory
guidance/counseling and oral treatment for infants, chil-
dren, and adolescents. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2021:241-51.
12. Griffin SO, Gray SK, Malvitz DM, Gooch BF. Caries risk
in formerly sealed teeth. J Am Dent Assoc 2009;140(4):
415-23.
13. Urquhard O, Tampi MP, Pilcher L, et al. Nonrestorative
treatment for caries: Systematic review and network
meta-analysis. J Dent Res 2019;98(1):14-26.
14. U.S. Department of Health and Human Services. Healthy
People 2020. Rockville, Md.: U.S. Department of Health
and Human Services, National Institutes of Health; 2020.
15. American Dental Association. Statement on preventive
coverage in dental benefits plans. In: ADA Current
Policies – Adopted 1954-2020. Chicago, Ill.: American
Dental Association; 2018:312.
16. Lee I, Monahan S, Serban N, Griffin PM, Tomar SL.
Estimating the cost savings of preventive dental services
delivered to Medicaid-enrolled children in six south-
eastern states. Health Serv Res 2018;53(5):3592-616.
17. Atkins CY, Thomas TK, Lenaker D, Day GM, Hen-
nessy TW, Meltzer MI. Cost-effectiveness of preventing
dental caries and full mouth dental reconstructions
among Alaska Native children in the Yukon–Kuskokwim
delta region of Alaska. J Public Health Dent 2016;76(3):
228-40.
18. Neusser S, Krauth C, Hussein R, Bitzer EM. Clinical
effectiveness and cost-effectiveness of fissure sealants in
children and adolescents with a high caries risk. GMS
Health Technol Assess 2014;10:Doc02.
19. Chi D, van der Goes D, Ney JP. Cost-effectiveness of
pit-and-fissure sealants on primary molars in Medicaid-
enrolled children. Am J Public Health 2014;104(3):
555-61.
20. Ney JP, van der Goes DN, Chi DL. Economic modeling
of sealing primary molars using a “value of information”
approach. J Dent Res 2014;93(9):876-81.

Policy on Third-Party Fee Capping of Noncovered
Services
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
supports dental benefit plan provisions designed to meet the
oral health needs of patients by facilitating, beginning at birth,
the delivery of diagnostic, preventive, and therapeutic services
in a comprehensive, continuously accessible, coordinated and
family-centered manner.1 A well-constructed dental benefit
plan respects and meets the needs of the plan purchaser,
subscriber/patient, and provider.
Methods
This policy was developed by the Council on Dental Benefits
Programs, adopted in 20122, and last revised by the Council
on Clinical Affairs in 20173. This revision included a review
and analysis of state laws and pending legislation prohibiting
the capping of noncovered services by third-party providers,
related federal legislation, and the American Dental Associa-
tion’s Policy on Maximum Fees for Non-Covered Services4.
Background
The American Dental Association (ADA) defines covered
service as “any service for which reimbursement is actually
provided on a given claim”4 and noncovered services are
“procedures for which the plan pays no benefit”5. Capping of
noncovered services occurs when an insurance carrier sets a
maximum allowable fee for a service ineligible for third-party
reimbursement. While most contractual matters between in-
surers and providers are those of a private business relationship,
this business practice is contrary to the public interest for the
following reasons.
• Larger dental benefit carriers with greater market share
and more negotiating power are favored in this arrange-
ment. While dentists may refuse to contract with smaller
plans making this requirement, they are unable to make
the same decision with larger plans controlling greater
numbers of enrollees. Eliminating this practice levels the
playing field for all insurers and encourages greater com-
petition among dental plans. If smaller plans and insurers
are unable to survive, the group purchaser and subscriber
are ultimately left with less market choice and potentially
higher insurance cost.
ORAL HEALTH POLICIES: FEE CAPPING OF NONCOVERED SERVICES
How to Cite: American Academy of Pediatric Dentistry. Policy on
third-party fee capping of noncovered services. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:165-6.
• It is unreasonable to allow plans to set fees for services in
which they have no financial liability and that may not
cover the overhead expense of the services being pro-
vided. When this provision precludes dentist participation
in a reimbursement plan, subscribers realize less choice
in their selection of available providers. In many cases,
especially in rural or other areas with limited general or
specialty practitioners, this adversely affects the care. This
is particularly true for vulnerable populations, including
individuals with special health care needs.
• For dentists forced to accept this provision, the artificial
pricing of uncovered services results in cost-shifting from
those covered under a particular plan to uncovered pa-
tients. Thus, the uninsured and those covered under tra-
ditional indemnity or other plans will shoulder the costs
of these provisions. Capping of noncovered services is
not cost saving; it is cost-shifting – often to the most
vulnerable populations and to those least able to afford
healthcare.
• The ability to cap noncovered services allows insurance
plans to interfere with the patient-doctor relationship.
The House of Delegates of the ADA in 2020 adopted Reso-
lution 19H-2020 Maximum Fees for Non-Covered Services
which opposed third party contract provisions that establish
fee limits for non-covered services.6 Legislation to prohibit a
dental insurer or dental service plan from limiting fees for serv-
ices not covered under the plan, is the law in 42 states (Paul
O’Connor [oconnorp@ada.org], email, July 5, 2022). Such
legislation allows the dentist to utilize the usual and customary
fee for services not covered by the plan.
Policy statement
The AAPD believes that dental benefit plan provisions which
establish fee limitations for noncovered services are not in
the public’s interest and should not be imposed through
provider contracts.
ABBREVIATIONS
ADA: American Dental Association. AAPD: American Academy
Pediatric Dentistry.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 165
ORAL HEALTH POLICIES: FEE CAPPING OF NONCOVERED SERVICES
References
1. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:21-2.
2. American Academy of Pediatric Dentistry. Policy on third-
party fee capping of non-covered services. Pediatr Dent
2012;34(special issue):93-4.
3. American Academy of Pediatric Dentistry. Policy on third-
party fee capping of non-covered services. Pediatr Dent
2017;39(6):122-3.
4. American Dental Association. Maximum fees for non-
covered services. (Trans.2010:616;2020). In: American
Dental Association Current Policies Adopted 1954-2020.
Chicago, Ill.: American Dental Association; 2021:108.
Available at: “https://www.ada.org/-/media/project/ada-
organization/ada/ada-org/files/resources/research/oral-
health-topics/ada_current_policies_2020.pdf?rev=5360d35
2925c43279b326ded579fbff3&hash=DE47B7283270133
5B9FD038EDB0FD0EC”. Accessed July 6, 2022.
166 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
5. American Dental Association. Comprehensive ADA policy
statement on inappropriate or intrusive provisions and
practices by third party payers (Trans.2016:290; 2017:
266). In: American Dental Association Current Policies
Adopted 1954-2020. Chicago, Ill.: American Dental As-
sociation; 2021: 84. Available at: “https://www.ada.org/-/
media/project/ada-organization/ada/ada-org/files/resources/
research/oral-health-topics/ada_current_policies_2020.pd
f?rev=5360d352925c43279b326ded579fbff3&hash=DE4
7B72832701335B9FD038EDB0FD0EC”. Accessed July
6, 2022.
6. American Dental Association. Resolution 19. Amendment
of Policy, Maximum Fees for Non-Covered Services. In:
American Dental Association 2020 Supplement to Annual
Reports and Resolutions Volume 1. Chicago, Ill.: Amer-
ican Dental Association; 2020: 179. Available at: “https://
www.ada.org/-/media/project/ada-organization/ada/ada
-org/files/about/current-policies-and-historical-publica
tions/20_ar_supp_01.pdf ”. Accessed July 2, 2022.

Policy on Third-Party Payor Audits, Abuse, and
Fraud
Latest Revision
2019
Purpose
One of the aims of the Deficit Reduction Act1, approved by the
United States (U.S.) Congress in 2005, was to prevent Medicaid
fraud and abuse through an audit process. Despite the good
intentions of this law, experts predicted health care provid-
ers would see more investigations, enforcement actions, and
whistleblower cases and would need to devote more resources
toward compliance.2 Pediatric dentists play a critical role in the
Medicaid program, and there will be negative impact on access
to care if providers are burdened with excessive regulations and
unfounded audits. Nonetheless, the American Academy of
Pediatric Dentistry (AAPD) supports efforts to eliminate
Medicaid abuse. Such unprofessional conduct could result in
loss of membership status in AAPD.2 This policy is intended
to help AAPD members understand the audit process, both
internal and external audits.
Methods
This document was developed by the Council on Clinical
Affairs and adopted in 2014. This policy is based upon a
review of current dental and medical literature, including a
®
literature search of the PubMed /MEDLINE electronic data-
base using the terms: dental audits, dental abuse and fraud,
peer review, dental peer review committee, provider profiling,
practice management, Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) field: all; limits: within the last 10
years; human; English. Papers for review were chosen from
this list as well as references within the selected articles.
Definitions
Abuse: “provider practices that are inconsistent with sound
fiscal, business, or medical practices, and result in an unnec-
essary cost to the Medicaid program, or reimbursement for
services that are not medically necessary or that fail to meet
the professionally recognized standards for health care. It also
includes beneficiary practices that result in unnecessary cost
to the Medicaid program.”3 The AAPD supports medically-
necessary care (MNC) and recognizes that dental care is
medically necessary for the purpose of preventing and
eliminating orofacial disease, infection, and pain, restoring the
form and function of the dentition, and correcting facial
disfiguration or dysfunction.4
ORAL HEALTH POLICIES: AUDITS, ABUSE, FRAUD
How to Cite: American Academy of Pediatric Dentistry. Policy on
third-party payor audits, abuse, and fraud. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:167-70.
Audit: “planned and documented activity performed by
qualified personnel to determine by investigation, examination,
or evaluation of objective evidence, the adequacy and com-
pliance with established procedures, or applicable documents,
and the effectiveness of implementation”.5 After receiving a
notice of an impending audit from a third-party payor, the
dentist should ascertain in writing the type and scope of
audit to be conducted.6,7
Fraud: “an intentional deception or misrepresentation made by
a person with the knowledge that the deception could result
in some unauthorized benefit to him or some other person.”3
Recovery audit contractor (RAC): one who reviews claims on
a post-payment basis. The RAC detects and corrects past
improper payments so that Centers for Medicare and Medi-
caid Services (CMS) and carriers, fiscal intermediaries, and
Medicare administrative contractors can implement actions
that will prevent future improper payments.8
Third-party payor: “an organization other than the patient
(first party) or health-care provider (second party) involved
in the financing of health care services.”9
Background
External audits are increasingly common for a full range of
health care providers. Dentists are no exception, as some pedi-
atric dentists have experienced. If a provider requests payment
from third-party payors, the claims may be subject to review
by a RAC, a private entity that reviews paid claims and, in
some cases, earns contingency fees for improper payments it
retrieves. Private and public third-party payors use audits as
a mechanism to recoup over-payments, inspect for potential
improper behavior, and possibly guide health care providers
to control utilization and costs.10 Notably, there can be serious
financial and even criminal penalties associated with billing
errors.11
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CMS: Centers for
Medicare and Medicaid Services. EPSDT: Early and Periodic Screen-
ing, Diagnosis, and Treatment. MNC: Medically-necessary care.
RAC: Recovery audit contractor. U.S.: United States.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 167
ORAL HEALTH POLICIES: AUDITS, ABUSE, FRAUD
In 2017, an estimated $37 billion, or 10 percent, of the
federal Medicaid funds were absorbed by improper pay-
ments, which include fraud and abuse as well as unintentional
mistakes such as paper errors.12 Improper payments can occur
when funds go to the wrong recipient, the recipient receives
the incorrect amount of funds (either an underpayment or
overpayment), documentation is not available to support a
payment, or the recipient uses the funds in an improper
manner.12
The AAPD recognizes the concern its members have regard-
ing these external audits. The AAPD encourages its members
to develop internal self-audit programs to address these
challenges. Internal audits are used in order to pre-emptively
detect discrepancies before the external authorities can discover
them and impose penalties.10 Given the heightened concern
for compliance to avoid an external audit, internal audits have
taken on importance. A compliance program generally will
incorporate a credible internal audit system, which means that
it must be prepared to respond to an external audit by various
authorities. In addition, some pediatric dentists have discovered
that an internal audit system can be developed so that it not
only addresses the external audit, but also serves other quality
of care and performance improvement purposes.10
Credentials of auditors
The Affordable Care Act required that each state Medicaid
program use at least one RAC beginning in 2011. 13 Some
states have started employing the RACs to aid in recovery of
improper payments.14 The AAPD strongly believes that, while
audits are a part of third-party payment contracts and are
necessary to protect the integrity of these programs, such
audits must be completed by those who have credentials on
par with the dental provider being audited. For example, pedi-
atric dentists must be audited by a dentist who specializes in
pediatric dentistry and who understands the clinical guidelines
and standards of care which have been adopted and followed
by their specialty. The AAPD is adamantly opposed to audi-
tors receiving financial incentives for any money recuperated
through these audits. This represents a conflict of interest.
Provider profiling
The AAPD is opposed to provider profiling, a strategy that may
be used by health plans to assess efficiency among providers,
and believes that dentist providers selected for audits should
be chosen randomly or with compelling evidence that makes
them an outlier compared to peers practicing in similar geo-
graphic areas, on similar populations of patients, and within
the same specialty. Claims-based data used for provider pro-
filing are not collected exclusively for performance assessment
and, as a result, may be irrelevant or inadequate for profiling.15
Furthermore, the procedure codes included in claims-based
data cannot fully characterize the nature of a particular episode
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
168 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Peer review as part of audit outcomes
The AAPD supports peer review as a way to offer information
and support to dentists who need to review best practices
regarding chart documentation, coding, and billing practices
related to third-party payors. This should be offered in lieu
of financial penalties when an audit shows that no intent to
fraud was present, but that the dentists need education to
improve their practice systems. It provides practicing dentists
a means to preserve their reputation and good standing in the
community and fosters risk management, accountability, and
self-regulation among dental professionals. 16 This model
would be consistent with the peer review practices that occur
when clinical decision making is in question. The intent of
peer review is to resolve discrepancies between the dentists and
third-party payors expeditiously, fairly, and in a confidential
manner.16
Best practices for chart documenting, coding, and billing
The AAPD supports the education of pediatric dentistry
residents, pediatric dentists, and their staff to ensure good
understanding of appropriate coding and billing practices.
The AAPD, therefore, supports the creation of educational
resources and programs that promote best practices, which may
include:
• programming offered at the AAPD’s Annual Session or
other AAPD-sponsored continuing education course.
• programs offered by pediatric dentistry state unit and
district organizations.
• the creation of a web-based tutorial for dentists and
their staff, including the states’ dental Medicaid provider
manuals and frequently asked questions regarding
Medicaid.
• partnering with other public/private organizations and
agencies to distribute ‘Medicaid Updates’ that can be
received via e-mail and augmenting Medicaid Compliance
for the Dental Professional webinars offered jointly by
AAPD and CMS.17
• the development of a third-party payor submission
compliance program.
Medicaid policies that conflict with AAPD clinical practice
guidelines
The AAPD is opposed to Medicaid programs that have
policies which are in direct conflict with AAPD clinical
practice recommendations and are of detriment to patient
care. For example, in several states, children are not receiving
appropriate dental treatment covered by EPSDT because
there is a refusal to reimburse providers for EPSDT-covered
dental services.18 According to CMS, “federal law also requires
that states inform all families about EPSDT coverage”19; the
AAPD supports this requirement to enable caregivers to seek
necessary dental treatment for their children.

Policy statement
Dental care is medically necessary to prevent and eliminate
orofacial disease, infection, and pain, to restore the form and
function of the dentition, and to correct facial disfiguration
or dysfunction. MNC is based upon current preventive and
therapeutic practice guidelines formulated by professional
organizations with recognized clinical expertise. Expected
benefits of MNC outweigh potential risks of treatment or no
treatment. Early detection and management of oral conditions
can improve a child’s oral health, general health and well-
being, school readiness, and self-esteem. Early recognition,
prevention, and intervention could result in savings of health
care dollars for individuals, community health care programs,
and third-party payors. Because a child’s risk for developing
dental disease can change over time, continual professional
reevaluation and preventive maintenance are essential for good
oral health. Value of services is an important consideration,
and all stakeholders should recognize that cost-effective care
is not necessarily the least expensive treatment.4
The AAPD:
• encourages it members and all third-party payors to
support efforts to eliminate Medicaid abuse.
• opposes any of its dentist members committing abuse
and fraud as it relates to their relationship with third-
party payors.
• recognizes the concern its members have regarding
these external audits.
• encourages its members to develop internal self-audit
programs to address these challenges.
• cautions against ill-informed or misguided investiga-
tions that may discourage dental provider participation
in Medicaid.20
• strongly believes that, while audits are a part of third-
party payment contracts and are necessary to protect
the integrity of these programs, such audits must be
completed by those who have credentials on par with
the dental provider being audited.
• adamantly opposes auditors receiving financial incentives
for any money recuperated through audits.
• opposes provider profiling and believes that dentist
providers selected for audits should be chosen randomly
or with compelling evidence that makes them an outlier
as compared to their peers who practice in similar
geographic areas, on similar populations of patients,
and within the same specialty.
• supports peer review in lieu of financial penalties when
an audit shows that no intent to fraud was present, to
offer information and support to dentists who need to
re-acquaint themselves on best practices regarding chart
documentation, coding, and billing practices relating
to third-party payors.
• supports the education of pediatric dentistry residents,
pediatric dentists, and their staff to ensure a good under-
standing of appropriate coding and billing practices.
ORAL HEALTH POLICIES: AUDITS, ABUSE, FRAUD
• supports the creation of educational resources and
programs that promote appropriate coding and billing
practices.
• opposes Medicaid programs that have policies in direct
conflict with AAPD clinical practice recommendations
and are of detriment to patient care.
• endorses the enforcement of the “federal law that re-
quires that states inform all families about EPSDT
coverage”18 to enable caregivers to seek necessary dental
treatment for their children.
References
1. U.S. Congress. Deficit Reduction Act of 2005. Pub. No.
109-171, 120 Stat. 119, Feb 8, 2006. U.S. Government
Printing Office. Available at: “http://www.gpo.gov/fdsys/
pkg/BILLS-109s1932enr/pdf/BILLS-109s1932enr.pdf ”.
Accessed March 25, 2019.
2. American Academy of Pediatric Dentistry. Constitution
and Bylaws of the American Academy of Pediatric Den-
tistry. Available at: “https://www.aapd.org/assets/1/7/2018
-19_Constitution_and_Bylaws.pdf ”. Accessed March 25,
2019.
3. U.S Government. Code of Federal Regulations, Title 42:
Public Health Part 455, Program Integrity: Medicaid.
Centers for Medicare & Medicaid Services. 2018. Avail-
able at: “https://www.govinfo.gov/app/details/CFR-2018
-title42-vol4/CFR-2018-title42-vol4-sec455-2”. Accessed
July 13, 2019.
4. American Academy of Pediatric Dentistry. Definition of
medically-necessary care. Pediatr Dent 2018;40(6):15.
5. Project Auditors, LLC. Auditor Dictionary: Audit. Avail-
able at: “https://www.projectauditors.com/Auditor
_Ditionary/AuditorDictionary.php”. Accessed July 12,
2019.
6. Oberman SJ. Dental practice audits. Dental Tribune
International. November 12, 2010. Available at: “https:
//www.dental-tribune.com”. Accessed July 12, 2019.
7. Manchie M. Dentists facing compliance audits have
ADA resources in their reach. ADA News. April 16, 2018.
Available at: “https://www.ada.org/en/publications/ada
-news/2018-archive/april/dentists-facing-compliance-
audits-have-ada-resources-in-their-reach”. Accessed July
13, 2019.
8. Centers for Medicare and Medicaid Services. Medicare
fee for service recovery audit program. Available at:
“https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance
-Programs/Recovery-Audit-Program/”. Accessed March
25, 2019.
9. American Dental Association. Glossary of Dental Clinical
and Administrative Terms. American Dental Association,
Chicago, Ill. Available at: “https://www.ada.org/en/
publications/cdt/glossar y-of-dental-clinical-and-
administrative-ter#t”. Accessed July 13, 2019.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 169
ORAL HEALTH POLICIES: AUDITS, ABUSE, FRAUD
10. Jose DE. Payor audits: Preparation, response, and oppor-
tunities. July 2010. Krieg DevaultSM. Available at:
“http://www.kriegdevault.com/userfiles/file/DEJ%20
Presentation%20-%20Payor%20Audits.ppt”. Accessed
July 12, 2019.
11. U.S. Department of Justice. The Federal False Claims
Act, A Primer. Available at: “https://www.justice.gov/
sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_
FCA_Primer.pdf ”. Accessed July 12, 2019.
12. U.S. Department of Health and Human Services. Payment
Accuracy Report. Available at: “https://paymentaccuracy.
gov/resources/”. Accessed July 12, 2019.
13. U.S. Congress. The Patient Protection and the Affordable
Care Act. Pub. L. No. 111-148, 124 Stat. 119, Mar 23,
2010. U.S. Government Printing Office. Available at:
“http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/
pdf/BILLS-111hr3590enr.pdf ”. Accessed July 12, 2019.
14. U.S. Department for Health and Human Services Centers
for Medicare and Medicaid Services. Medicaid Integrity
Program, New Jersey Comprehensive Program Integrity
Review, June 2012. Available at: “https://www.cms.gov/
Medicare-Medicaid-Coordination/Fraud-Prevention/
FraudAbuseforProfs/Downloads/NJfy12.pdf ”. Accessed
July 12, 2019.
15. Charvet H. The problem with physician profiling: What
have we learned? Quill and Scope 2009;2(1):43-7. Avail-
able at: “https://touroscholar.touro.edu/cgi/viewcontent.
cgi?article=1057&context=quill_and_scope”. Accessed
July 13, 2019.
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://
www.ada.org/~/media/ADA/Member%20Center/FIles/
peer_review_overview.pdf?la=en”. Accessed July 12, 2019.
170 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
17. Mouden LD, U.S. Department for Health and Human
Services Centers for Medicare and Medicaid Services,
American Academy of Pediatric Dentistry. Medical
Compliance for the Dental Professional. Webinar offered
by American Academy of Pediatric Dentistry and Centers
for Medicare and Medicaid Services, 2013. American
Academy of Pediatric Dentistry, Chicago, Ill. Available
at: “http://www.aapd.org/assets/1/7/MedicaidCompliance
Webinar2013.pdf ”. Accessed July 12, 2019.
18. Hom JM, Lee JY, Silverman J, Casamassimo PS. State
Medicaid early and periodic screening, diagnosis, and
treatment guidelines adherence to professionally recom-
mended best oral health practices. J Am Dent Assoc
2013;144(3):297-305.
19. U.S. Department for Health and Human Services,
Centers for Medicare and Medicaid Services. Guide to
children’s dental health care in Medicaid; 2004. U.S.
Department of Health and Human Services, Centers
for Medicare and Medicaid Services, Washington, D.C.
Available at: “https://www.medicaid.gov/medicaid/
benefits/downloads/child-dental-guide.pdf ”. Accessed July
13, 2019.
20. Litch CS. The government’s Medicaid fraud tools: Good
reason to stay out of trouble and strategies to preempt
trouble. American Academy of Pediatric Dentistry. Chi-
cago, Ill.; 2007. Available at: “http://www.aapd.org/
assets/1/7/2935.pdf ”. Accessed March 25, 2019.

Policy on the Role of Pediatric Dentists as Both
Primary and Specialty Care Providers
Latest Revision
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD)
emphasizes that health care providers and other interested
third parties must recognize the dual role that pediatric den-
tists play in the provision of professional preventive and
therapeutic oral health care, which includes both primary and
specialty care services.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2003. This is a revision of the last version,
revised in 2008 and reaffirmed in 2013. It was based on a
review of Accreditation Standards for Advanced Specialty
Training Programs in Pediatric Dentistr y 1 and the AAPD
position paper on the role of pediatric dentists as primary and
specialty care providers.2 An electronic search was conducted
using the terms: pediatric dentist, pediatric specialist, primary
care provider, dual care provider, and specialty care provider.
Background
“Pediatric dentistry is an age-related specialty that provides
both primary and comprehensive preventive and therapeutic
oral health needs for infants and children through adoles-
cence, including those with special health care needs.”1 The
American Dental Association, the American Academy of
General Dentistry, and the AAPD all recognize the pediatric
dentist as both a primary care provider and specialty care
provider. The dual role of pediatric dentists is similar to that
of pediatricians, gynecologists, and internists in medicine.
Within the medical profession, clinicians and third-party
payors recognize these physicians in a dual role and have
designed payment plans to accommodate this situation.
ORAL HEALTH POLICIES: ROLE OF PEDIATRIC DENTISTS AS PROVIDERS
How to Cite: American Academy of Pediatric Dentistry. Policy on
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; 2022:171.
The AAPD respects the rights of employers to negotiate
health care benefits for their employees. Sometimes, third-
party payors do not recognize pediatric dentists as primary
care providers. This position restricts access to pediatric
dentists for children who have reached a predetermined age
and/or who may be best served by specialized oral health care
providers and counseling. In some instances, this restriction
necessitates a specialty referral to a pediatric dentist prior to
evaluation.
Policy statement
The AAPD recognizes that infants, children, adolescents, and
individuals with special health care needs have the right to
quality oral health care. The AAPD encourages third-party
payors to recognize pediatric dentists as both primary and
specialty oral health care providers and to refrain from age-
related restrictions when a parent or referring clinician desires
to utilize the services and expertise of a pediatric dentist to
establish a dental home or for limited specialized care.
References
1. American Dental Association Commission on Dental
Accreditation. Accreditation standards for advanced spe-
cialty education programs in pediatric dentistry. Chicago,
Ill.; 2017. Available at: “https://www.ada.org/~/media/
CODA/Files/ped.pdf?la=en”. Accessed March 16, 2018.
2. American Academy of Pediatric Dentistry, Council on
Dental Benefits Programs. Position paper: The role of
pediatric dentists as primary and specialty care providers.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2002.
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 171
ORAL HEALTH POLICIES: TRANSITIONING DENTAL HOMES FOR INDIVIDUALS WITH SHCN
Policy on Transitioning from a Pediatric to an
Adult Dental Home for Individuals with Special
Health Care Needs
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the importance of transitioning patients with special
health care needs (SHCN) to an adult dental home as they
reach the age of majority. Finding a dental home1 to address
their special circumstances while providing all aspects of oral
care in a comprehensive, continuously accessible, coordinated,
and family-centered manner may be a challenge. This policy
addresses transition of young adult patients with SHCN and
identifies barriers that may challenge delivery of oral health
care to this population.
Methods
This policy was developed by the Council on Clinical Affairs,
adopted in 20112, and revised in 20163. This revision included
electronic database and hand searches of dental and medical
literature using the terms: special needs, disabled patients,
handicapped patients, adolescent development, adolescent
health, special health care needs AND health care transition,
oral health; fields: all; limits: within the last 10 years, humans,
English, birth through age 18, young adult: 19-24 years.
Additionally, websites for the American Dental Association,
American Medical Association, American Academy of Pediatric
Dentistry, Agency for Healthcare Research and Quality, Spe-
cial Care Dentistry Association, and International Association
for Disability and Oral Health were reviewed. Expert opinions
and best current practices were relied upon when clinical
evidence was not available.
Background
AAPD is aware of the challenges that patients with SHCN
and their families encounter when seeking oral health care.
Due to advances in diagnostic medicine, the prevalence of
children with SHCN has increased.4-6 With improvements
in medical care, patients with SHCN are living longer and
require continued medical and oral health care.7 In the United
States (U.S.), there are 65 million people who are of transition
age, and an estimated 25-35 percent of these young adults
have one or more chronic conditions.8 Of the five million
transition-age youth in the U.S. with special health care needs,
172 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
transitioning from a pediatric to an adult dental home for indi-
viduals with special health care needs. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:172-5.
only 17 percent received adequate transition planning from
their health care providers.9
Transitions are part of normal, healthy development and
occur across the life span. Health care transition for older
adolescents with SHCN is a dynamic process that seeks to
meet their individual needs. The goal is to maximize lifelong
functioning and potential through uninterrupted provision
of high-quality, developmentally-appropriate health care as
the individual moves from adolescence into adulthood. The
cornerstones of patient-centered health care are flexibility,
responsiveness, continuity, comprehensiveness, and co-
ordination.10
Transitioning patients with SHCN
Facilitating health care transition for patients with SHCN has
received national attention from other organizations recogni-
zing the need to support the process.11-13 The medical commu-
nity, specifically, and the broader health care community
(including dentistry) have yet to ensure that young people
with SHCN who are the most dependent on coordinated
health care services are able to make the transition to the
adult health care system and still receive the services that they
need.6,14,15 Adolescents who do not receive medical transitions
are less likely to receive dental transitions.16 Additional factors
associated with limited access to care during adulthood tran-
sitioning include living in poverty, being a minority, and
the independence level of the individual with SHCN.17-20 A
proper handoff, including clear direct or indirect communica-
tion between providers, can reduce medical errors during the
transition.14 The transition process should begin during early
adolescence and continue until the transfer of care is com-
plete.21 This transitioning period is potentially stressful for
parents and adolescents or young adults with SHCN, and re-
sources for acquiring adulthood health care are insufficient.22-24
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. SHCN: Special health
care needs. U.S.: United States.

To improve health care transition for adolescents and young
adults with chronic conditions, a policy statement was estab-
lished by several medical organizations.17 The policy statement
articulated six critical steps to ensuring the successful transition
to adult-oriented care. They are:
“1. to ensure that all young people with special health care
needs have a health care provider who takes specific
responsibility for transition in the broader context of care
coordination and health care planning.
2. to identify the core competencies required by health care
providers to render developmentally appropriate health
care and health care transition and ensure that the skills
are taught to primary care providers and are an integral
component of their certification requirements.
3. to develop a portable, accessible, medical summary to
facilitate the smooth collaboration and transfer of care
among and between health care professionals.
4. to develop an up-to-date detailed written transition plan,
in collaboration with young people and their families.
5. to ensure that the same standards for primary and pre-
ventive health care are applied to young people with
chronic conditions as to their peers.
6. to ensure that affordable, comprehensive, continuous
health insurance is available to young people with chronic
health conditions throughout adolescence and into
adulthood.”13
Although these steps represent a medical perspective, they
may be applied to oral health care as well.
Education and preparation of the minor patient and parent
on the value of transitioning to a dentist who is knowledge-
able in adult oral health needs are important. At a time agreed
upon by the parent, patient, and pediatric dentist, the patient
should be transitioned to a dentist knowledgeable and com-
fortable with managing the patient’s specific health care
needs. In cases where this is not possible or desired, the dental
home can remain with the pediatric dentist and referrals for
specialized dental care should be recommended when
needed.25
Discussion about transition can begin early, although the
transfer of care may not take place for many years.5,21 Evidence
supports initiating a transition plan between the ages of 14
and 16 years.26 Anecdotal evidence suggests that transition
planning may be happening even earlier.10
Barriers in transitioning patients with SHCN
The most common category of unmet health care for children
with special needs is dentistry.27 Only 10 percent of surveyed
general dentists reported that they treat patients with SHCN
often or very often, while 70 percent reported that they rarely
or never treat patients with SHCN. 28 Pediatric dentists
appear more likely to provide dental care for this population,
with 99.5 percent of pediatric dentists reporting they care for
patients with SHCN.29
According to the 2017/2018 National Survey of Children
with Special Care Needs, there are approximately 13.6 million
ORAL HEALTH POLICIES: TRANSITIONING DENTAL HOMES FOR INDIVIDUALS WITH SHCN
children with SHCN under age 17 (representing 18.5 percent
of U.S. children). 30 The U.S. has approximately 8,600
pediatric dentists (M. Alonso [alonsom@ada.org], email, May
24, 2021). The relatively small number and distribution of
pediatric dentists mean that broader involvement by general
dentists is necessary to address access to care issues, especial-
ly transition of patients with SHCN.31 When patients reach
adulthood, their oral health care needs may go beyond the
scope of the pediatric dentist’s expertise. Even if a patient is
best served by maintaining a dental home with a pediatric
dentist, he may require additional dental providers to man-
age some aspects of his oral health care. It may not be in the
young adult’s best interest to be treated solely in a pediatric
facility.32
Oral health care for adults with special needs is often difficult
to access because of a lack of trained providers. 5,31 A survey
revealed that most pediatric dentists help patients with SHCN
transition into adult care, but the principal barrier is the
availability of general dentists and specialists willing to accept
these patients.33 A 2005 survey of senior dental students noted
that the provision of oral health care to patients with special
needs was among the top four topics in which they were least
prepared.34 This self-perceived lack of preparation of future
dentists bodes poorly for effective transitioning of adult
patients with SHCN. Improving training at the predoctoral and
postdoctoral levels is needed to increase the general practi-
tioner’s skills and comfort for treating patients with SHCN.35,36
Addressing the manpower issue is of utmost importance.
Training and instruction for health care providers can be
obtained through postdoctoral educational courses. In the
U.S., programs such as general practice residencies and
advanced education in general dentistry provide opportunity
for additional medical, behavior guidance, and restorative
training needed to treat patients with SHCN. The Special
Care Dentistry Association’s fellowship and diplomate pro-
grams and the Academy of General Dentistry’s mastership
program also may provide opportunities to increase workforce
competency.36-39 In other countries (e.g., Australia, Brazil, the
United Kingdom) where special care dentistry is a recognized
academic discipline, a variety of postdoctoral education and
clinical training programs, as well as organizations (e.g.,
International Association for Disability and Oral Health),
seek to reduce inequities in oral health care.40
Most patients with special needs can receive primary oral
health care in traditional settings utilizing clinicians and sup-
port staff trained in accommodating these individuals. Others
require treatment by clinicians with more advanced training
in special facilities.34 Some pediatric hospitals may enforce age
restrictions that can create a barrier to care for patients who
have reached the age of majority.23 Hospitals frequently require
that dentists eligible for medical staff membership be board
certified, thus making it difficult for general dentists to obtain
hospital privileges. While surgery centers abound, these may
not be the preferred setting to treat medically compromised
patients.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 173
ORAL HEALTH POLICIES: TRANSITIONING DENTAL HOMES FOR INDIVIDUALS WITH SHCN
Young adults may be discontinued from their parents’
insurance, resulting in a financial barrier to care. Additional
barriers to dental transition include low socioeconomic back-
ground and insufficient health insurance benefits.16
For patients with special needs, overall health care involves
intensive and ongoing medical supervision and coordination
between medical and dental care. The integration of dentistry
within the medical care system presents a series of logistical
challenges. 41 Special programs or alternative care delivery
arrangements (e.g., mobile dental programs, nursing homes,
group home facilities) to complement the care provided
through private practices to address access issues for patients
with SHCN are lacking.42
The medical home43 reflects recognition that care is best
served by having a central point of contact for ongoing pri-
mary care and coordination of care when delivered by a
multitude of health care providers and support service pro-
viders. The dental home1 closely parallels the essential elements
of the medical home as they relate to dental care. 42 Linkages
between patients’ medical and dental homes, however, often
are not established as formally as those among medical care
providers, frequently resulting in inattention to dental services
for patients with SHCN.16 Efforts to establish stronger rela-
tionships between medical and dental homes are an important
endeavor.44 The most efficient but least common arrangement
of care for patients with SHCN is a single institution having
providers from both disciplines (typically a hospital or regional
care center).41 Transitioning may become less of an issue in
these facilities; however, those with comprehensive dental
clinics are limited in number and spread unevenly across the
country.
Policy statement
A coordinated transition from a pediatric to an adult dental
home is critical for extending the level of oral health and
health trajectory established during childhood.
The AAPD encourages:
• expansion of the medical and dental home across the
life-span of a patient, especially to enable successful
transition of the adolescent with SHCN.
• partnerships with other organizations to prepare general
dentists to accommodate and provide primary health
care for these patients in the usual dental setting.
• development of special programs or alternative care del-
ivery arrangements (e.g., mobile dental programs, nursing
home, group home facilities) to complement the care
provided through private practices to address issues for
patients with SHCN.
• utilization of the six critical steps to maximize seamless
health care transition for the adolescent dental patient
with special needs. These steps provide a framework to
organize and prepare the dentist, patient, and patient’s
family for the transition process.
• provision of financial assistance for dental treatment for
adults with SHCN by local, state, and federal programs.
174 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• emphasis on the education of predoctoral dental students
in treating patients with SHCN.
References
1. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:43-4.
2. American Academy of Pediatric Dentistry. Policy on
transitioning from a pediatric-centered to an adult-
centered dental home for individuals with special health
care needs. Pediatr Dent 2011;33(special issue):88-90.
3. American Academy of Pediatric Dentistry. Policy on
transitioning from a pediatric-centered to an adult-
centered dental home for individuals with special health
care needs. Pediatr Dent 2016;38(suppl issue):117-20.
4. McManus MA, Pollack LR, Cooley WC, et al. Current
status of transition preparation among youth with special
needs in the United States. Pediatrics 2013;131(6):1090-7.
5. Blum RW. Transition to adult care: Setting the stage. J
Adolesc Health 1995;17(1):3-5.
6. Sharma N, O’Hare K, Antonelli RC, Sawicki GS. Transi-
tion care: Future directions in education, health policy,
and outcomes research. Acad Pediatr 2014;14(2):120-7.
7. Norwood KW, Slayton RL. Oral health care for children
with developmental disabilities. Pediatrics 2013;131(3):
614-9.
8. McManus M, White P, Schmidt A, et al. Health care
gap affects 20% of United States population: Transition
from pediatric to adult health care. Health Policy OPEN
2020;1:100007. Available at: “https://doi.org/10.1016/j.
hpopen.2020.100007”. Accessed June 23, 2021.
9. Lebrun-Harris LA, McManus MA, Ilango SM, et al. Tran-
sition planning among us youth with and without special
health care needs. Pediatrics 2018;142(4):e20180194.
10. American Academy of Pediatrics, American Academy of
Family Physicians, and American College of Physicians
Transitions Clinical Report Authoring Group. Support-
ing the health care transition from adolescence to adult-
hood in the medical home. Pediatrics 2011;128(1):
182-200.
11. McPheeters M, Davis AM, Taylor JL, Brown RF, Potter
SA, Epstein RA, Jr. Transition Care for Children with
Special Health Needs. Technical Brief No. 15 (Prepared
by the Vanderbilt University Evidence-based Practice
Center under Contract No. 290-2012-00009-I). AHRQ
Publication No.14-EHC027-EF. Rockville, Md.: Agency
for Healthcare Research and Quality; June 2014. Avail-
able at: “https://effectivehealthcare.ahrq.gov/sites/default/
files/pdf/children-special-needs-transition_technical-brief.
pdf ”. Accessed October 18, 2021.
12. Koop CE. Executive summary. In: McGrab P, ed. Grow-
ing Up and Getting Medical Care: Youth with Special
Health Care Needs. Jekyll Island, Ga.: U.S. Public Health
Service; 1989.

13. Rosen DS, Blum RW, Britto M, Sawyer SM, Siegle DM,
Society for Adolescent Medicine. Transition to adult health
care for adolescents and young adults with chronic con-
ditions: Position paper for the Society for Adolescent
Medicine. J Adolesc Health 2003;33(4):309-11.
14. Starmer AJ, Spector ND, Srivastava R, et al. Changes
in medical errors after implementation of a handoff pro-
gram. N Engl J Med 2014;372(5):490-1.
15. Blum RW. Improving transition for adolescents with
special health care needs from pediatric to adult-centered
care. Pediatrics 2002;110(6 Pt 2):1301-3.
16. Chi DL. Medical care transition planning and dental care
use for youth with special health care needs during the
transition from adolescence to young adulthood: A
preliminary explanatory model. Matern Child Health J
2014;18(4):778-88.
17. Amaria K, Stinson J, Cullen-Dean G, Sappleton K, Kaufman
M. Tools for addressing systems issues in transition.
Healthc Q 2011;14(Spec No 3):72-6.
18. Andemariam B, Owarish-Gross J, Grady J, Boruchov D,
Thrall RS, Hagstrom JN. Identification of risk factors
for an unsuccessful transition from pediatric to adult
sickle cell disease care. Pediatr Blood Cancer 2014;61(4):
697-701.
19. Annunziato RA, Shemesh E. Tackling the spectrum of
transition: What can be done in pediatric settings?
Pediatr Transplant 2010;14(7):820-2.
20. Borromeo GL, Bramante G, Betar D, Bhikha C, Cai YY,
Cajili C. Transitioning of special needs paediatric patients
to adult special needs dental services. Aust Dent J 2014;
59(3):360-5.
21. Chavis S, Carares G. The transition of patients with
special healthcare needs from pediatric to adult based
dental care: A scoping review. Pediatr Dent 2020;42(2):
101-9.
22. Arango P. Family-centered care. Acad Pediatr 2011;11
(2):97-9.
23. Cruz S, Neff J, Chi DL. Transitioning from pediatric
care to adult care for adolescents with special health care
needs: Adolescent and parent perspectives (Part 1).
Pediatr Dent 2015;37(5):442-6.
24. Bayarsaikhan Z, Cruz S, Neff J, Chi DL. Transition-
ing from pediatric care to adult care for adolescents with
special health care needs: Dentist perspectives (Part 2).
Pediatr Dent 2015;37(5):447-51.
25. American Academy of Pediatric Dentistry. Management
of dental patients with special health care needs. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2021:287-94.
26. Geenen SJ, Powers LE, Sells W. Understanding the role
of health care providers during the transition of adoles-
cents with disabilities and special health care needs. J
Adolesc Health 2003;32(3):225-33.
27. Newacheck PW, Hung YY, Wright KK. Racial and eth-
nic disparities in access to care for children with special
healthcare needs. Ambul Pediatr 2002;2(4):247-54.
28. Casamassimo PS, Seale NS, Ruehs K. General dentists’
perceptions of educational and treatment issues affecting
access to care for children with special health care needs.
J Dent Educ 2004;68(1):23-5.
29. American Dental Association. 2012 Survey of Dental Prac-
tice. Pediatric Dentists in Private Practice. Characteristics
ORAL HEALTH POLICIES: TRANSITIONING DENTAL HOMES FOR INDIVIDUALS WITH SHCN
Report. Available at: “https://www.aapd.org/assets/1/7/
SurveyofDentalPracticeReport.pdf ”. Accessed October
18, 2021.
30. U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and
Child Health Bureau. Children with Special Health Care
Needs. National Survey of Children’s Health Data Brief
July 2020. U.S. Department of Health and Human
Services, Health Resources and Services Administration,
Maternal and Child Health Bureau. Available at: “https:
//mchb.hrsa.gov/sites/default/files/mchb/Data/NSCH/
nsch-cshcn-data-brief.pdf ”. Accessed October 18, 2021.
31. American Academy of Pediatric Dentistry. Symposium
on lifetime oral health care for patients with special
needs. Pediatr Dent 2007;29(2):92-152.
32. Woldorf JW. Transitioning adolescents with special
health care needs: Potential barriers and ethical conflicts.
J Spec Pediatr Nurs 2007;12(1):53-5.
33. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating
the transition of patients with special health care needs
from pediatric to adult oral health care. J Am Dent Assoc
2010;141(11):1351-6.
34. Chmar J, Weaver R, Valachovic R. Annual ADEA survey
of dental school seniors: 2005 graduating class. J Dent
Educ 2006;70(3):315-39.
35. Williams JJ, Spangler CC, Yusaf NK. Barriers to dental
care access for patients with special needs in an affluent
metropolitan community. Spec Care Dent 2015;35(4):
190-6.
36. Espinoza K. Healthcare transitions and dental care. In:
Hergenroeder AC, Wiemann CM, eds. Health Care
Transition: Building a Program for Adolescents and
Young Adults with Chronic Illness and Disability. Cham,
Switzerland: Springer International Publishing; 2018:
339-49.
37. Special Care Dentistry. Fellowship in special care
dentistry. Available at: “https://www.scdaonline.org/
page/DentalFellowship”. Accessed October 29, 2021.
38. Special Care Dentistry. Diplomate in special care den-
tistry. Available at: “https://www.scdaonline.org/page/
Diplomate”. Accessed October 29, 2021.
39. Academy of General Dentistry. Mastership award guide-
lines. Available at: “https://www.agd.org/docs/default
-source/get-recognized/mastership- guidleines_6_17.pdf?
sfvrsn=36b774b1_8”. Accessed October 29, 2021.
40. Faulks D, Freedman L, Thompson S, Sagheri D, Dougall
A. The value of education in special care dentistry as a
means of reducing inequalities in oral health. Eur J Dent
Educ 2012;16(4):195-201.
41. Edelstein BL. Conceptual frameworks or understanding
system capacity in the care of people with special health
care needs. Pediatr Dent 2007;29(2):108-16.
42. Crall JJ. Improving oral health for individuals with
special health care needs. Pediatr Dent 2007;29(2):
98-104.
43. American Academy of Pediatrics. The medical home.
Pediatrics 2002;110(1Pt1):184-6.
44. Lewis C, Robertson AS, Phelps S. Unmet dental care
needs among children with special health care needs:
Implications for medical home. Pediatrics 2005;116(3):
426-31.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 175
ORAL HEALTH POLICIES: PATIENT SAFETY
Policy on Patient Safety
Latest Revision
2021
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes patient safety as an essential component of quality
oral health care for infants, children, adolescents, and those
with special health care needs. The AAPD encourages dentists
to consider thoughtfully the environment in which they deliver
health care services and to implement practices to improve
patient safety. This policy is not intended to duplicate safety
recommendations for medical facilities accredited by national
commissions such as The Joint Commission or those related
to workplace safety such as Occupational Safety and Health
Administration.
Methods
This document is a revision of the policy developed by the
Council on Clinical Affairs, adopted in 20081, and last revised
in 20182. This policy is based on a review of current dental
and medical literature, including search of the PubMed /
MEDLINE database using the terms: patient safety AND
® approach to promote safe and quality patient care.27 Identi-
dentistry, fields: all; limits: within the last 10 years, humans,
English. Four hundred seventy-seven articles met these criteria.
Papers for review were chosen from this list and from the
references within selected articles.
Background
All health care systems should be designed to provide a
practice environment that promotes patient safety.3 The
World Health Organization (WHO) defines patient safety as
“the reduction of risk of unnecessary harm associated with
healthcare to an acceptable minimum.”4 The most important
challenge in the field of patient safety is prevention of harm,
particularly avoidable harm, to patients during treatment and
care.4 Dental practices must be in compliance with federal
laws that help protect patients from preventable injuries and
potential dangers such as the transmission of disease.5-7 Laws
help regulate hazards related to chemical and environmental
factors (e.g., spills, radiation) and facilities (e.g., fire prevention
systems, emergency exits).8 The AAPD’s recommendations and
oral health policies provide additional information regarding
the delivery of safe pediatric dental care.9-22 Furthermore, state
dental practice acts and hospital credentialing committees are
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.23-25
Patient-centered health care systems that focus on pre-
venting errors are critical to assuring patient safety.25,26 Some
176 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
patient safety. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:176-80.
possible sources of error in the dental office are miscom-
munication, interruptions, stress, fatigue, failure to review the
patient’s medical history (e.g., current medications, allergies),
and lack of standardized records, abbreviations, and
processes.3,25,27 Treating the wrong patient or tooth/surgical
site, delay in treatment, disease progression after misdiagnosis,
inaccurate referral, incorrect medication dosage ordered/
administered, breach in sterilization, waterline contamination,
and unintentional swallowing, aspiration, or retention of a
foreign object are examples of patient safety events that occur
in dentistry.28-32 Adverse events may be classified in terms of
severity of harm (e.g., none, mild, moderate, severe, death).33
Standardized processes and workflows help assure clerical
and clinical personnel execute their responsibilities in a safe
and effective manner.27 Policy and procedure manuals that
describe a facility’s established protocols serve as a valuable
training tool for new employees and reinforce a consistent
fying deviations from established protocols and studying
patterns of occurrence can help reduce the likelihood of
adverse events.13
Safety checklists are used by many industries and health-
care organizations to reduce preventable errors.34,35 Data
supports the use of procedural checklists (e.g., pre-sedation)
to minimize the occurrence of adverse events in dentistry.36-39
In addition, order sets, reminders, and clinical guidelines built
into an electronic charting system may improve adherence to
best practices.32 Zero harm, the concept that a patient will not
experience preventable harm or injury, is a goal in medicine
today.40 The medical profession generally has embraced the
systematic approach to safety change, but the dental profession
has been slower to adopt this approach.41-43 The journey to
achieve zero harm does not occur without effort. For change
to occur in dental practices and organizations, it is important
that dental professionals publicly commit to the establish-
ment of a safety culture, encourage effective teamwork, and
promote effective communication and training.43,44 Reducing
clinical errors requires a careful examination of adverse
events27,32,45 and near-miss events26,46. In a near-miss event, an
error was committed, but the patient did not experience
clinical harm.26,46 Detection of errors and problems within a
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. WHO: World
Health Organization.

practice or organization may be used as teaching points to
motivate changes and avoid recurrence.47 A root cause analysis
can be conducted to determine causal factors and corrective
actions so these types of events may be avoided in the
future.34,40,44,48 Embracing a patient safety culture demands
a nonpunitive or no-blame environment that encourages all
personnel to report errors and intervene in matters of patient
safety.26,48 Alternatively, a fair and just culture is one that
learns and improves by openly identifying and examining its
own weaknesses; individuals know that they are accountable
for their actions but will not be blamed for system faults in
their work environment beyond their control.40,44 Evidence-
based systems have been designed for healthcare professionals
to improve team awareness, clarify roles and responsibilities,
resolve conflicts, improve information sharing, and eliminate
barriers to patient safety.40,49,50
The environment in which dental care is delivered impacts
patient safety. In addition to structural issues regulated by
state and local laws, other design features should be planned
and periodically evaluated for patient safety, especially as they
apply to young children. Play structures, games, and toys are
possible sources for accidents and infection.51,52
The dental patient would benefit from a practitioner who
follows current literature and participates in professional con-
tinuing education courses to increase awareness and knowl-
edge of best current practices and public health concerns.
Scientific knowledge and technology continually advance, and
patterns of care evolve due, in part, to recommendations
by organizations with recognized professional expertise and
stature, including the American Dental Association, The Joint
Commission, WHO, Institute for Health Improvement, and
Agency for Healthcare Research and Quality. Data-driven
solutions are possible through documenting, recording, re-
porting, and analyzing patient safety events.30,41,53 Continuous
quality improvement efforts including outcome measure
analysis to improve patient safety should be implemented
into practices.32,54 Patient safety incident disclosure is lower
in dentistry compared with medicine since a dental-specific
reporting system does not exist in the United States.41,42
Identifiable patient information that is collected for analysis is
considered protected under the Health Insurance Portability
and Accountability Act (HIPAA).55
Dental practitioners should be aware of and minimize the
potential for patient fire during procedures when an ignition
source, fuel, and oxidizer are present simultaneously.56-58
(Figure) Patient fire is rare but can result in injury and
death.56,57 Sparks from burs, lasers, and electrosurgical units
can serve as an ignition source.57 Combustible agents (e.g.,
dry gauze, throat pack, paper and cotton products; hair;
petroleum-based lubricants; alcohol-based products; rubber
dam and nitrous mask) can act as a fuel.57 Delivery of nitrous
oxide and/or oxygen, both of which are oxidizers, can produce
an oxidizer enriched atmosphere (OEA).
ORAL HEALTH POLICIES: PATIENT SAFETY
Ignition Source
+LJKVSHHGKDQGSLHFHEXU
DJDLQVW]LUFRQLDRUPHWDO
HOHFWURVXUJHU\XQLWODVHU
Fire
'HQWDO
SDWLHQW¿UH
Fuel
Oxidizer
'U\JDX]HSDWLHQWGUDSHV
WUDFKHDOWXEHVWKURDWSDFNV
2[\JHQ
KDLUSHWUROHXPMHOO\ QLWURXVR[LGH
Figure. Dental fire triangle: dental fire may result when all three factors
are present simultaneously.
Policy statement
To promote patient safety, the AAPD encourages:
• patient safety instruction in dental curricula to promote
safe, patient-centered care.
• professional continuing education by all licensed den-
tal professionals to maintain familiarity with current
regulations, technology, and clinical practices.
• compliance with and recognition of the importance of
infection control policies, procedures, and practices in
dental health care settings in order to prevent disease
transmission from patient to care provider, from care
provider to patient, and from patient to patient.4-6
• routine inspection of physical facility in regards to
patient safety. This includes development and periodic
review of office emergency and fire safety protocols
and routine inspection and maintenance of clinical
equipment.
• recognition that informed consent by the parent, and
assent from the child when applicable, is essential in
the delivery of health care10 and effective relationship/
communication practices can help avoid problems and
adverse events. The parent should understand and be
actively engaged in the planned treatment.
• accuracy of patient identification with the use of at
least two patient identifiers, such as name and date of
birth, when providing care, treatment, or services.
• an accurate and complete patient chart that can be
interpreted by a knowledgeable third party.21 Standard-
izing abbreviations, acronyms, and symbols throughout
the record is recommended.21
• an accurate, comprehensive, and up-to-date medical/
dental history including medications and allergy list
to ensure patient safety during each visit. Ongoing com-
munication with health care providers, both medical
and dental, who manage the child’s health helps ensure
comprehensive, coordinated care of each patient.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 177
ORAL HEALTH POLICIES: PATIENT SAFETY
• a pause or time out with dental team members present
before an invasive procedure to confirm the patient,
planned procedure, and tooth/surgical site are correct.
• inclusion of fire prevention and management protocols
in procedure and emergency plans. A time out may be
used to assess the fire potential57 of a procedure when
nitrous oxide or oxygen is to be used. If an ignition
source and fuel are present, risk of a patient fire may be
reduced by monitoring the flow of gases and using high
volume suction for at least one minute prior to the use
of a potential ignition source.57,59 In addition, maintain-
ing a moist working field and avoiding cutting dry can
decrease fire risk.58,59
• appropriate staffing and supervision of patients treated
in the dental office.
• adherence to AAPD recommendations on behavior
guidance,9 especially as they pertain to use of advanced
behavior guidance techniques (i.e., protective stabili-
zation, sedation, general anesthesia).
• standardization and consistency of processes within the
practice. A policies and procedures manual, with on-
going review and revision, could help increase employee
awareness and decrease the likelihood of untoward events.
Dentists should emphasize procedural protocols that
protect the patient’s airway (e.g., rubber dam isolation),
guard against unintended retained foreign objects (e.g.,
surgical counts; observation of placement/removal of
throat packs, retraction cords, cotton pellets, and ortho-
dontic separators), and minimize opportunity for
iatrogenic injury during delivery of care (e.g., protective
eyewear).
• minimizing exposure to nitrous oxide by maintaining
the lowest practical levels in the dental environment.
This includes routine inspection and maintenance of
nitrous oxide delivery equipment as well as adherence
to clinical recommendations for patient selection and
delivery of inhalation agents.
• minimizing radiation exposure through adherence to
the as low as reasonably achievable (ALARA) principle,
equipment inspection and maintenance, and patient
selection criteria.
• all facilities performing sedation for diagnostic and
therapeutic procedures to maintain records that track
adverse events. Such events then can be examined
for assessment of risk reduction and improvement in
patient safety.
• dentists who utilize in-office anesthesia providers take
all necessary measures to minimize risk to patients. Prior
to delivery of sedation/general anesthesia, appropriate
documentation shall address rationale for sedation/
general anesthesia, informed consent, instructions to
parent, dietary precautions, preoperative health evalua-
tion, and any prescriptions along with the instructions
given for their use. Rescue equipment should have
178 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
regular safety and function testing and medications
should not be expired. The dentist and anesthesia pro-
viders must communicate during treatment to share
concerns about the airway or other details of patient
safety.
• ongoing quality improvement strategies and routine
assessment of risk, adverse events, and near misses. A
plan for improvement in patient safety and satisfaction
is imperative for such strategies.40
• comprehensive review and documentation of indication
for medication order/administration. This includes a
review of current medications, allergies, drug interac-
tions, and correct calculation of dosage.
• vigilance in monitoring public health concerns (e.g.,
severe acute respiratory syndrome coronavirus 2 [SARS-
CoV-2]). This includes taking appropriate steps to
ensure patient and staff safety as recommended by local
and national sources with recognized expertise.
• promoting a culture where staff members are empowered
and encouraged to speak up or intervene in matters of
patient safety.
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26. Ramoni RB, Walji MF, White J, et al. From good to
better: Towards a patient safety initiative in dentistry. J
Am Dent Assoc 2012;143(9):956-60.
27. Jadhav A, Kumar S, Acharya S, Payoshnee B, Ganta S.
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28. Black I, Bowie P. Patient safety in dentistry: Develop-
ment of a candidate ‘never event’ list for primary care. Br
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29. Cullingham P, Saksena A, Pemberton MN. Patient safety:
Reducing the risk of wrong tooth extraction. Br Dent
J 2017;222(10):759-63.
30. Obadan EM, Ramoni RB, Kalenderian E. Lessons learned
from dental patient safety case reports. J Am Dent Assoc
2015;146(5):318-26.
31. Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens
A, Cresswell K, Bedi R, Sheikh A. Patient safety incidents
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00000316”. Accessed October 18, 2021.
32. American Academy of Pediatrics. Principles of patient
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33. Kalenderian E, Obadan-Udoh E, Maramaldi P, et al.
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18, 2021.
34. Harden SW, Roberson JB. 8.5 tips for dental safety
checklists. Todays FDA 2013;25(6):40-3, 45.
35. World Health Organization. Surgical Safety Checklist
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36. Bailey E, Tickle M, Campbell M, O’Malley L. Systematic
review of patient safety interventions in dentistry. BMC
Oral Health 2015;15(152):1-11.
37. Saksena A, Pemberton MJ, Shaw A, Dickson S, Ashley
MP. Preventing wrong tooth extraction: Experience in
development and implementation of an outpatient safety
checklist. Br Dent J 2014;217(7):357-62. Erratum in Br
Dent J 2014;217(10):585.
38. Robert R, Patel C. Oral surgery patient safety concepts
in anesthesia. Oral Maxillofac Surg Clin North Am
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39. Wali R, Halai T, Koshal S. WHO surgical safety check-
list training: An alternative approach to training in local
safety standard for invasive procedures. Eur J Dent Educ
2020;24(1):71-8.
40. Leonard M, Frankel A, Federico F, Frush K, Haradan
C. The Essential Guide for Patient Safety Officers, 2nd
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41. Thusu S, Panasar S, Bedi R. Patient safety in dentistry –
State of play as revealed by a national database of errors.
Br Dent J 2012;213(E3):1-8.
42. Stahl J, Mack K, Cebula S, Gillingham. Dental patient
safety in the military health system: Joining medicine in
the journey to high reliability. Military Med 2020;185
(1):262-8.
43. Yansane A, Lee J, Hebballi N, et al. Assessing the patient
safety culture in dentistry. JDR Clin Trans Res 2020;5
(4):399-408.
44. Frankel AS, Leonard MW, Denham CR. Fair and just
culture, team behavior, and leadership engagement: The
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45. Hurst D. Little research on effective tools to improve
patient safety in the dental setting. Evid Based Dent
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46. Frankel A, Haraden C, Federico F, Lenoci-Edwards J.
A framework for safe, reliable, and effective care. White
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47. Tucker AL, Edmondson AC. Why hospitals don’t learn
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Looking into the safety culture of dental school clinics.
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Policy for Selecting Anesthesia Providers for the
Delivery of Office-Based Deep Sedation / General
Anesthesia
Adopted
2018
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that it is the exclusive responsibility of dental prac-
titioners when employing anesthesia providers to administer
office-based deep sedation/general anesthesia (DS/GA) to
verify and carefully review the credentials and experience of
those providers.1 An understanding of the educational and
training requirements of the various anesthesia professions
and candid discussions with potential anesthesia providers can
assist in the vetting and selection of highly skilled licensed
providers in order to help minimize risk to patients.
Methods
This policy was developed by the Council on Clinical Affairs
and is based on a review of current dental and medical
literature pertaining to the education and training accredita-
tion requirements of potential anesthesia providers.
Background
Historically, care necessitating DS/GA was provided in a
surgical center or hospital-based setting by an anesthesiologist
selected and vetted by the facility or institution. The dental
surgeon had little, if any, choice as to who would provide
these services. Current trends find an increasing number of
dental providers electing to complete such care in the confines
of their office using the services of an anesthesia provider.2
Over the last decade, office-based DS/GA in the dental office
has proven to be safe and effective when delivered by a
highly competent and attentive individual.3 Substantial societal
cost savings associated with the delivery of care outside of a
surgical center or hospital setting have been well documented.4
With the use of office-based DS/GA, the primary dental
provider takes on the significant responsibility of creating a
team of highly qualified professionals to deliver care in an
optimal and safe fashion. DS/GA techniques in the dental
office require at least three individuals:
• independently practicing and currently licensed anesthesia
provider;
• operating dentist; and
• support personnel.1
ORAL HEALTH POLICIES: SELECTING ANESTHESIA PROVIDERS
How to Cite: American Academy of Pediatric Dentistry. Policy for
selecting anesthesia providers for the delivery of office-based deep
sedation/general anesthesia. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:181-3.
No other responsibility is more important than identifying
an anesthesia provider who is highly competent. Significant
pediatric training, including anesthesia care of the very young,
and experience in a dental setting are important considerations,
especially when caring for young pediatric and special needs
populations. Advanced training in recognition and manage-
ment of pediatric emergencies is critical in providing safe
sedation and anesthetic care.1 Close collaboration between the
dentist and the anesthesia provider can provide access to care,
establish an enhanced level of patient cooperation, improve
surgical quality, and offer an elevated level of patient safety
during the delivery of dental care.
Federal, state, and local credentialing and licensure laws,
regulations, and codes dictate who legally can provide office-
based anesthesia services. Practitioners choosing to use these
modalities must be familiar with the regulatory and professional
requirements needed to provide this level of pharmacologic
behavior management.1 The operating dentist must confirm
any potential anesthesia provider’s compliance with all licen-
sure and regulatory requirements. Additional considerations in
anesthesia provider selection may include proof of liability
insurance and recommendations from professional colleagues.
Lastly, dentists must recognize potential liability issues associ-
ated with the delivery of DS/GA within their office.
It is important to acknowledge that not all anesthesia pro-
viders have equal training and experience delivering care during
procedures performed within and around the oral cavity,
especially in the pediatric or special healthcare needs patient
populations or on a mobile basis. The following table sum-
marizes the educational requirements of various anesthesia
professions.
Because of the diversity in anesthesia education among po-
tential providers, operating dentists should further investigate
an individual’s training and experience. A candid discussion
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. DS/GA: Deep
sedation/general anesthesia. OMFS: Oral and maxillofacial surgery.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 181
ORAL HEALTH POLICIES: SELECTING ANESTHESIA PROVIDERS

Table. ANESTHESIA EDUCATION AND TRAINING COMPARISON

Anesthesia provider Permitted to Minimum Minimum Minimum Definition Minimum # of National examination/
function duration of # of # of of pediatric DS/GA cases certification organization
independent of program DS/GA pediatric patient involving
supervision by required for cases cases 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. N / A = Not applicable.

* 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
comfort and experience with unique patient populations
(e.g., patients with development disabilities or medical
comorbidities, infants and toddlers) is extremely important,
especially if it is anticipated that this will represent a large
portion of a dental practice’s DS/GA focus. Selection of a
skilled and knowledgeable anesthesia provider is paramount in
providing patients with the safest and most effective care possible.
Policy statement
The AAPD encourages dental practitioners when employing
anesthesia providers to administer office-based DS/GA to
verify and carefully review the credentials and experience of
those providers. In addition to the credentialing process, the
AAPD encourages dentists to engage a potential anesthesia
provider in a candid discussion to determine expectations,
practices, and protocols to minimize risk for patients. Sample
questions to assist in this conversation appear below.
Sample questions to ask a potential office-based anesthesia
provider *
1. What is your experience with pediatric patient popu-
lations? …special healthcare needs populations?
2. What is your background/experience in providing
office-based DS/GA care? …and specifically for
pediatric dental patients?
3. How do you evaluate a dental facility and staff prior
to initiating anesthesia services? What expectations and
requirements do you have for the dentist, auxiliary
staff, and facility?

* ItThewasinformation included in the preceding sample questions, developed by the AAPD, is provided as a tool for pediatric dentists and other dentists treating children.
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.

182 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


4. What equipment do you use to administer and moni-
tor DS/GA in the office, and what is your maintenance
protocol for this equipment?
5. What equipment and/or medications should be
maintained by the dental facility?
6. What are some potential emergencies associated with
the delivery of DS/GA in the pediatric dental office,
noting any that may be unique to these clinical
circumstances?
7. What is your training/experience in recognition and
management of pediatric anesthetic emergencies?
8. In the event of a medical emergency, what is your
plan of action? What are the roles of the dentist and
auxiliary staff during a medical emergency?
9. Do you have an affiliation with any area hospitals in
case a patient requires transfer?
10. What patient selection criteria (e.g., age, weight, co-
morbidities) do you use to identify potential candidates
for office-based DS/GA?
11. When a decision has been made that a patient is a
candidate for office-based sedation/general anesthesia,
what is the office’s role in preparing a patient for
office-based DS/GA? How and when do you prepare
the patient for the procedure?
12. What is your protocol for monitoring a patient
post-operatively?
13. What are your discharge criteria and your follow-up
protocols for patients who receive office-based DS/
GA?
14. Would you describe a typical general anesthesia case
from start to finish?
15. What is your protocol for ordering, storing, and
recording controlled substances for DS/GA cases?
16. What are the patient fees associated with office-based
DS/GA services?
17. How and where are patients records related to the
office-based administration of and recovery from DS/
GA stored?
References
1. American Academy of Pediatric Dentistry. Use of anes-
thesia providers in the administration of office-based
deep sedation/general anesthesia to the pediatric dental
patient. Pediatr Dent 2018;40(6):317-20.
2. Saxen MA, Urman RD, Yepes JF, Gabriel RA, Jones
JE. Comparison of anesthesia for dental/oral surgery by
office-based dentist anesthesiologists versus operating
room-based physician anesthesiologists. Anesth Prog
2018;64(4):212-20.
3. Spera AL, Saxen MA, Yepes JF, Jones JE, Sanders BJ.
Office-based anesthesia: Safety and outcomes in pediatric
dental patients. Anesth Prog 2017;64(3):144-52.
ORAL HEALTH POLICIES: SELECTING ANESTHESIA PROVIDERS
4. Rashewsky S, Parameswaran A, Sloane C, et al. Time and
cost analysis: Pediatric dental rehabilitation with general
anesthesia in the office and the hospital settings. Anesth
Prog 2012;59(4):147-58.
5. Commission on Accreditation of Allied Health Edu-
cation Programs. Standards and Guidelines for the
Accreditation of Educational Programs for the Anesthe-
siologist Assistant, Revised 2016. Available at: “https://
www.caahep.org/CAAHEP/media/CAAHEP-Documents/
StandardsAnesthesiologistAssistant.pdf ”. Accessed
February 14, 2018.
6. Council on Accreditation of Nurse Anesthesia Educational
Programs. Standards for Accreditation of Nurse Anesthe-
sia Educational Programs, Revised January, 2018.
Available at: “http://home.coa.us.com/accreditation/
Documents/2004%20Standards%20for%20Accreditation
%20of%20Nurse%20Anesthesia%20Educational%20
Programs,%20revised%20January%202018.pdf ”. Accessed
February 14, 2018.
7. Commission on Dental Accreditation. Accreditation
Standards for Advanced General Dentistry Education
in Dental Anesthesiology, 2017. Available at: “https://
www.ada.org/~/media/CODA/Files/2018_Dental_
Anesthesiology_Standards.pdf?la=en”. Accessed February
14, 2018.
8. Accreditation Council for Graduate Medical Education.
ACGME Program Requirements for Graduate Education
in Anesthesiology, July 1, 2017. Available at: “https://
www.acgme.org/Portals/0/PFAssets/ProgramRequirements/
110_emergency_medicine_2017-07-01.pdf ”. Accessed
February 14, 2018.
9. Accreditation Council for Graduate Medical Education.
ACGME Program Requirements for Graduate Medical
Education in Pediatric Anesthesiology. July 1, 2017.
Available at: “https://www.acgme.org/Portals/0/PFAssets
/ProgramRequirements/042_pediatric_anesthesiology
_2017-07-01.pdf?ver=2017-06-28-085120-903”. Accessed
June 13, 2018.
10. American Board of Anesthesiology. Pediatric anesthe-
siology registration eligibility. Available at: “http://www.
theaba.org/Exams/Pediatric-Anesthesiology/Registration
-Eligibility”. Accessed June 13, 2018.
11. Commission on Dental Accreditation. Accreditation
Standards for Advanced Specialty Educational Programs
in Oral and Maxillofacial Surgery, 2017. Available at:
“https://www.ada.org/~/media/CODA/Files/oms.pdf?la=en”.
Accessed February 14, 2018.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 183
ORAL HEALTH POLICIES: ETHICAL RESPONSIBILITIES IN OHC MANAGEMENT
Policy on Ethical Responsibilities in the Oral
Health Care Management of Infants, Children,
Adolescents, and Individuals with Special Health
Care Needs
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD) believes
that all infants, children, adolescents, and individuals with
special health care needs (SHCN) are entitled to oral health
care that meets the treatment and ethical standards set by our
specialty.
Methods
This policy was developed by the Council on Clinical
Affairs and adopted in 2003.1 This document is a revision of
the previous version, revised in 2015.2
Background
Dentists have an obligation to act in an ethical manner in the
care of patients with consideration of the virtues of ethics
including autonomy, beneficence, nonmaleficence, and justice.
Autonomy reflects the patient’s or, when the patient is a
minor or an intellectually disabled adult who lacks capacity to
give consent, the parent’s3 or guardian’s right to be involved in
treatment decisions. The caregiver must be informed of the
problem and that treatment is recommended. Beneficence in-
dicates the dentist has the obligation to act for the benefit of
the patient in a timely manner even when there may be con-
flicts with the dentist’s personal self interests. Nonmaleficence
dictates that the dentist’s care does not result in harm to the
patient. In situations where a dentist is not able to meet the
patient’s needs, referral to a practitioner capable of providing
the needed care is indicated. Justice expresses that the dentist
should deal fairly with patients, colleagues, and the public.4,5
Denial of care by the provider because of age, behavior, in-
ability to cooperate, disability, or medical status can result in
unnecessary pain, discomfort, increased treatment needs and
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
patient to a practitioner or facility capable of providing
the care.
184 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
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.:
American Academy of Pediatric Dentistry; 2022:184-5.
Oral health care practitioners may offer services for children
and individuals with SHCN in a variety of settings (e.g., solo
practice, general dentistry group practice, specialty group
practice, dental service organization, educational institution,
hospital, public health or military clinic). Although each
entity will have its own administrative policies and procedures
to which practitioners must adhere, each provider also must
be aware of and follow established standards and evidence-
based guidelines promulgated by organizations with recognized
professional expertise and stature.
Dentists are held responsible for their clinical and ethical
decisions regardless of who holds the responsibility for busi-
ness decisions.7 The “ultimate responsibility for compliance
with state laws and regulations falls upon the practicing
licensed dentist.”8 All patients must receive dental care con-
sistent with the moral, ethical, and evidence-based standards
of care regardless of the care setting. The treating doctor’s
clinical judgment should not be influenced by financial
considerations of the business entity.
Patients/parents need to play an active role in decision
making with their doctors and must be informed about their
medical and dental problems and treatment options. 4
Evidence-based knowledge and treatment options are evolving
at a rapid pace. As a result, patients/parents and health care
providers are seeking second opinions so that more informed
decisions based on the risks and benefits can be made for treat-
ment. A provider has an ethical obligation, subject to privacy
regulations, on request of either the patient or the patient’s new
provider to furnish records, including radiographs, or copies
of them. These may be beneficial for the future treatment of
that patient.4 Health Insurance Portability and Accountability
Act (HIPAA) privacy rules9 and state laws apply to all exchanges
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. SHCN: Special
health care needs.

of health care information. Educating the patient/parent
regarding the diagnosis and available treatment options, in-
cluding their risks and benefits, should be the goal of a second
opinion consultation. Health care providers may disagree on
the best treatment for an individual patient. Any opinion
should be rendered only after careful consideration of all the
facts and with due attention given to current and previous
health status of the patient. When presented with requests
for second opinions, practitioners should consider the legal
implications of such requests. Health care providers rendering
second opinions unwarily could be involved in litigation,
either on behalf of the patient or in defending themselves
against other practitioners as a result of the consult. The fact
that one is the second or third consulted professional does
not mean that the provider is exempt from liability.10 Parents
and patients should be fully advised of their health status
without disparaging comments about their prior treatment
or previous provider.
Policy statement
Infants and children through adolescence, including those with
special health care needs, have a right to dental care. The AAPD
believes it is unethical for a dentist to ignore a disease or
condition because of the patient’s age, behavior, or disabilities.
Dentists have an ethical obligation to provide therapy for
patients with oral disease or refer for treatment patients whose
needs are beyond the skills of the practitioner.
The AAPD encourages all entities and practitioners who
provide oral health care services to children to follow evidence-
based clinical practice guidelines and best practices developed
by organizations with recognized professional expertise and
stature. Under no circumstance should the business or cor-
porate entity interfere with the clinical judgment of the
treating dentist.
A patient/parent has a right to a second opinion. A provider
who is trained and experienced in diagnosing and treating the
condition is encouraged to provide the second opinion. When
presented with requests for second opinions, practitioners must
consider the legal implications of such requests. Patients/parents
should be fully advised of their health status without disparaging
comments about their prior treatment or previous provider.
The AAPD advocates legislation or regulation at the federal
and state levels to ensure that dentists are free to exercise
individual professional clinical judgment and render appro-
priate treatment to their patients without undue influence or
infringement by any third-party business and entity.11,12
References
1. American Academy of Pediatric Dentistry. Policy on the
ethics of failure to treat or refer. Pediatr Dent 2003;25
(Suppl):49.
2. American Academy of Pediatric Dentistry. Policy on the
ethical responsibilities in the oral health care management
of infants, children, adolescents, and individuals with
special health care needs. Pediatr Dent 2015;37(special
issue):114-5.
ORAL HEALTH POLICIES: ETHICAL RESPONSIBILITIES IN OHC MANAGEMENT
3. American Academy of Pediatric Dentistry. Overview:
Definition of parent. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:8.
4. American Dental Association. Principles of Ethics and
Code of Professional Conduct. With official advisory
opinions revised to November 2018. Available at: “https:
//www.ada.org/~/media/ADA/Member%20Center/
Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions
_Revised_to_November_2018.pdf?la=en”. Accessed
September 14, 2020.
5. American College of Dentists. Ethics Handbook for Den-
tists. Introduction to Ethics, Professionalism, and Ethical
Decision Making. Gaithersburg, Md.: American College
of Dentists; 2016. Available at: “https://www.acd.org/
publications-2/ethics-handbook/”. Accessed September
14, 2020.
6. American Academy of Pediatric Dentistry. Definition of
medically-necessary care. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2020:18.
7. Academy of General Dentistry Practice Models Task Force.
Investigative Report on the Corporate Practice of Dentis-
try, 2013. Chicago, Ill.: Academy of General Dentistry.
Available at: “https://www.agd.org/docs/default-source/
advocacy-papers/agd-white-paper-investigate-report-on
-corporate-dentistry.pdf?sfvrsn=c0d75b1_2”. Accessed
September 14, 2020.
8. Association of Dental Support Organizations, Dentists for
Oral Health Innovation, Waller. Toward a common goal:
The role of dental support organizations in an evolving
profession. July 1, 2014. Dentists for Oral Health Inno-
vation, Waller, contributors. Available at: “https://www.
dentalonejobs.com/wp-content/uploads/2017/02/ADSO
-White-Paper.pdf ”. Accessed July 21, 2020.
9. U.S. Department of Health and Human Services. Health
Information Privacy: The HIPAA privacy rule. Available
at: “https://www.hhs.gov/hipaa/for-professionals/privacy/
index.html#:~:text=The%20HIPAA%20Privacy%20
Rule%20establishes,certain%20health%20care%20
transactions%20electronically”. Accessed July 21, 2020.
10. Machen DE. Legal aspects of orthodontic practice: Risk
management concepts. Am J Orthod Dentofacial Orthop
1990;937(3):269-70.
11. American Dental Association. Dentist’s freedom to exercise
individual clinical judgment (Trans.1997:705). Current
Policies 2018:177. Chicago, Ill.: American Dental Asso-
ciation; 2018. Available at: “https://www.ada.org/~/media
/ADA/Member%20Center/Members/current_policies.
pdf?la=en”. Accessed September 26, 2019.
12. American Dental Association. Statement Regarding Em-
ployment of a Dentist. (Trans.2013:353). Practice
Administration. In: Current Policies Adopted 1954-2019.
Chicago, Ill.: American Dental Association; 2019:168 .
Available at: “https://www.ada.org/~/media/ADA/Member
%20Center/Members/current_policies.pdf?la=en”. Accessed
September 26, 2019.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 185
ORAL HEALTH POLICIES: BILL OF RIGHTS AND RESPONSIBILITIES
Policy on a Patient’s Bill of Rights and Responsibilities
Latest Revision
2019
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that pediatric oral health care should be rendered
under conditions acceptable to both patient and dentist. The
expectation is that oral health care providers, their staff,
patients, and parents of patients will support this policy,
thereby enhancing patient care.
Methods
This policy was developed by the Council on Clinical Affairs
and adopted in 2009. This document is based on electronic
database and hand searches of articles in medical and dental
literature using the following parameters: terms: patient
freedoms, patient’s bill of rights, bill of rights, consumer
bill of rights; fields: all; limits: within the last 10 years,
English, and birth through age 18. Nineteen articles met these
criteria.
Background
The AAPD is the leader in representing the oral health
interests of infants, children, adolescents, and persons with
special health care needs.1 Effective oral health care requires
collaboration between pediatric dentists, their patients/
parents, and other health care professionals. Optimal patient
care requires open and honest communication between
provider and patient, mutual respect for personal and
professional values, and sensitivity to differences.2
Often, the delivery of contemporary pediatric oral health
care can be confusing to parents. It is normal for parents to
have expectations about their child’s proposed care. Yet, it
is important that these parents have realistic expectations as
well as a clear understanding of their responsibilities in the
delivery of care to their children.
A patient’s bill of rights is a statement of the rights to
which patients are entitled as recipients of medical/dental
care. These rights can be exercised on the patient’s behalf
by a parent or legal guardian if the patient is a minor, lacks
decision-making capacity, or is legally incompetent. It artic-
ulates the positive rights that health care providers and facil-
ities should provide patients, thereby providing information,
offering fair treatment, and granting them autonomy over
medical decisions.
The collaborative nature of health care requires that
patients, or their families/surrogates, participate in their care.
The effectiveness of care and patient satisfaction with the
course of treatment depend, in part, on the patient’s fulfilling
186 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
a patient’s bill of rights and responsibilities. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:186-7.
certain responsibilities. As such, the AAPD proposes this
Policy on a Patient’s Bill of Rights and Responsibilities in the
planning and delivery of pediatric oral health care.
Policy statement
The AAPD encourages oral health care providers to tailor
this bill of rights and responsibilities to their patient
community by translating and/or simplifying it as necessary
to ensure that patients and their families understand their
rights and responsibilities.3
Patient’s rights
The patient has the right to:
• receive treatment at a dental home that provides
comprehensive, considerate, and respectful care;
• have oral health diagnoses made by a dentist;
• know the identity, education, and training of providers
involved in his/her care, as well as when those involved
are students, residents, or other trainees;3
• choose an oral health care provider. The parent has a
right to designate a pediatric dentist as a primary oral
health care provider for the child;
• participate fully in all the decisions related to his/her care;
• receive accurate, relevant, current, and easily understood in-
formation concerning diagnosis, treatment, and prognosis;
• discuss and request information related to specific pro-
cedures and/or treatments, including accompanying risks
and benefits, and the medically reasonable alternatives.
Life threatening emergency care could be an exception;
• make decisions about the plan of care prior to and
during the course of treatment, to refuse a recommended
treatment or plan of care to the extent permitted by law,
and to be informed of the health consequences of this
refusal. In case of refusal, the patient is entitled to other
appropriate care and services that the pediatric dentist
offers or to transfer to another dentist;4
• consent to or decline to participate in proposed research
studies affecting care and treatment or requiring direct
patient involvement and to have those studies explained
fully prior to consent. A patient who declines to partici-
pate in research is entitled to the most effective care that
the pediatric dentist can otherwise provide;
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

• expect reasonable continuity of care;
• emergency care as needed for acute dental trauma and
odontogenic infections;
• know the immediate and long-term financial implica-
tions of treatment choices, insofar as they are known by
the provider. The patient has the right to be informed of
the charges for services and available payment methods;
• be informed of the provider’s policies and practices that
relate to patient care, treatment, and responsibilities.
This includes available resources for resolving disputes,
grievances, and conflicts, such as ethics committees,
patient representatives, or other mechanisms available in
an organization;
• have privacy considered in every interaction. Case dis-
cussion, consultation, examination, and treatment should
be conducted in a way that best protects each patient’s
privacy;
• advise staff regarding specific privacy concerns or
questions;5
• expect that all communications and records pertaining
to his/her care will be treated as confidential, except in
cases where reporting is permitted or required by law
(e.g., suspected abuse, public health hazards). The
patient has the right to expect that the provider will
emphasize the confidentiality of information released to
other parties entitled to review this information;
• review the records pertaining to his/her medical care and
to have the information explained or interpreted as
necessary, except when restricted by law. The patient has
the right to request amendments to his/her record; and
• ask and be informed of the existence of business rela-
tionships among institutions, other health care providers,
or payors that may influence the patient’s treatment and
care.
Patient’s responsibilities
These responsibilities can be exercised on the patient’s behalf
by a parent or legal guardian if the patient is a minor, lacks
decision-making capacity, or is legally incompetent. The patient
is responsible for:
• providing, to the best of his/her knowledge, accurate and
complete information about past illnesses, hospitaliza-
tions, medications, and other matters related to his/her
health status;
• requesting additional information or clarification about
his/her health status or treatment when he/she does not
fully understand information and instructions;
• his/her actions if he/she refuses treatment or does not
follow the instructions of the provider.3 It is the patient’s
responsibility to inform dentists and other caregivers of
anticipated problems in following prescribed treatment,
including follow-up treatment instructions;
• keeping appointments and, when unable to do so,
notifying the dental office as soon as possible;
ORAL HEALTH POLICIES: BILL OF RIGHTS AND RESPONSIBILITIES
• being considerate of the rights of other patients and health
care workers.6 This includes not interfering with the
functioning of the facility, avoiding profane or derogatory
behavior, and minimizing noise;
• his/her conduct with staff. The patient must resolve
conflicts using available institutional mechanisms. Verbal
and physical abuse of staff is prohibited;7
• following Health Insurance Portability and Accountabil-
ity Act (HIPAA) guidelines including not taking videos/
photographs of people and/or protected health
information; and
• providing accurate insurance information and for
accepting the financial obligations associated with the
services rendered.
References
1. American Academy of Pediatric Dentistry. Who is AAPD?
Available at: “https://www.aapd.org/about/about-aapd/
who-is-aapd/”. Accessed July 11, 2019.
2. American Hospital Association. Patient care partnership,
Understanding expectations, rights and responsibilities.
Available at: “https://www.aha.org/system/files/2018-01/
aha-patient-care-partnership.pdf ”. Accessed July 11, 2019.
3. Kaiser Permanente. Your rights and responsibilities South-
ern, California. Available at: “https://m.kp.org/health/
care/consumer/center/!ut/p/a1/hZBPT4QwEMU_yx4
4QgcI_7wBLhtAxc0aF3sxQCo0lpa0dYnfXmDjwUTjJ
JPMJG9-efMQRjXCvLnQvtFU8IatO_Zfs-JUJYkdQ-
VVHuT33iEq_AcH0gCdUYFwz0S7iV8GracbAwyYp6k-
TXBOuu6WJNADhRmraMYLqIEqSGBLfDNPs1rTt-
vWNGkKVmGKZ-5kV2sHfTf2nXiTfjApS0H7QyJVG-
T4Iq2lFFNiVoZMW_dsEdYkjciibQ-5GJ0BasreZ6tXoi-
eEasT48L95WQQSqP6p3J5HG_ZgJsft2wOjz5AHpZ-
P5XNUugDOt-CPigFNY_jpsssdOZvvx3i3-wLRPKsu/dl5/
d5/L2dBISEvZ0FBIS9nQSEh/”. Updated March 2014.
Accessed July 11, 2019.
4. University of Pittsburgh Medical Center (UPMC).
Patient rights and responsibilities at UPMC Hospitals.
Updated 2019. Available at: “https://www.upmc.com/
patients-visitors/patient-info/rights-and-responsibilities”.
Accessed July 11, 2019.
5. Vanderbilt Health. Patient rights and responsibilities.
Vanderbilt Health. Available at: “https://vanderbilthealth.
com/comprehensivecare/30764”. Published March 25,
2004. Accessed July 11, 2019.
6. PeaceHealth St. Joseph Medical Center. Patient rights
and responsibilities. Available at: “https://www.peace
health.org/sites/default/files/patient-rights-english_0.pdf ”.
Published 2018. Accessed July 11, 2019.
7. Mayo Clinic. Rights and responsibilities of patients.
Available at: “https://www.mayoclinic.org/documents/
mcj6256-pdf/doc-20079310”. Published 2008. Accessed
July 11, 2019.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 187
ORAL HEALTH POLICIES: DENTAL STEM CELLS
Policy on Using Harvested Dental Stem Cells
Latest Revision
2022
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the emerging field of regenerative medicine and
encourages dentists to follow evidence-based literature in
order to educate parents about the collection, storage, viability,
and use of dental stem cells with respect to autologous regen-
erative therapies. The AAPD also recognizes that harvested
dental stem cells is an emerging science which may have
application for oral health care but, at present, there are no
treatments available using harvested dental stem cells in
humans. This policy is related to the use of harvested dental
stem cells from a tooth or follicle.
Methods
This policy was developed by the Council on Clinical Affairs,
adopted in 2008 1, and last revised in 2017 2. This revision
included a review of current dental and medical literature and
sources of recognized professional expertise related to dental
stem cells. A literature search of the PubMed /MEDLINE
®
database was conducted using the terms: dental stem cell,
harvested tooth cell; fields: all; limits: within the last 10 years,
humans, English, birth through age 99, resulting in 151 papers
that were reviewed by title and abstract. Papers for review
were chosen from this list and from the references within
selected articles. Expert and/or consensus opinion by experi-
enced researchers and clinicians was also considered.
Background
Stem cells are pluripotential cells that can divide and multiply
for an extended period of time, differentiating into a diverse
range of specialized cell types and tissues. Dental stem cells
are a minor population of mesenchymal stem cells (MSCs)
existing in specialized dental tissues, such as dental pulp,
periodontium, apical papilla, and dental follicle.3,4 Numerous
types of stem cells have been isolated from dental tissue,
such as dental pulp stem cells (DPSC), stem cells isolated
from human pulp of exfoliated deciduous teeth (SHED cells),
periodontal ligament stem cells (PDLSC), stem cells from
apical papilla (SCAP), and dental follicle cell. All these cells
can regenerate the tissue of tooth to provide theoretical
basis for clinical treatments.5,6 DPSC have received special
attention because they represent a readily accessible source
of stem cells. Their high plasticity and multipotential capacity
to differentiate and produce a variety of dental tissues can
be explained by its neural crest origin, which supports
188 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
using harvested dental stem cells. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:188-9.
applications beyond the scope of oral tissues. 7 Stem cells
used for regenerative endodontics and scaffolding have shown
successful regeneration in laboratory and animal studies.8-10
Dental stem cells-based regenerative medicine provides the
possibility to repair damaged dental tissues or generate new
teeth. 4,11 Clinical studies for pulpal regeneration and peri-
odontal tissue generation using dental tissue-derived stem
cells have been published, and evidence that these cells could
be beneficial in therapies beyond oral tissues is growing.12
Due to their differentiation potential, oral-derived MSCs
are promising for tissue engineering and regenerative medi-
cine. 11,13 The most familiar application of adult stem cell
therapy is bone marrow transplantation to treat hematopoietic
cancers, metabolic disorders, and congenital immunodeficiency
syndromes. Dental stem cells with high potentials such as
ability of self-renewal, MSCs characteristics, multilineage
differentiation, and immunomodulation are promising tools
for in vitro and in vivo differentiation studies as well as the
therapy of immune-related diseases.14 Dental MSCs are not
only easily accessible but are also expandable in vitro with
relative genomic stability for a long period of time.15 Several
preclinical studies and clinical trials have been performed using
dental MSCs in the treatment of multiple ailments, ranging
from dental diseases to nondental diseases15; these are a promi-
sing treatment alternative for neurological disease including
stroke.16 Some clinical trials with dental MSCs have demon-
strated the efficacy and safety of dental MSC-based therapy
for oral diseases.15 Human exfoliated deciduous teeth stem cells
have shown promise in an initial small safety-phase clinical
trial for treating a non-dental disease.17
Parents may elect to preserve umbilical cord blood of their
child for future harvesting of stem cells if autologous regen-
erative therapies are indicated. Pulpal tissue of exfoliating
primary teeth, oral mucosa fibroblasts18, surgically removed
third molars, periodontal ligament19, and gingival fibroblasts19
may serve as a source of mesenchymal stem cells.9,20
The public is increasingly aware of this emerging science,
and more parents are expressing interest in harvesting/banking
dental stem cells. While sources of dental stem cells are read-
ily accessible, those cells must be secured and stored properly
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. DPSC: Dental
pulp stem cells. MSCs: Mesenchymal stem cells.

to maintain the potential to proliferate and differentiate.21,22
Ongoing clinical trials using human dental pulp stem cells may
be searched using the web-based resources of the National
Library of Medicine at the National Institutes of Health.23
Policy statement
While no treatment using harvested dental stem cells in
humans is currently available, the AAPD recognizes that
this is an emerging science which may have application for
oral healthcare. As the technology continues to evolve, the
process of procurement of dental stems cells should be
accomplished only with deliberate integrity and appropriate
informed consent to assure the highest ethical standards and
quality of outcomes.
References
1. American Academy of Pediatric Dentistry. Policy on stem
cells. Pediatr Dent 2008;30(suppl):84.
2. American Academy of Pediatric Dentistry. Policy on
using harvested dental stem cells. Pediatr Dent 2017;
39(6):142-3.
3. Govindasamy V, Ronald VS, Abdullah AN, et al. Differen-
tiation of dental pulp stem cells into islet-like aggregates.
J Dent Res 2011;90(5):626-52.
4. Shuai Y, Ma Y, Guo T, et al. Dental stem cells and tooth
regeneration. Adv Med Biol 2018;1107:41-52.
5. Zhai Q, Dong Z, Wang W, Li B, Jin Y. Dental stem cell
and dental tissue regeneration. Front Med 2019;13(2):
152-9.
6. Bansal R, Jain A. Current overview on dental stem cells
applications in regenerative dentistry. J Nat Sci Biol Med
2015;6(1):29-34.
7. Anitua E, Troya M, Zalduendo M. Progress in the use
of dental pulp stem cells in regenerative medicine.
Cytotherapy 2018;20(4):479-98.
8. Conde MC, Chisini LA, Demarco FF, et al. Stem cell-
based pulp tissue engineering: Variables enrolled in
translation from the bench to the bedside, a systematic
review of literature. Int Endod J 2016;49(6):543-50.
9. Hynes K, Menichanin D, Bright R, et al. Induced
pluripotent stem cells: A new frontier for stem cells in
dentistry. J Dent Res 2015;94(11):1508-15.
10. Yang J, Yuan G, Chen Z. Pulp regeneration: Current
approaches and future challenges. Front Physiol 2016;
7:58.
11. Morsczek C, Reicjert TE. Dental stem cells in tooth
regeneration and repair in the future. Expert Opin Biol
Ther 2018;18(2);187-96.
12. Campanella V. Dental stem cells: Current research and
future applications. Eur J Paediatr Dent 2018;19(4):257.
Available at: “https://www.ejpd.eu/pdf/EJPD_2018_19
_4_1.pdf ”. Accessed June 26, 2022.
ORAL HEALTH POLICIES: DENTAL STEM CELLS
13. Tatullo M, Codispoti B, Paduano F, Nuzzolese M,
Makeeva I. Strategic tools in regenerative and translational
dentistry. Int J Mol Sci 2019;20(8):1879. Available at:
“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC65
14784/”. Accessed June 26, 2022.
14. Ayadin S, Sahin F. Stem cells derived from dental tissues.
Adv Exp Med Biol 2019;1144:123-32.
15. Gan L, Liu Y, Cui D, Pan Y, Zheng L, Wan M. Dental
tissue-derived human mesenchymal stem cells and their
potential in therapeutic application. Stem Cells Int
2020;2020:8864572. Available at: “https://pubmed.ncbi.
nlm.nih.gov/32952572/”. Accessed June 26, 2022.
16. Gancheva MR, Kremer KL, Gronthos S, Koblar SA.
Using dental pulp stem cells for stroke therapy. Front
Neurol 2019;10:422.
17. Li W, Jiao X, Song J, et al. Therapeutic potential of stem
cells from human exfoliated deciduous teeth infusion into
patients with type 2 diabetes depends on basal lipid levels
and islet function. Stem Cells Transl Med 2021;10(7):
956-67.
18. Miyoshi K, Tsuji D, Kudoh K, et al. Generation of
human induced pluripotent stem cells from oral mucosa.
J Biosci Bioeng 2010;110(3):345-50.
19. Wada N, Wang B, Lin NH, Laslett AL, et al. Induced
pluripotent stem cell lines derived from human gingival
fibroblasts and periodontal ligament fibroblasts. J
Periodontal Res 2011;46(4):438-47.
20. Eslaminejad MB, Vahabi S, Shariati M, Nazarian H. In
vitro growth and characterization of stem cells from
human dental pulp of deciduous versus permanent teeth.
J Dent (Tehran) 2010;7(4):185-95.
21. Perry BC, Zhou D, Wu X, et al. Collection, cryopreserva-
tion, and characterization of human dental pulp-derived
mesenchymal stem cells for banking and clinical use.
Tissue Eng Part C Methods 2008;14(2):149-56.
22. Yildirim S, Zibandeh N, Genc D, Ozcan EM, Goker K,
Akkoc T. The comparison of the immunologic properties
of stem cells isolated from human exfoliated deciduous
teeth, dental pulp, and dental follicles. Stem Cells Int
2016;2016:4682875. Available at: “https://www.hindawi.
com/journals/sci/2016/4682875/”. Accessed June 26,
2022.
23. National Institutes of Health National Library of
Medicine. Find a Study. Available at: “https://www.
clinicaltrials.gov/ct2/home”. Accessed March 23, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 189
ORAL HEALTH POLICIES: INFECTION CONTROL
Policy on Infection Control
Latest Revision
2020
Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the importance of infection control policies, pro-
cedures, and practices in dental health care settings in order
to prevent disease transmission.
Methods
This policy was developed by the Infectious Disease Control
Subcommittee of the Clinical Affairs Committee and adopted
in 1989.1 This document is a revision of the previous version,
revised in 2019.2 The revision of the policy is based upon a
review of current dental and medical literature related to in-
fection control, expert opinion, and best current practices.
®
Literature searches of PubMed /MEDLINE and Google
Scholar databases were conducted using the terms: dentistry
infection control AND health care and infection control AND
dental; fields: all; limits: within the last 10 years, English,
humans, comparative study, meta-analysis, multicenter study,
systematic reviews, and validation study. The search returned
365 articles that matched the criteria. The articles were eval-
uated by title and/or abstract and relevance to dental care for
children and adolescents. Twenty articles were chosen from
this method and from references within selected articles.
Background
The application of standard precautions regarding infection
control during dental treatment is paramount. The environ-
ment in which dental care is delivered impacts both patient
and provider safety. Knowledge of current best practices in
infection control can help reduce exposure to and contamina-
tion risks from infectious materials. This would include body
substances, contaminated supplies, equipment, environmental
surfaces, water, and air. Some infection control practices rou-
tinely used by health-care professionals cannot be rigorously
evaluated by clinical trials for ethical and logistical reasons.3
Many resources are available to aid dental providers in
creating checklists, standard operating procedures, or other
quality assurance mechanisms for use in daily practice. The
Centers for Disease Control and Prevention (CDC)4,5 and the
Occupational Safety and Health Administration (OSHA)6, as
well as state and local regulatory boards or agencies and equip-
ment manufacturers, provide guidance for patient care,
laboratory procedures, and equipment management. Such
entities can serve as valuable sources for current infection
control recommendations. Until more is known about severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a
190 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on
infection control. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:190-2.
combination of standard precautions, contact precautions, and
droplet precautions may be utilized when performing patient
care.5,6
The possibility of contamination within the internal com-
ponents of dental handpieces has led to the recommendation4,6
that all dental handpieces, including low-speed motors and
removable prophylaxis angles, undergo heat sterilization be-
tween patients. Following instructions for sterilization provided
by the manufacturer of reusable equipment can help ensure
effectiveness of sterilization techniques3 and compliance with
current standards4-6.
Infections associated with microbial transmission from
dental waterlines have been reported.7-12 To help prevent such
infections, it has been recommended that practitioners “follow
manufacturer guidelines to disinfect waterlines, monitor water
quality to ensure recommended bacterial counts, use point-of-
use water filters, and eliminate dead ends in plumbing where
stagnant water can enable biofilm formation.”10 In 2015, an
outbreak of Mycobacterium abscessus odontogenic infections in
children receiving pulpotomy treatment from a pediatric den-
tal clinic was investigated.10 The source of the Mycobacterium
was contaminated water from dental unit waterlines.9-14 In
California, 22 confirmed and over 70 suspected non-
immunocompromised pediatric dental patients had a diagnosis
of Mycobacterium abscessus odontogenic infections following
pulpal therapy.8,9,14
Water from the dental operatory units is subject to the
standard for safe drinking water set by the Environmental
Protection Agency, the American Public Health Association,
and the American Water Works Association.3 A water man-
agement plan that includes routine maintenance procedures
for dental unit waterlines (according to the manufacturer’s
instructions) and monitoring water quality can help keep
bacterial counts low.15 The CDC states “conventional dental
units cannot reliably deliver sterile water even when equipped
with independent water reservoirs containing sterile water
because the water-bearing pathway cannot be reliably sterilized.”16
Sterile water and sterile saline have been recommended for use
as a coolant or irrigant during oral surgical procedures.3,15,17
When a pulp exposure occurs and pulp therapy is indicated,
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CDC: Centers for
Disease Control and Prevention. OSHA: Occupational Safety and
Health Administration. PPE: Personal protective equipment.

irrigants should not come from dental unit water lines. A
single-use disposal syringe should be used to dispense irrigants
for pulpal therapy.
Although no adverse health effects have been reported
with use of saliva ejectors, the CDC cautions dental health
care providers to be aware of the possibility of suctioned
fluids in tubing flowing back into the patient’s mouth.3 This
can happen when:
1. the pressure in patient’s mouth, as a result of closing
their lips and forming a seal around the tip of the
ejector, is lower than the pressure in saliva ejector;
2. the suction tubing attached to the ejector is posi-
tioned above patient’s mouth; or
3. the saliva ejector is used at same time with other
high-volume suctions.
Policy statement
The AAPD:
• acknowledges the Centers for Disease Control and Pre-
vention’s Guidelines for Infection Control in the Dental
Health-Care Setting–20033, Guidelines for Disinfection
and Sterilization in Healthcare Facilities–2008 18 ,
Updated CDC Recommendations for the Management
of Hepatitis B Virus-infected Health Care Providers and
Students–201219, and Statement on Reprocessing Dental
Handpieces–2018 20, as in-depth reviews of infection
control measures for dental settings and supports the
strategies therein.
• encourages dental practitioners to follow current literature
and consider carefully infection control measures in their
practices to minimize the risk of disease transmission.
• encourages providers to heat sterilize all dental hand-
pieces, including low-speed motors and reusable
prophylaxis angles, between patients.3
• encourages providers and their dental teams to be pro-
active in addressing infection control concerns. Staff
may benefit from additional training to better answer
questions from parents regarding the infection control
practices in their treatment facility.
• encourages practitioners to develop a water management
plan that includes routine maintenance procedures for
dental unit waterlines (according to the manufacturer’s
instructions) and monitoring water quality to help keep
waterline bacterial counts low.
• encourages practitioners to use irrigants for operative and
surgical procedures that are consistent with CDC recom-
mendations. Because conventional dental units cannot
reliably deliver sterile water even when equipped with
independent water reservoirs, a single-use disposable
syringe should be used to dispense irrigants for pulpal
therapy and oral surgical procedures.
• encourages clinicians to take necessary precautions to
prevent potential backflow associated with use of saliva
ejectors.
ORAL HEALTH POLICIES: INFECTION CONTROL
References
1. American Academy of Pediatric Dentistry. Guideline on
infection control. Presented at: Annual Meeting of the
American Academy of Pediatric Dentistry; May 1989;
Orlando, Fla.
2. American Academy of Pediatric Dentistry. Policy on
infection control. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2019:162-3.
3. Kohn WG, Collins AS, Cleveland JL, et al. Centers for
Disease Control and Prevention guidelines for infection
control in dental health-care settings–2003. MMWR
Recomm Rep 2003;52(RR-17):1-61.
4. Centers for Disease Control and Prevention. Summary
of infection prevention practices in dental settings: Basic
expectations for safe care. 2020. Available at: “https://
www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.
pdf ”. Accessed October 5, 2020.
5. Centers for Disease Control and Prevention. Guidance for
Dental Settings. Interim Infection Prevention and Control
Guidance for Dental Settings During the Coronavirus
Disease 2019 (COVID-19) Pandemic. Accessed October
5, 2020.
6. U.S. Department of Labor Occupational Safety and
Health Administration. COVID-19–Control and
Prevention/Dentistry Workers and Employers. Available
at: “https://www.osha.gov/SLTC/covid-19/dentistry.html”.
Accessed October 5, 2020.
7. Hu-Friedy Manufacturing Company LLC. Responses to
infection control breaches for dental teams. Dent Assist
2013;82(4):28-9.
8. Mills SE, Porteous N, Zawada J. Dental unit water
quality: Organization for Safety, Asepsis and Prevention
white paper and recommendations–2018. J Dent Infect
Control Safety 2018;1(1):1-27.
9. Hatzenbuehler LA, Tobin-D’Angelo M, Drenzek C, et al.
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
Mycobacterium abscessus infection. J Pediatric Infect Dis
Soc 2017;6(3):e116-e122.
10. Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes
from the Field: Mycobacterium abscessus infections among
patients of a pediatric dentistry practice – Georgia,
2015. MMWR Morb Mortal Wkly 2016;65(13):355-6.
Errata in MMWR Morb Mortal Wkly Rep 2016;65
(13):484. Available at: “https://www.cdc.gov/mmwr/
volumes/65/wr/mm6513a5.htm?s_cid=mm6513a5_w”.
Accessed October 5, 2020.
11. Ricci ML, Fontana S, Pinci F, et al. Pneumonia associated
with a dental unit waterline. Lancet 2012;379(9816):
684.
12. Adler-Shohet FC, Singh J, Nieves D, et al. Safety and
tolerability of clofazimine in a cohort of children with
odontogenic Mycobacterium abscessus infection. J
Pediatric Infect Dis Soc 2019:piz049.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 191
ORAL HEALTH POLICIES: INFECTION CONTROL
13. Moe J, Rajan R, Caltharp S, Abramowicz S. Diagnosis and
management of children with Mycobacterium abscessus
infections in the head and neck. J Oral Maxillofac Surg
2018;76(9):1902-11.
14. Lamb G, Starke J. Mycobacterium abscessus infections in
children: A review of current literature. J Pediatric Infect
Dis Soc 2018;7(3):e131-144.
15. U.S. Food and Drug Administration. Dental unit water-
lines. 2018. Available at: “https://www.fda.gov/medical-
devices/dental-devices/dental-unit-waterlines”. Accessed
October 5, 2020.
16. Centers for Disease Control and Prevention. Dental unit
water quality. 2016. Available at: “https://www.cdc.gov/
oralhealth/infectioncontrol/faqs/dental-unit-water-quality.
html”. Accessed October 5, 2020.
17. American Dental Association. Dental unit waterlines.
2019. Available at: “https://www.ada.org/en/member-
center/oral-health-topics/dental-unit-waterlines”. Accessed
May 13, 2020.
192 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
18. Rutula WA, Weber DJ, Healthcare Infection Control
Practices Advisory Committee. Guideline for disinfection
and sterilization in healthcare facilities—2008. Update:
May 2019. Available at: “https://www.cdc.gov/infection
control/pdf/guidelines/disinfection-guidelines-H.pdf ”.
October 5, 2020.
19. Centers for Disease Control and Prevention. Updated
CDC recommendations for the management of hepatitis
B virus-infected health-care providers and students.
MMWR Recomm Rep 2012;61(RR-3):1-12. Erratum in
MMWR Recomm Rep 2012;61(28):542.
20. Centers for Disease Control and Prevention. CDC State-
ment on Reprocessing Dental Handpieces. April 11, 2018.
Infection Prevention & Control in Dental Settings. Avail-
able at: “https://www.cdc.gov/oralhealth/infectioncontrol/
statement-on-reprocessing-dental-handpieces.htm”. Accessed
October 5, 2020.
Order The Handbook of Pediatric Dentistry at www.aapd.org today!
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".
 CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE

Use of Silver Diamine Fluoride for Dental Caries

Management in Children and Adolescents, Including
Those with Special Health Care Needs
Developed by
American Academy of Pediatric Dentistry
 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
The guideline intends to inform the clinical practices involving
the application of silver diamine fluoride (SDF) to enhance
dental caries management outcomes in children and adolescents,
including those with special health care needs. Silver diamine
fluoride in this guideline’s recommendation refers to 38 percent
SDF, the only formula available in the United States. These rec-
ommended practices are based upon the best available evidence
to-date. However, the ultimate decisions regarding disease man-
agement and specific treatment modalities are to be made by
the dental professional and the patient or his/her representative,
acknowledging individuals’ differences in disease propensity,
lifestyle, and environment.
The guideline provides practitioners with easy to understand
evidence-based recommendations. The American Academy of
Pediatric Dentistry's (AAPD) evidence-based guidelines are being
produced in accordance with standards created by the National
Academy of Medicine (formerly known as the Institute of Med-
icine) and mandated by the National Guideline Clearinghouse™
(NGC), a database of evidence-based clinical practice guidelines
and related documents maintained as a public resource by the
Agency for Healthcare Research and Quality (AHRQ) of the
U.S. Department of Health and Human Services (USDHHS).
Health intents and expected benefits or outcomes. The
guideline is based on analysis of data included in a recent system-
atic review and meta-analysis1 and summarizes evidence of the
benefits and safety of SDF application in the context of dental
caries management, mainly its effectiveness in arresting cavitated
caries lesions 2 † in the primary dentition. Its intent is to provide
the best available information for practitioners and patients
or their representatives to determine the risks, benefits, and
alternatives of SDF application as part of a caries management
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. CCTs: Controlled
clinical trials. EBDC: Evidence-based dentistry committee. EPA: Envi-
ronmental Protection Agency. GRADE: Grading of Recommendations
Assessment, Development and Evaluation. NaF: Sodium fluoride. NGC:
National Guideline Clearinghouse. PICO: Population, intervention,
control, and outcome. RCTs: Randomized control trials. SDF: Silver
diamine fluoride.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 195

CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE

program. Prevention of new caries lesion development and out-
comes in permanent teeth, such as root caries lesion arrest, were
not the focus of this guideline; however, because they are of
interest and relevant to caries management within the scope
of pediatric dentistry, they are mentioned and will be included
in future iterations of the guideline as the supporting evidence
base increases.
Clinical questions addressed. The panel members used the
Population, Intervention, Control, and Outcome (PICO)3 for-
mulation to develop the clinical questions that will aid practi-
tioners in the use of SDF in primary teeth with caries lesions.
Does the application of SDF arrest cavitated caries lesions as
effectively as other treatment modalities in primary teeth?
Methods
This guideline adheres to the National Academy of Medicine's
guideline standards4 and the recommendations of the Appraisal
of Guidelines Research and Evaluation (AGREE) instrument.5
The guidance presented is based on an evaluation of the evidence
presented in a 2016 systematic review published by Gao and
colleagues.1
Search strategy. Literature searches were used to identify sys-
tematic reviews that would serve as the basis of the guideline.
Secondly, the results of the searches served as sources of evidence
or information on issues related to, but outside the context of,
the PICO, such as cost, adverse effects, and patient preferences.
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
randomized controlled trials of SDF. Search results were reviewed
in duplicate at both the title and abstract and the full-text level
when warranted. Disagreements were resolved by consensus;
if agreement could not be reached, the AAPD Evidence-Based
Dentistry Committee (EBDC) overseeing the workgroup was
consulted to settle the question. A detailed description of the
search strategies is presented in Appendix I.
† A caries lesion is a detectable change in the tooth structure that results from
the biofilm-tooth interactions occurring due to the disease caries. It is the
clinical manifestation (sign) of the caries process.
Inclusion and exclusion criteria. The criteria used to iden-
tify publications for use in the guideline were determined by
the clinical PICO question. See Appendix I for search strat-
egies. Publications which addressed the use of SDF to arrest
caries lesions in primary teeth, regardless of language, merited
full-text review; in vitro studies and studies of the use of SDF
outside of the guideline’s stated outcomes were excluded. No
new randomized controlled trials were identified that warranted
updating the meta-analysis found in the systematic review 1
selected as the basis for this guideline.
Assessment of the evidence. The main strength of this
guideline is that it is based on a systematic review of prospective
randomized and controlled trials of SDF1. Evidence was assessed
via the Grading of Recommendations Assessment, Develop-
ment, and Evaluation (GRADE) approach6, a widely adopted
and peer reviewed system of evaluating study quality (Table 1).
The guideline recommendation is based on the meta-analysis of
four controlled trials (three randomized), extracted in duplicate,
from a systematic review of SDF 1. Randomized (RCTs) and
controlled clinical trials (CCTs) offer the highest level of clin-
ical evidence; therefore, a recommendation based on a systematic
review and meta-analysis of graded RCTs/CCTs provides more
reliable and accurate conclusions that can be applied towards
patient care.
This guideline is limited by the small number of RCTs
evaluating SDF, the heterogeneity of the included trials, and
sequence generation 7,8 and selective reporting by one study 7.
Weaknesses of this guideline are inherent to the limitations
found in the systematic review 1 upon which this guideline is
based. Major limitations of the supporting literature include
lack of calibration and/or evidence of agreement for examiners
assessing clinical outcomes and unclear definitions or inconsist-
ent criteria for caries lesion activity.9,10 Arguably, without a valid
and reliable method to determine lesion activity at baseline and
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
detection and activity measurement criteria in the reviewed
literature can decrease the validity of the reported results.9,10

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”.

196 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Other reviewers of the systematic review 1 noted similar and
additional limitations.9,10
Formulation of the recommendations. The panel formul-
ated this guideline collectively via surveys, teleconferences, and
electronic communications from January 2017–August 2017.
The panel used the evidence-to-decision framework in an
iterative manner to formulate the recommendations. Specifically,
the main methods used were discussion, debate, and consensus
seeking.11 To reach consensus, the panel voted anonymously on
all contentious issues and on the final recommendation. GRADE
was used to determine the strength of the evidence.12
Understanding the recommendations. GRADE rates
the strength of a recommendation as either strong or condi-
tional. A strong recommendation “is one for which guideline
panel is confident that the desirable effects of an intervention
outweigh its undesirable effects (strong recommendation for an
intervention) or that the undesirable effects of an intervention
outweigh its desirable effects (strong recommendation against an
intervention).”6 A strong recommendation implies most patients
would benefit from the suggested course of action (i.e., either
for or against the intervention). A conditional recommendation
“is one for which the desirable effects probably outweigh the
undesirable effects (conditional recommendation for an inter-
vention) or undesirable effects probably outweigh the desirable
effects (conditional recommendation against an intervention), but
appreciable uncertainty exists.”6 A conditional recommendation
implies that not all patients would benefit from the intervention.
The individual patient’s circumstances, preferences, and values
need to be assessed more than usual. Practitioners need to allo-
cate more time for consultation along with explanation of the
potential benefits and harms to the patients and their caregivers
when recommendations are rated as conditional. Practitioners’
expertise and judgment as well as patients’ and their caregivers’
needs and preferences establish the suitability of the recommen-
dation to individual patients. The strength of a recommendation
presents different implications for patients, clinicians, and policy
makers (Table 2).
Table 2. IMPLICATIONS OF STRONG AND CONDITIONAL RECOMMENDATIONS FOR DIFFERENT USERS OF GUIDELINES
Strong recommendation
For patients Most individuals in this situation would want the recommended
course of action and only a small proportion would not.
For clinicians Most individuals should receive the recommended course of action.
Adherence to this recommendation according to the guideline
could be used as a quality criterion or performance indicator. Formal
decision aids are not likely to be needed to help individuals make
decisions consistent with their values and preferences.
For policy The recommendation can be adapted as policy in most situations
makers including for the use as performance indicators.
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”.
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE
Recommendations
The SDF panel supports the use of 38 percent SDF for the
arrest of cavitated caries lesions in primary teeth as part of a
comprehensive caries management program. (Conditional
recommendation, low-quality evidence)
Summary of findings
The recommendation is based on data from a meta-analysis of
data extracted from RCTs and CCTs of SDF efficacy with va-
rious follow-up times and controls (Table 3). Based on the
pooled estimates of SDF group, approximately 68 percent (95
percent confidence interval [95% CI]=9.7 to 97.7) of cavitated
caries lesions in primary teeth would be expected to be arrested
two years after SDF application (with once or twice a year
application). Using data with longest follow-up time (at least
30 months follow-up; n=2,567 surfaces from one RCT7 and
one CCT8), SDF had 48 percent higher (95% CI=32 to 66)
success rate in caries lesion arrest compared to the controls (76
percent versus 51 percent arrested lesions, in absolute terms).
In other words, 248 more cavitated caries lesions would be ex-
pected to arrest by treatment with SDF compared to control
treatments, per 1000 surfaces after at least 30 months follow-
up. Considering the stratum with most data (n=3,313 surfaces
from three RCTs and one CCT, with follow-up of 24 months
or more), similar estimates of relative and absolute efficacy
were produced (i.e., RR 1.42 [95% CI=1.17 to 1.72]) and 72
percent versus 50 percent arrested lesions, in absolute terms.
Other follow-up and application frequency strata are listed in the
summary of findings (Table 3). The range of estimates of SDF
efficacy between the included trials was categorically wide.
Rates of arrest on untreated groups may seem unusually high,
and this may be due to background fluoride exposure. In one
of the trials 7, all participants (i.e., both the SDF-treated and
control children) received 0.2 percent sodium fluoride (NaF)
rinse every other week in school, while in other trials, children
were either given fluoride toothpaste13 or reported use of fluoride
toothpaste 8. The panel determined the overall quality of the
Conditional recommendation
The majority of individuals in this situation would want the suggested
course of action, but many would not.
Recognize that different choices will be appropriate for different pa-
tients, and that you must help each patient arrive at a management
decision consistent with her or his values and preferences. Decision
aids may well be useful helping individuals making decisions consistent
with their values and preferences. Clinicians should expect to spend
more time with patients when working towards a decision.
Policymaking will require substantial debates and involvement of
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.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 197
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE

evidence for this comparison was low or very low, owing to
serious issues of risk of bias (unclear method for randomization,
selective reporting, and high heterogeneity) in the included
studies. No studies were identified regarding the arresting effect
of SDF on cavitated caries lesions in adult patients. The panel
suggests that similar treatment effects may be expected for other
age groups, but the lack of evidence informing this recommen-
dation restrained the panel from providing an evidence-based
recommendation.
The panel made a conditional recommendation regarding the
use of SDF for the arrest of cavitated caries lesions in primary
teeth as part of a comprehensive caries management program.
After taking in 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 out-
weigh its possible undesirable effects. Specifically:
1. Untreated decay in young children remains a challenge,
from clinical and public health standpoints, in the U.S.
and worldwide.14 It confers significant health and quality
of life impacts to children and their families, and it is
marked by pronounced disparities.15
2. Surgical-restorative work in young children and those
with special management considerations (e.g., individuals
with special health care needs) often requires advanced
pharmacologic behavior guidance modalities (e.g., sedation,
general anesthesia). These pathways of care have additional
health risks and limitations (e.g., possible effects on brain
development in young children, mortality risks 16), and
often are not accessible, at all or in a timely manner. 17-19
The U.S. Food and Drug Administration has issued a
warning “that repeated or lengthy use of general anesthetic
and sedation drugs during surgeries or procedures in chil-
dren younger than three may affect the development of
children’s brains.”20
3. The cost of managing severe early childhood caries is
disproportionally high, especially when hospitalization is
necessary. The need to treat children in a hospital setting
with general anesthesia is a common scenario in the U.S.
and other countries.21 Studies report that children from the
less-affluent regions have higher dental surgery rates than
those from more-affluent communities (25.7 vs. 6.9 per
1,000)17, which results in an economic burden for commu-
nities already impacted by the effects of poverty-related
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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198 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


4. With caries lesion arrest rates upwards of 70 percent (i.e.,
higher than other comparable interventions), SDF pre-
sents as an advantageous modality. Besides its efficacy,
SDF is favored by its less invasive (clinically and in terms
of behavior guidance requirements) nature and its inex-
pensiveness.
5. The undesirable effects of SDF (mainly esthetic concerns
due to dark discoloration of carious SDF-treated dentin)
are outweighed by its desirable properties in most cases,
while no toxicity or adverse events associated with its use
have been reported.
In sum, the panel felt confident that a conditional recom-
mendation was merited because, although a majority of patients
would benefit from the intervention, individual circumstances,
preferences, and values need to be assessed by the practitioner
after explanation and consultation with the caregiver.
Research considerations. Research is needed on the use
of SDF to arrest caries lesions in both primary and permanent
teeth. The panel urges researchers to conduct well-designed
randomized clinical trials comparing the outcomes of SDF to
other treatments for the arrest of caries lesions in primary and
permanent teeth.
Potential adverse effects. Silver diamine fluoride contains
approximately 24-28 percent (weight/volume) silver and 5-6
percent fluoride (weight/volume).23 Exposure to one drop of SDF
orally would result in less fluoride ion content than is present
in a 0.25 milliliters topical treatment of fluoride varnish. The
exact amount of silver and fluoride present in one drop of
SDF is determined by the specific gravity of the liquid and the
dropper used. More studies are required to determine that
amount, given the stability of the product manufactured and
packaged in the U.S.
In published clinical trials encompassing over 4,000 young
children worldwide, exposure to manufacturer’s recommended
amounts of SDF has not resulted in any reported deaths or
systemic adverse effects.
Oral absorption can include absorption in mucous mem-
branes in the mouth and the nasal cavity. The short-term health
effects in humans as a result of exposure to water or food con-
taining specific levels of silver are unknown. The Environmental
Protection Agency (EPA) suggests levels of silver in drinking
water not to exceed 1.142 milligrams per liter (1.142 parts per
million). Silver diamine fluoride should not be used in patients
with an allergy to silver compounds.24
The main disadvantage of SDF is its esthetic result (i.e.,
permanently blackens enamel and dentinal caries lesions and
creates a temporary henna-appearing tattoo if allowed to come
in contact with skin). Skin pigmentation is temporary since
the silver does not penetrate the dermis. Desquamation of the
skin with pigmentation occurs when keratinocytes are shed
over a period of 14 days.25 Silver diamine fluoride also perma-
nently stains most surfaces (e.g., counters, clothing) with which
it comes into contact.
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE
Guideline implementation. This guideline will be pub-
lished in the AAPD’s Reference Manual and the journal, Pediatric
Dentistry. Social media, news items, and presentations will be
used to notify AAPD members about the new guideline.
This guideline will be available as an open access publication
on the AAPD’s website. Patient education materials are being
developed and will be offered in the AAPD’s online bookstore.
See Appendix II for practical SDF guidance and the Resource
Section of the AAPD Reference Manual for a SDF chairside
guide.26
Cost considerations. Silver diamine fluoride is an effective
and inexpensive means of arresting cavitated caries lesions in
primary teeth. 27 It is inexpensive due to the low cost of ma-
terials and supplies and relatively short chair time required for
application. Nevertheless, an empirical cost analysis discussion
for SDF would need to address the several additional considera-
tions and parameters. First, given the wide array of surgical and
non-surgical management approaches for cavitated caries lesions
in the primary dentition, agreement on consensus endpoints
and, therefore, total cost is challenging and controversial. Second,
cost should include patient/family and practitioner time, health
care services utilized, and cost of non-health impacts, if any.
Third, SDF economic analyses are likely best approached via a
cost-utility framework, wherein expenditures are juxtaposed to
quality-adjusted or disease-free years. To illustrate the import-
ance of defining a consensus treatment endpoint, in this scenario
disease-free years can be interpreted as caries inactive, no surgical
intervention needed, or pain-free years. Finally, the economic
benefits of SDF application must be considered in the context
of pathways of clinical care (i.e., disease management) and
account, among other factors, for the risks and costs associated
with advanced behavior management techniques (e.g., indicated
surgical-restorative work may require sedation or general anes-
thesia in some cases), families’ preferences, and opportunity costs
(e.g., time investment beyond the direct costs).
Recommendation adherence criteria
Guidelines are used by insurers, patients, and health care practi-
tioners to determine quality of care. In principle, following best
practices and guidelines is believed to improve outcomes and
reduce inappropriate care.28 Therefore, measuring adherence to
oral health-related guidelines is key and can serve as manifesta-
tion of the dental community’s role as a “responsible steward of
oral health.”29 Though measurement of oral health outcomes is
in its early days at both system and practice levels, system-level
performance measures for some oral health areas have been de-
veloped by the Dental Quality Alliance of the American Dental
Association in partnership with the AAPD and other dental
organizations. The goals of professional accountability, trans-
parency, and oral health care quality can be furthered through
these measures.
Workgroup. In December 2016, the AAPD’s Board of
Trustees approved a panel nominated by the EBDC to develop
a new evidence-based clinical practice guideline on SDF. The
panel consisted of general and pediatric dentists in public and
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 199
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE
private practice involved in research and education; the stake-
holders consisted of representatives from general dentistry, dental
hygiene, governmental and non-governmental agencies, and
international and specialty dental organizations.
Stakeholders and external review. This guideline was re-
viewed by external and internal stakeholders continuously from
the beginning of the process until the formulation of the guide-
line. Stakeholders were invited to take part in anonymous surveys
to determine the scope and outcomes of the guideline, bringing
in points of view from different geographical regions, dental
specialties, and patient advocates. Comments also were sought
on the draft of the guideline. All stakeholder comments were
taken into consideration, addressed, and acted upon as appro-
priate per group deliberation. Additional feedback from
stakeholders is expected after publication and dissemination of
the guideline.
Appendices
Appendix I—Search strategies
®
PubMed (MEDLINE)– no date limit
Search #1. 145 results
cariestop OR "silver diamine fluoride"[Supplementary Concept]
OR "silver diamine" OR "silver diammine" OR “diamine fluor-
ide” OR “diammine fluoride” OR saforide OR “Riva star”
Search #2. 6589771 results
(randomized controlled trial[pt] OR controlled clinical trial
[pt] OR randomi*[tiab] OR randomization[tiab] OR random-
isation[tiab] OR placebo[tiab] OR drug therapy[sh] OR
randomly[tiab] OR trial[tiab] OR groups[tiab] OR Clinical
trial[pt] OR "clinical trial"[tw] OR "clinical trials"[tw] OR
"evaluation studies"[Publication Type] OR "evaluation studies
as topic"[MeSH Terms] OR "evaluation study"[tw] OR evalu-
ation studies[tw] OR "intervention studies"[MeSH Terms] OR
"intervention study"[tw] OR "intervention studies"[tw] OR
"cohort studies"[MeSH Terms] OR cohort[tw] OR "longitu-
dinal studies"[MeSH Terms] OR "longitudinal"[tw] OR
longitudinally[tw] OR "prospective"[tw] OR prospectively[tw]
OR "follow up"[tw] OR "comparative study"[Publication
Type] OR "comparative study"[tw] OR systematic[subset] OR
"meta-analysis"[Publication Type] OR "meta-analysis as topic"
[MeSH Terms] OR "meta-analysis"[tw] OR "meta-analyses"
[tw]) NOT (animals [mh] NOT humans [mh])
Search #3. 14 results
#1 and #2
200 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Intended users. The target audience for this guideline is
general dentists, pediatric dentists, pediatricians, and family
practice physicians. Public and private payors will benefit from
reviewing the evidence for coverage decisions regarding SDF
use, and patients and patient advocates may find it useful as a
reference for current available treatments for caries management.
The target populations include children and adolescents, in-
cluding those with special health care needs.
Guideline updating process. The AAPD’s EBDC will
monitor the biomedical literature to identify new evidence that
may impact the current recommendations. These recommen-
dations will be updated five years from the time the last
systematic search, unless the EBDC determines that an earlier
revision or update is warranted.
References appear after Appendices.
Search #4. 410530 results
(systematic[sb] OR meta-analysis[pt] OR meta-analysis as
topic[mh] OR meta-analysis[mh] OR meta analy*[tw] OR
metanaly*[tw] OR metaanaly*[tw] OR met analy*[tw] OR research
overview*[tiab] OR collaborative review*[tiab] OR col-
laborative overview*[tiab] OR systematic review*[tiab] OR
comparative efficacy[tiab] OR comparative effectiveness[tiab]
OR outcomes research[tiab] OR systematic overview*[tiab] OR
methodological overview*[tiab] OR methodologic overview*
[tiab] OR methodological review*[tiab] OR methodologic
review*[tiab] OR quantitative review*[tiab] OR quantitative
overview*[tiab] OR quantitative synthes*[tiab] OR pooled
analy*[tiab] OR Cochrane[tiab] OR Medline[tiab] OR Pubmed
[tiab] OR Medlars[tiab] OR handsearch*[tiab] OR hand search*
[tiab] OR meta-regression*[tiab] OR metaregression*[tiab]
OR data synthes*[tiab] OR data extraction[tiab] OR data
abstraction*[tiab] OR mantel haenszel[tiab] OR peto[tiab] OR
dersimonian[tiab] OR dersimonian[tiab] OR fixed effect*
[tiab] OR "Cochrane Database Syst Rev"[Journal])
Search #5. 14 results
#1 and #4*
Search #6. 890576 results
("Economics"[Mesh] OR "Cost of Illness"[Mesh] OR "Cost
Savings"[Mesh] OR "Cost Control"[Mesh] OR "Cost-Benefit
Analysis"[Mesh] OR "Health Care Costs"[Mesh] OR "Direct
Service Costs"[Mesh] OR "economics"[Subheading] OR cost))
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 *
* Silver diamine fluoride in this guideline’s recommendation
refers to 38 percent SDF, the only formula available in
the United States.
Setting
Practitioners must first consider the current standard of care of
the setting where SDF therapy is intended for use. Silver dia-
mine fluoride is optimally utilized in the context of a chronic
disease management protocol, one that allows for the moni-
toring of the clinical effectiveness of SDF treatment, disease
control, and risk assessment.
Practical recommendation: Know the setting where SDF is
to be used to be consistent with goals of patient-centered care.
Indications and usage
The following scenarios may be well-suited for the use SDF:
• High caries-risk patients with anterior or posterior active
cavitated lesions.
• Cavitated caries lesions in individuals presenting with be-
havioral or medical management challenges.
• Patients with multiple cavitated caries lesions that may not
all be treated in one visit.
• Difficult to treat cavitated dental caries lesions.
• Patients without access to or with difficulty accessing dental
care.
• Active cavitated caries lesions with no clinical signs of pulp
involvement.
Practical recommendation: SDF is a valuable caries lesion–
arresting tool that can be used in the context of caries man-
agement. Evaluate carefully which patients/teeth will benefit
from SDF application.
Preparation of patients and practitioners
Informed consent, particularly highlighting expected staining
of treated lesions, potential staining of skin and clothes, and need
for reapplication for disease control, is recommended.
The following practices are presented to support patient safety
and effectively use SDF:
• Universal precautions.
• No operative intervention (e.g., affected or infected dentin
removal) is necessary to achieve caries arrest.8
• Protect patient with plastic-lined bib and glasses.
• Cotton roll or other isolation as appropriate.
• Use a plastic dappen dish as SDF corrodes glass and metal.
• Carefully dispose of gloves, cotton rolls, and micro brush
into plastic waste bag.
Application
Carious dentin excavation prior to SDF application is not neces-
sary.8 Caries dentin excavation may reduce proportion of arrested
caries lesions that become black, and may be considered for
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE
esthetic purposes.30 Functional indicator of effectiveness (i.e.,
caries arrest) is when staining on dentinal carious surfaces is
visible.
The following steps may vary depending on differing prac-
tices, settings, and patients:
• Remove gross debris from cavitation to allow better SDF
contact with denatured dentin.
• Minimize contact with gingiva and mucous membranes to
avoid potential pigmentation or irritation; consider apply-
ing cocoa butter or use cotton rolls to protect surrounding
gingival tissues, with care to not inadvertently coat the
surfaces of the carious lesion.
• Dry with a gentle flow of compressed air (or use cotton
rolls/gauze to dry) affected tooth surfaces.
• Bend micro sponge brush, dip and dab on the side of the
dappen dish to remove excess liquid before application;24
apply SDF directly to only the affected tooth surface.
• Dry with a gentle flow of compressed air for at least one
minute.
• Remove excess SDF with gauze, cotton roll, or cotton pellet
to minimize systemic absorption.4 Continue to isolate site
for up to three minutes when possible.
Practical recommendation: No need for surgical intervention
(e.g., dentin excavation). SDF application is minimally invasive
and easy for the patient and the practitioner. It may be desirable
for the caries lesion to be free of gross debris for SDF to have
maximum contact with the affected dentin surface.
Application time
An application time of one minute, drying with a gentle flow
of compressed air, is recommended. Clinical studies that report
application times range from 10 seconds to three minutes. A
current review states that application time in clinical studies
does not correlate to outcome. 24 More studies are needed to
confirm an ideal protocol.
Practical recommendation: Ideal time of application should
be one minute, using a gentle flow of compressed air until
liquid is dry. When using shorter application periods, monitor
carefully at post-op and re-care to evaluate arrest and consider
re-application.
Post-operative instructions
No postoperative limitations are listed by the manufacturer.
Eating and drinking immediately following application is
acceptable. Patients may brush with fluoridated toothpaste as
per regular routine following SDF application.
Several SDF clinical trials recommended no eating or drink-
ing for 30 minutes – one hour. 13,31,32 As patients are used to
these recommendations for in-office topical fluoride applications,
the recommendation may not be unreasonable to patients, and
it may allow for better arrest results. More clinical studies are
needed to establish best practices.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 201
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE
Application frequency
The effectiveness of one-time SDF application in arresting dental
caries lesions ranges from 47 percent to 90 percent, depending
on the lesion size and the location of the tooth and the lesion.
One study showed that anterior teeth had higher rates of
caries lesion arrest than posterior teeth.33 The effectiveness of
caries lesion arrest, however, decreases over time. After a single
application of 38 percent SDF, 50 percent of the arrested sur-
faces at six months had reverted to active lesions at 24 months.13
Reapplication may be necessary to sustain arrest.8,31-33 Annual
application of SDF is more effective in arresting caries lesions
than application of five percent sodium fluoride varnish four
times per year.30 Increasing frequency of application can increase
caries arrest rate. Biannual application of SDF increased the rate
of caries lesion arrest compared to annual application.33 Studies
that had three times per year applications showed higher arrest
rates.7,31,33,34 Frequency of application after baseline has been
suggested at three month follow up, and then semiannual recall
visits over two years. 24 One option is to place SDF on active
lesions in conjunction with fluoride varnish (FV) on the rest of
the dentition, or alternate SDF on caries lesions and FV on the
rest of the dentition at three months interval to achieve arrest
and prevention in high risk individuals.35 Another study recom-
mends one month post operative evaluation of treated lesions
with optional reapplication as required to achieve arrest of all
targeted lesions.35 Individuals with high plaque index and lesions
with plaque present display lower rates of arrest. Addressing
other risk factors like presence of plaque may increase the rate of
successful treatment outcomes.33
Practical recommendation: If the setting allows, monitor caries
lesion arrest after 2-4 week period and consider reapplication
as necessary to achieve arrest of all targeted lesions. Provide
re-care monitoring based on patient’s disease activity and
caries risk level (every three, four, or six months). Careful
monitoring and behavioral intervention to reduce individual
risk factors should be part of a comprehensive caries manage-
ment program that aims not only to sustain arrest of existing
caries lesions, but also to prevent new caries lesion development.
202 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Adverse reactions
No severe pulpal damage or reaction to SDF has been re-
ported.7,36-38 However, SDF should not be placed on exposed
pulps. Teeth with deep caries lesions should be closely monitored
clinically and radiographically.
Serum concentration of fluoride following SDF application
per manufacturer recommendations posed little toxicity risk
and was below EPA oral reference dose in adults.39
The following adverse effects have been noted in the literature:
• Metallic/bitter taste.24
• Temporary staining to skin which resolves in 2-14 days.24
• Mucosal irritation/lesions resulting from inadvertent con-
tact with SDF, resolved within 48 hours.7
Esthetics
The hallmark of SDF is a visible dark staining that is a sign of
caries arrest on treated dentin lesions. This dark discoloration
is permanent unless restored. A recent study that assessed pa-
rental perceptions and acceptance of SDF based on the staining
found that staining on posterior teeth was more acceptable than
on anterior teeth. 40 Although staining on anterior teeth was
perceived as undesirable, most parents preferred this option to
avoid the use of advanced behavioral guidance techniques such
as sedation or general anesthesia to deliver traditional restorative
care. It was also found that about one-third of parents found
SDF treatment unacceptable under any circumstance due to
esthetic concerns. To identify those patients, a thorough in-
formed consent, preferably with photographs that show typical
staining, is imperative.40 To improve esthetics, once the disease
is controlled and patient’s circumstances allow, treated and
now-arrested cavitated caries lesions can be restored.35
Other considerations
• Coding – D1354; Reimbursement for this procedure varies
among states and carriers. Third-party payors’ coverage is
not consistent on the use of this code per tooth or per visit.
Practitioners are cautioned to check insurance coverage for
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

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18. Griffin SO, Gooch BF, Beltrán E, Sutherland JN, Barsley R.
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19. Nagarkar SR, Kumar JV, Moss ME. Early childhood caries–
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20. U.S. Food and Drug Administration. FDA Drug Safety
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21. Hicks CG, Jones JE, Saxen MA, et al. Demand in pediat-
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22. Liu J, Probst JC, Martin AB, Wang J-Y, Salinas CF. Dispari-
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23. Mei ML, Chu CH, Lo ECM, Samaranayake LP. Fluoride
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24. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol
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26. American Academy of Pediatric Dentistry. Chairside guide:
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31. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial on
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trial on arresting dentine caries in preschool children by
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35. Crystal YO, Niederman R. Silver diamine fluoride treat-
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of topically applied ammoniacal silver fluoride on dental
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37. Okuyama T. [On the penetration of diammine silver
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38. Gotjamanos T. Pulp response in primary teeth with deep
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39. Vasquez E, Zegarra G, Chirinos E, et al. Short term serum
pharmacokinetics of diammine silver fluoride after oral
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41. Quock RL, Barros JA, Yang SW, Patel SA. Effect of silver
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42. Selvaraj K, Sampath V, Sujatha V, Mahalaxmi S. Evaluation
of microshear bond strength and nanoleakage of etch-and-
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Indian J Dent Res 2016;27(4):421-5.
 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
prevent and control carious lesions on primary and permanent
teeth. Sealants are still underused despite their documented effi-
cacy and the availability of clinical practice guidelines. 1,2 New
sealant materials and techniques continue to emerge for man-
aging pit-and-fissure caries, further complicating the clinician’s
decision making. Accordingly, continuous critical review of the
available evidence is necessary to update evidence-based recom-
mendations and assist health care providers in clinical decision
making.1,7
The American Dental Association (ADA) Council on
Scientific Affairs convened an expert panel to develop the pre-
vious evidence-based clinical recommendations for the use of
sealants, published in 2008. 3 In an effort to update the 2008
recommendations, the ADA Council on Scientific Affairs and
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,
stakeholders, and methodologists to develop a systematic review8
and accompanying evidence-based clinical practice recommenda-
tions for publication in 2016.
Our goal for this 2016 clinical practice guideline was to
provide clinicians with updated evidence-based recommendations
regarding when and how the placement of pit-and-fissure
sealants is most likely to be effective in preventing carious lesions
on the occlusal surfaces of primary and permanent teeth in
children and adolescents. The target audience for this guideline
includes general and pediatric dental practitioners and their
support teams, public health dentists, dental hygienists, pediatri-
cians, primary-care physicians, and community dental health
coordinators; policy makers may also benefit from this guideline
to inform clinical decision making, programmatic decisions,
and public health policy.
Definition of dental caries
Dental caries is a disease caused by an ecological shift in the
composition and activity of the bacterial biofilm when exposed
over time to fermentable carbohydrates, leading to a break in
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. ADA: American Den-
tal Association. BPA: Bisphenol A. CIs: Confidence intervals. GI: Glass
ionomer. GRADE: Grading of Recommendations Assessment, Devel-
opment and Evaluation. NHANES: National Health and Nutrition
Examination Survey. OR: Odds ratio.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 205

CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
the balance between demineralization and remineralization. 4
Carious lesions are preventable by averting onset, and manage-
able by implementing interventions, which may halt progression
from early stage of the disease to cavitation, characterized by
enamel demineralization, to frank cavitation.3 In 2015, the ADA
published the Caries Classification System, which defines a non-
cavitated or initial lesion as “initial caries lesion development,
before cavitation occurs. 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.”4
Epidemiology
National Health and Nutrition Examination Survey (NHANES)
2011-20125 data show that 21% of children aged 6 to 11 years
and 58% of adolescents aged 12 to 19 years had experienced
carious lesions (untreated and treated [restored]) in their perma-
nent teeth.
The NHANES report also found the prevalence of carious
lesions in permanent teeth increased with age and differed among
sociodemographic groups. Children in the 9- to 11-year range
had higher carious lesion prevalence (29%) compared with chil-
dren in the 6- to 8-year range (14%). Similarly, children in the
16- to 19-year age range had higher carious lesion prevalence
(67%) compared with children in the 12- to 15-year range
(50%). In addition, dental caries incidence for both 6- to 11-
year and 12- to 19-year age groups was highest among Hispanic
children compared with non-Hispanic black children, non-
Hispanic white children, and Asian children. The surgeon
general’s report on oral health similarly indicated that Hispanic
and non-Hispanic black children are at the highest risk of
developing dental caries. 6 Overall, NHANES 2011-2012
indicates a higher prevalence of untreated carious lesions in
the 12- to 19-year age group (15%) compared with the 6- to
11-year age group (6%).5
Although there has been a decline in prevalence of caries
in adolescents and children in particular, the decrease in occlusal
surface caries has not kept pace with the decrease in the smooth
surface caries.7 Although this overall decline has been attributed
to preventive interventions such as water fluoridation, fluoride
tooth-paste, fluoride varnishes, and sealants, topical fluoride
applications—such as fluoride varnishes—may have a greater
effect reducing carious lesions on smooth surfaces compared
with caries in pits and fissures.1-7,9,10
NHANES 2011-2012 data show that 41% of children aged
9 to 11 years and 43% of adolescents aged 12 to 19 years had at
least 1 dental sealant. Non-Hispanic black children had the
lowest dental sealant prevalence in both age groups compared
with Hispanic, non-Hispanic white, and Asian children.5 There-
fore, underutilization of sealants is of key concern.
Potential role of pit-and-fissure sealants in primary and
secondary prevention
From a primary prevention perspective, anatomic grooves or pits
and fissures on occlusal surfaces of permanent molars trap food
206 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
debris and promote the presence of bacterial biofilm, thereby
increasing the risk of developing carious lesions. Effectively
penetrating and sealing these surfaces with a dental material—
for example, pit-and-fissure sealants—can prevent lesions and
is part of a comprehensive caries management approach.11
From a secondary prevention perspective, there is evidence
that sealants also can inhibit the progression of noncavitated
carious lesions. 9 The use of sealants to arrest or inhibit the
progression of carious lesions is important to the clinician
when determining the appropriate intervention for noncavitated
carious lesions.
Sealant materials and placement techniques
For the purposes of this report, there are 4 sealant materials
under a classification proposed by Anusavice and colleagues11:
resin-based sealants, glass ionomer (GI) cements, GI sealants,
polyacid-modified resin sealants, and resin-modified GI sealants.
They defined the materials as follows.11
• Resin-based sealants are urethane dimethacrylate, “UDMA,”
or bisphenol A-glycidyl methacrylate (also known as
“bis-GMA”) monomers polymerized by either a chemical
activator and initiator or light of a specific wavelength and
intensity. Resin-based sealants come as unfilled, colorless,
or tinted transparent materials or as filled, opaque, tooth-
colored, or white materials.
• GI sealants are cements that were developed and are used
for their fluoride-release properties, stemming from the acid-
base reaction between a fluoroaluminosilicate glass powder
and an aqueous-based polyacrylic acid solution.
• Polyacid-modified resin sealants, also referred to as compo-
mers, combine resin-based material found in traditional
resin-based sealants with the fluoride-releasing and adhesive
properties of GI sealants.
• Resin-modified GI sealants are essentially GI sealants with
resin components. This type of sealant has similar fluoride-
release properties as GI, but it has a longer working time
and less water sensitivity than do traditional GI sealants.
Placement techniques for pit-and-fissure sealants vary based
on sealant type and the manufacturer or brand.3 Manufacturers’
instructions usually detail cleaning and isolation of the occlusal
surface and encourage a dry environment during sealant place-
ment and curing. Acid etching of occlusal surfaces is required
before resin-based sealant placement. Other techniques men-
tioned in the studies included in the 2008 report are the use of
bonding agents or adhesives, as well as mechanical preparations
such as air abrasion or enameloplasty.3
Clinical questions regarding pit-and-fissures sealants
To assist clinicians in the use of pit-and-fissure sealants in
occlusal surfaces of primary and permanent molars, the guide-
line panel developed the following clinical questions:
• Should dental sealants, when compared with nonuse of
sealants, be used in pits and fissures of occlusal surfaces of
primary and permanent molars on teeth deemed to have clin-
ically sound occlusal surfaces or noncavitated carious lesions?

• Should dental sealants, when compared with fluoride var-
nishes, be used in pits and fissures of occlusal surfaces of pri-
mary and permanent molars on teeth deemed to have clin-
ically sound occlusal surfaces or noncavitated carious lesions?
• Which type of sealant material should be used in pits and
fissures of occlusal surfaces of primary and permanent mo-
lars on teeth deemed to have clinically sound occlusal sur-
faces or noncavitated carious lesions?
• Are there any adverse events associated with the use of pit-
and-fissure sealants?
Methods
This clinical practice guideline follows the recommendations of
the Appraisal of Guidelines Research & Evaluation (known as
“AGREE”) reporting checklist.10
Guideline panel configuration. The ADA Council on
Scientific Affairs and the AAPD convened a guideline panel in
2014. The members of this panel were recognized for their
level of clinical and research expertise and represented the differ-
ent perspectives required for clinical decision making (general
dentists, pediatric dentists, dental hygienists, and health policy
makers). Methodologists from the ADA Center for Evidence-
Based Dentistry oversaw the guideline development process.
Scope and purpose. The purpose of these recommendations
is to provide guidance on sealant use for the prevention of pit-
and-fissure occlusal carious lesions in both primary and per-
manent molars. The target audience for this guideline are
front-line clinicians in general practice, pediatric dentists, dental
hygienists, dental therapists, community dental health coordina-
tors, dental health policy makers and program planners, and
other members of the dental team. Although the evidence came
from various settings, we excluded those sealant materials not
commercially available at the time of this review.
Retrieving the evidence. Our systematic review methodol-
ogy for developing this guideline is presented elsewhere. 8
Briefly, we conducted systematic searches 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. After pairs of independent reviewers conducted title
and abstract retrieval, full-text screening, and data extraction,
we organized the data retrieved using Grading of Recommenda-
tions Assessment, Development, and Evaluation (GRADE) evi-
dence profiles. In addition, we requested the guideline panel to
rank the relative importance of outcomes for decision making
in 3 categories (critical, important, and not important) following
guidance from the GRADE working group.12
Assessing the certainty in the evidence. We assessed the
certainty in the evidence (also known as the quality of the evi-
dence) using the approach described by the GRADE working
group.13 The certainty in the evidence in the context of clinical
practice guidelines reflects the extent to which the guideline
panel felt confident about the estimates of effect used for the
decision-making process. The GRADE approach classifies the
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
certainty in the evidence as high, moderate, low, or very low
(Table 113-15), depending on whether the body of evidence
at an outcome level includes serious or very serious issues as
follows:
• Risk of bias: When the studies that are part of the body of
evidence are affected by serious or very serious limitations in
study design, the confidence in the estimates of effect is re-
duced owing to the increased risk of bias.16
• Imprecision: When the confidence intervals (CIs) of the data
used for the treatment effects are too wide to make decisions,
the confidence in the estimates of effect is reduced owing to
issues of imprecision. Typically, imprecision occurs when the
CIs suggest both a large benefit on one side and a large harm
on the other side.17
• Inconsistency: When the studies comprising the body of evi-
dence provide inconsistent results, the confidence in the
estimates of effect is reduced owing to the unexplained hetero-
geneity among them.18
• Indirectness: When the population, interventions, comparator,
or outcomes reported in the studies comprising the body of
evidence do not directly match the ones the panel requires to
make an informed decision, the confidence in the estimates
of effect is reduced owing to this mismatching issue.19
• Publication bias: When there is suspicion that not all studies
conducted to inform a particular treatment effect are avail-
able or they were selectively published or unpublished, the
confidence in the estimates of effect is reduced owing to the
suspicion of reporting bias.20
Moving from the evidence to the decisions. To assist the
guideline panel with formulating recommendations and grading
the strength of the recommendations, we used the evidence-to-
decision framework, including the following domains: balance
between the desirable and undesirable consequences (net effect),
certainty in the evidence (also called quality of the evidence),
patients’ values and preferences, and resource use.14,15 According
to the GRADE approach, the strength of a recommendation is
either strong or conditional, in which each grade of the strength
has different implications for patients, clinicians, and policy
makers (Table 1).
The guideline recommendations in this article were formu-
lated collectively via 3 videoconferences with members of the
guideline panel and methodologists from the ADA Center for
Evidence-Based Dentistry and the AAPD held in January 2016.
Deliberation and consensus were the main methods to develop
these recommendations using the “evidence-to-decision” frame-
work.14,15 When consensus was elusive, the panel was presented
with the positions under assessment, and it voted accordingly.21
We identified potential conflicts of interest and managed them
according to the recommendations from the World Health
Organization and other guideline development agencies.22
Guideline updating process. The ADA Center for Evidence-
Based Dentistry and the AAPD monitor the literature to iden-
tify new studies that may be included in the recommendations.
These recommendations will be updated 5 years from the date
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 207
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

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

208 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

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-
duced the incidence of carious lesions in this population by 75%
(OR, 0.25; 95% CI, 0.19-0.34) after 2 to 3 years of follow-up.
The guideline panel determined the overall quality of the evi-
dence for this comparison as moderate owing to serious issues of
risk of bias (unclear method for randomization and allocation
concealment) in the included studies. No data on the effect of
sealants in adult patients were identified.
Recommendation. The sealant guideline panel recommends
the use of sealants compared with nonuse in primary and perma-
nent molars with both sound occlusal surfaces and noncavitated
occlusal carious lesions in children and adolescents. (Strong rec-
ommendation, moderate-quality evidence.)
Remarks.
• No studies were identified regarding the effect of sealants
on preventing and arresting occlusal carious lesions in adult
patients. For clinicians and patients attempting to extend
this recommendation to adults, the guideline panel suggests
that similar treatment effects may be expected for other age
groups, particularly in adults with a recent history of dental
caries. The lack of direct evidence informing this recommen-
dation restrained the guideline panel from formulating a
more definitive recommendation in this regard.
• This recommendation is intended to inform clinicians about
the benefit of sealing a tooth compared with not sealing it,
irrespective of the type of sealant material applied.
• The panel highlighted that a number of studies have shown
that sealing children’s and adolescents’ permanent molars
reduces costs to the health system by delaying and preventing
the need for invasive restorative treatment, particularly when
these patients are classified as having an “elevated caries risk”
(that is, previous caries experience).32 Under these conditions,
dental sealants seem to be a cost-effective intervention.33-36
• In addition to the evidence collected by the panel from ran-
domized controlled trials suggesting a beneficial effect of
sealants in noncavitated occlusal carious lesions, the body of
evidence from observational studies shows similar results.37,38
Research priorities.
• Although the analysis was stratified using 2 caries baseline
risks (30% caries prevalence in the article and 70% caries
prevalence in the tables), the guideline panel acknowledged
that clinicians lack a valid and reliable tool to conduct a
chair-side caries risk assessment, especially when it comes to
assessing a specific tooth surface or site. There is a need for
such a tool to enable clinicians to perform a more accurate

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 209

CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
assessment of the patient’s caries risk and to enable the panel
to provide more specific recommendations using an accurate
patient caries risk estimation.
• The panel highlighted the need for additional studies assess-
ing the effect of sealants in the primary dentition.
Question 2. Should dental sealants, when compared with
fluoride varnishes, be used in pits and fissures of occlusal
surfaces of primary and permanent molars on teeth deemed
to have clinically sound occlusal surfaces or noncavitated
carious lesions?
Summary of findings. Data from 3 randomized controlled
trials25,27,39 suggest that in children and adolescents with sound
occlusal surfaces, the use of pit-and-fissure sealants compared
with fluoride varnishes may reduce the incidence of occlusal
carious lesions in permanent molars by 73% after 2 to 3 years
of follow-up (OR, 0.27; 95% CI, 0.11-0.69) (sTable 2, available
in the supplemental data following references). In absolute terms,
for a population with a caries baseline risk (prevalence) of 30%,
196 carious lesions would be prevented out of 1,000 sealant
applications (95% CI, 72-255 fewer lesions) when using sealants
compared with using fluoride varnish after 2 to 3 years of follow-up.
When assessing the effect of sealants compared with fluoride
varnishes in a mixed population of patients with sound occlusal
surfaces and noncavitated occlusal carious lesions, sealants may
reduce the incidence of caries by 34%; however, this difference
was not statistically significant (OR, 0.66; P=.30; 95% CI, 0.30-
1.44). The guideline panel determined the overall quality of the
evidence for this comparison as low owing to serious issues of
risk of bias (unclear method for randomization and allocation
concealment) and inconsistency. No data on the effect of sealants
versus fluoride varnish in adult patients were identified.
Recommendation. The sealant guideline panel suggests the
use of sealants compared with fluoride varnishes in primary
and permanent molars, with both sound occlusal surfaces and
noncavitated occlusal carious lesions, in children and adoles-
cents. (Conditional recommendation, low-quality evidence.)
Research priorities.
• Although the analysis was stratified using 2 caries baseline
risks (30% caries prevalence in the article and 70% caries
prevalence in the tables), the guideline panel acknowledged
that clinicians lack a valid and reliable tool to conduct a
chairside caries risk assessment. There is a need for such a
tool to enable clinicians to understand the evidence in the
context of different caries risk estimations.
• The guideline panel suggests that more research should be
conducted on other noninvasive approaches for caries arrest
in occlusal surfaces of primary and permanent molars (for
example, silver diamine fluoride).
Question 3. Which type of sealant material should be
used in pits and fissures of occlusal surfaces of primary and
permanent molars on teeth deemed to have clinically sound
occlusal surfaces or noncavitated carious lesions in children
and adolescents?
210 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Comparison 3.1. GI sealants compared with resin-based
sealants.
Summary of findings. Data from 10 randomized controlled
trials40-49 included in the meta-analysis suggest that in children
and adolescents with sound occlusal surfaces, the use of GI seal-
ants compared with resin-based sealants may reduce the inci-
dence of occlusal carious lesions in permanent molars by 37%
after 2 to 3 years of follow-up (OR, 0.71; 95% CI, 0.32-1.57);
however, this difference was not statistically significant (P=.39)
(sTable 3, available in the supplemental data following refer-
ences). In absolute terms, for a population with a caries baseline
risk (prevalence) of 30%, this means that use of a GI sealant
would prevent 67 carious lesions out of 1,000 sealant applications
(95% CI, 102 more -179 fewer lesions) compared with using a
resin-based sealant after 2 to 3 years of follow-up; however, this
difference was not statistically significant. One additional study
with 200 participants that we were unable to include in the meta-
analysis owing to the data presentation failed to show a clinically
or statistically significant difference in caries incidence when GI
sealants and resin-based sealants were placed on the occlusal
surfaces of primary and permanent molars.50 When looking at
available data assessing the effect of GI sealants compared with
resin-based sealants in a population of patients with noncavitated
occlusal carious lesions, the data suggest that GI sealants may
increase the incidence of carious lesions by 53% (OR, 1.53; 95%
CI, 0.58-4.07); however, this difference was not statistically signi-
ficant (P=.39). When assessing retention, glass ionomer sealants
may have 5 times greater risk of experiencing loss of retention
from the tooth compared with resin-based sealants after 2 to 3
years of follow-up (OR, 5.06; 95% CI, 1.81-14.13). The guide-
line panel determined the overall quality of the evidence for this
comparison as very low owing to serious issues of risk of bias
(unclear method for randomization and allocation concealment),
inconsistency, and imprecision. No data on the effect of GI
versus resin-based sealants in adult patients were identified.
Comparison 3.2. Glass ionomer sealants compared with resin-
modified GI sealants
Summary of findings. Data from 1 randomized controlled trial29
suggest that in children and adolescents with sound occlusal
surfaces the use of GI sealants compared with resin-modified GI
sealants may increase the incidence of occlusal carious lesions
in permanent molars by 41% after 2 to 3 years of follow-up
(OR, 1.41; 95% CI, 0.65-3.07); however, this difference was
not statistically significant (P=.38) (sTable 4, available in the
supplemental data following references). In absolute terms, for a
population with a caries baseline risk (prevalence) of 30%, we
are expecting to have 77 more carious lesions over 1,000 sealant
applications (95% CI, 82 fewer-268 more lesions) when using
GI sealants compared with using a resin-modified glass ionomer
sealant after 2 to 3 years of follow-up; however, this difference
was not statistically significant. When assessing retention, GI seal-
ants would have 3 times greater risk of experiencing retention
loss from the tooth compared with resin-modified glass ionomer
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
issues of risk of bias (unclear method for randomization and
allocation concealment), and very serious issues of imprecision.
No data on the effect of GI versus resin-modified GI sealants in
adult patients were identified.
Comparison 3.3. Resin-modified glass ionomer sealants com-
pared with polyacid-modified resin sealants.
Summary of findings. Data from 1 randomized controlled trial48
suggest that in children and adolescents with sound occlusal
surfaces, the use of resin-modified GI sealants compared with
polyacid-modified GI sealants may reduce the incidence of
occlusal carious lesions in permanent molars by 56% after 2
to 3 years of follow-up (OR, 0.44; 95% CI, 0.11-1.82); how-
ever, this difference was not statistically significant (P=.26)
(sTable 5, available in the supplemental data following refer-
ences). In absolute terms, for a population with a caries baseline
risk (prevalence) of 30% this means that use of resin-modified
GI sealants would prevent 141 carious lesions out of 1,000 sealant
applications (95% CI, 138 more-255 fewer lesions) compared
with the use of polyacid-modified resin sealants after 2 to 3 years
of follow-up; but this difference was not statistically significant.
When assessing retention, resin-modified GI sealants may increase
the risk of loss of retention by 17% compared with polyacid-
modified resin sealants after 2 to 3 years of follow-up (OR, 1.17;
95% CI, 0.52-2.66); however, this difference was not statistically
significant (P=.70). The guideline panel determined the overall
quality of the evidence for this comparison as very low owing to
serious issues of risk of bias (unclear method for randomization
and allocation concealment) and very serious issues of imprecision.
No data on the effect of resin-modified versus polyacid-modified
resin sealants in adult patients were identified.
Comparison 3.4. Polyacid-modified resin sealants com-
pared with resin-based sealants.
Summary of findings. Data from 2 randomized controlled
trials48,51 suggest that in children and adolescents with sound
occlusal surfaces, the use of polyacid-modified resin sealants
compared with resin-based sealants may increase the incidence
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,
this difference was not statistically significant (P=.97) (sTable 6,
available in the supplemental data following references). In ab-
solute terms, for a population with a caries baseline risk (prev-
alence) of 30%, the use of polyacid-modified resin sealant would
increase carious lesions by 2 out of 1,000 sealant applications
(95% CI, 129 fewer-178 more lesions) compared with using a
resin-based sealant after 2 to 3 years of follow-up; however, this
difference was not statistically significant. When assessing the
outcome retention, polyacid-modified resin sealants seem to
reduce the risk of loss of retention by 13% compared with resin-
based sealants after 2 to 3 years of follow-up (OR, 0.87; 95% CI,
0.12-6.21); however, this difference was not statistically signifi-
cant (P=.89). The guideline panel determined the overall quality
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
of the evidence for this comparison as very low owing to serious
issues of risk of bias (unclear method for randomization and
allocation concealment) and very serious issues of imprecision.
No data on the effect of polyacid-modified resin versus resin-
based sealants in 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
quality of evidence for comparative studies. The panel recom-
mends that any of the materials evaluated (for example,
resin-based sealants, resin-modified GI sealants, GI cements, and
polyacid-modified resin sealants in no particular order) can be
used for application in permanent molars with both sound
occlusal surfaces and noncavitated occlusal carious lesions in
children and adolescents. (Conditional recommendation, very
low-quality evidence.)
Remarks.
• The head-to-head analyses of all comparisons did not allow
the guideline panel to provide specific recommendations
using a hierarchy of effectiveness for the sealant materials.
In addition, the quality of the evidence across head-to-head
comparisons was assessed to be low to very low at best. The
guideline panel suggests that clinicians 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, GI)
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.
• The lack of reporting in relation to resealing did not allow the
panel to include this as 1 more element for decision making.
However, it can be inferred from the data on retention loss
that clinicians may need to monitor sealants showing a higher
risk of experiencing retention loss more often.
• To obtain optimal levels of retention, the guideline panel
suggests clinicians carefully follow the manufacturers’ instruc-
tions for each type of sealant material.
Research priorities.
• The panel urges the research community to conduct high-
quality randomized controlled trials to understand further the
relative merits of the different types of sealant materials. Such
studies should meet the optimal information size17 to reduce
the very serious issues of imprecision affecting this body of
evidence.
• New trials should improve reporting quality to allow the panel
to conduct a more accurate assessment of the risk of bias.
• Further research is needed to understand the role of different
types of sealant materials in the primary dentition and adult
population.
• Although the analysis conducted was stratified using 2 caries
baseline risks (30% caries prevalence in the article and 70%
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 211
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
caries prevalence in the tables), the guideline panel acknowl-
edged that clinicians lack a reliable and valid chairside tool
to conduct a caries risk assessment. There is a need for such a
tool to enable clinicians to extrapolate the results from this
analysis to their patients in a more accurate manner.
• The poor quality or complete lack of reporting in relation to
resealing prevented the panel from using this information
during the decision-making process. The panel highlighted
the need for improving the report of reapplication of sealants
as 1 more relevant outcome in primary studies assessing the
effect of this intervention.
Question 4. Are there any adverse events when using pit-and-
fissure sealants?
Summary of findings. There has been concern that dental seal-
ants might exhibit adverse effects. This is primarily associated
with bisphenol A (BPA). It has been suggested that the BPA
present in some sealants may have estrogenlike effects 52’ 53;
however, the evidence does not support the transient effect of a
small amount of BPA in placing patients at risk.54 Studies also
have evaluated the correlation of developing carious lesions in
teeth with fully or partially lost sealants and found no greater
risk than in teeth that had never been sealed.55 Two randomized
controlled trials measuring the occurrence of adverse effects asso-
ciated with sealants found no events related to this outcome.27,56,57
Conclusions
The evidence shows that sealants available in the U.S. market at
the time of this systematic review are an effective intervention for
reducing the incidence of carious lesions in the occlusal surfaces
of primary and permanent molars in children and adolescents
compared with the nonuse of sealants or fluoride varnishes. This
benefit is inclusive to both sound occlusal surfaces and non-
cavitated occlusal carious lesions. Clinicians should use these
recommendations but consider carefully individual patient
factors, especially where the guideline panel offered conditional
recommendations. In addition, sealant use should be increased
along with other preventive interventions to manage the caries
disease process, especially in patients with an elevated risk of
developing caries. Further research is needed to provide more
risk-oriented recommendations, particularly regarding the devel-
opment of a valid and reliable chairside tool for clinicians to
assess a patient’s caries risk.
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27. Liu BY, Lo EC, Chu CH, Lin HC. Randomized trial on
fluorides and sealants for fissure caries prevention. J Dent
Res 2012;91(8):753-8.
28. Mertz-Fairhurst EJ, Fairhurst CW, Williams JE, Della-
Giustina VE, Brooks JD. A comparative clinical study of
two pit and fissure sealants: 7-year results in Augusta, GA.
J Am Dent Assoc 1984;109(2):252-5.
29. Pereira AC, Pardi V, Mialhe FL. Meneghim Mde C, Ambro-
sano GM. A 3-year clinical evaluation of glass-ionomer ce-
ments used as fissure sealants. Am J Dent 2003;16(1):23-27.
30. Richardson AS, Gibson GB, Waldman R. Chemically
polymerized sealant in preventing occlusal caries. J Can
Dent Assoc 1980;46(4):259-60.
31. Tagliaferro EP, Pardi V, Ambrosano GM, Meneghim Mde
C, da Silva SR, Pereira AC. Occlusal caries prevention in
high and low risk schoolchildren: a clinical trial. Am J Dent
2011;24(2):109-14.
32. Zero D, Fontana M, Lennon AM. Clinical applications and
outcomes of using indicators of risk in caries management.
J Dent Educ 2001;65(10):1126-32.
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
33. Dasanayake AP, Li Y, Kirk K, Bronstein J, Childers NK.
Restorative cost savings related to dental sealants in Alabama
Medicaid children. Pediatr Dent 2003;25(6):572-6.
34. Weintraub JA, Stearns SC, Rozier RG, Huang CC. Treatment
outcomes and costs of dental sealants among children
enrolled in Medicaid. Am J Public Health 2001;91(11):
1877-81.
35. Bhuridej P, Kuthy RA, Flach SD, et al. Four-year cost-utility
analyses of sealed and nonsealed first permanent molars in
Iowa Medicaid-enrolled children. J Public Health Dent
2007;67(4):191-8.
36. Leskinen K, Salo S, Suni J, Larmas M. Practice-based study
of the cost-effectiveness of fissure sealants in Finland. J
Dent 2008;36(12):1074-9.
37. Griffin SO, Oong E, Kohn W, et al; CDC Dental Sealant
Systematic Review Work Group. The effectiveness of seal-
ants in managing caries lesions. J Dent Res 2008;87(2):
169-74.
38. Fontana M, Platt JA, Eckert GJ, et al. Monitoring of caries
lesion severity under sealants for 44 months. J Dent Res
2014;93(11):1070-5.
39. Houpt M, Shey Z. The effectiveness of a fissure sealant after
six years. Pediatr Dent 1983;5(2):104-6.
40. Amin HE. Clinical and antibacterial effectiveness of three
different sealant materials. J Dent Hyg 2008;82(5):45.
41. Antonson SA, Antonson DE, Brener S, et al. Twenty-four
month clinical evaluation of fissure sealants on partially
erupted permanent first molars: glass ionomer versus resin-
based sealant. J Am Dent Assoc 2012;143(12):115-22.
42. Arrow P, Riordan PJ. Retention and caries preventive effects
of a GIC and a resin-based fissure sealant. Community
Dent Oral Epidemiol 1995;23(5):282-5.
43. Baseggio W, Naufel FS, Davidoff DC, Nahsan FP, Flury S,
Rodrigues JA. Caries-preventive efficacy and retention of
a resin-modified glass ionomer cement and a resin-based
fissure sealant: a 3-year split-mouth randomised clinical
trial. Oral Health Prev Dent 2010;8(3):261-8.
44. Chen X, Du M, Fan M, Mulder J, Huysmans MC, Frencken
JE. Effectiveness of two new types of sealants: retention
after 2 years. Clin Oral Investig 2011;16(5):1443-50.
45. Chen X, Liu X. Clinical comparison of Fuji VII and a
resin sealant in children at high and low risk of caries.
Dent Mater J 2013;32(3):512-8.
46. Dhar V, Chen H. Evaluation of resin based and glass ionomer
based sealants placed with or without tooth preparation: a
two year clinical trial. Pediatr Dent 2012;34(1):46-50.
47. Guler C, Yilmaz Y. A two-year clinical evaluation of glass
ionomer and ormocer based fissure sealants. J Clin Pediatr
Dent 2013;37(3):263-7.
48. Pardi V, Pereira AC, Ambrosano GM, Meneghim Mde C.
Clinical evaluation of three different materials used as pit
and fissure sealant: 24-months results. J Clin Pediatr Dent
2005;29(2):133-7.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 213
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

49. Haznedaroğlu E, Güner S, Duman C, Menteş A. A 48-
month randomized controlled trial of caries prevention
effect of a one-time application of glass ionomer sealant
versus resin sealant. Dent Mater J 2016;35(3):532-8.
50. Ganesh M, Tandon S. Clinical evaluation of FUJI VII
sealant material. J Clin Pediatr Dent 2006;31(1):52-7.
51. Güngör HC, Altay N, Alpar R. Clinical evaluation of a
polyacid-modified resin composite-based fissure sealant:
two-year results. Oper Dent 2004;29(3):254-60.
52. Arenholt-Bindslev D, Breinholt V, Preiss A, Schmalz G.
Time-related bisphenol-A content and estrogenic activity in
saliva samples collected in relation to placement of fissure
sealants. Clin Oral Investig 1999;3(3):120-5.
53. Zimmerman-Downs JM, Shuman D, Stull SC, Ratzlaff
RE. Bisphenol A blood and saliva levels prior to and after
dental sealant placement in adults. J Dent Hyg 2010;84(3):
145-50.
54. Azarpazhooh A, Main PA. Is there a risk of harm or toxicity
in the placement of pit and fissure sealant materials? A
systematic review. J Can Dent Assoc 2008;74(2):179-83.
55. Griffin SO, Gray SK, Malvitz DM, Gooch BF. Caries risk in
formerly sealed teeth. J Am Dent Assoc 2009;140(4):415-23.
56. Bravo M, Montero J, Bravo JJ, Baca P, Llodra JC. Sealant
and fluoride varnish in caries: a randomized trial. J Dent
Res 2005;84(12):1138-43.
57. Fleisch AF, Sheffield PE, Chinn C, Edelstein BL, Landrigan
PJ. Bisphenol A and related compounds in dental materials.
Pediatrics 2010;126(4):760-8.

Supplemental data

sTable 1. EVIDENCE PROFILE: SEALANTS COMPARED WITH NONUSE OF SEALANTS IN PIT-AND-FISSURE OCCLUSAL SURFACES
IN CHILDREN AND ADOLESCENTS *
QUALITY ASSESSMENT

No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Caries incidence (follow-up: range 2-3 y) ‡

9 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

#
Caries incidence (follow-up: range 4-7 y)

3 5DQGRPL]HGWULDOV 6HULRXV§ 6HULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

#
Caries incidence (follow-up: range 7 y or more)

 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

Lack of retention (follow-up: range 2-3 y)

9 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

* 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.

214 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

sTable 1. CONTINUED
PATIENTS (N) EFFECT QUALITY IMPORTANCE

Sealants Nonuse Relative odds ratio Absolute

of sealants† FRQ¿GHQFH FRQ¿GHQFH
interval) interval)

¶
      IHZHUSHU IHZHU 0RGHUDWH &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

††
      IHZHUSHU IHZHU /RZ &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

‡‡
      IHZHUSHU IHZHU 0RGHUDWH &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

,QFOXGLQJ DOO VHDODQW PDWHULDO W\SHV DQG WRRWK SUHSDUDWLRQ WHFKQLTXHV  RI VHDODQWV ZHUH IXOO\ 0RGHUDWH ,PSRUWDQW
UHWDLQHGDW\DQGZHUHIXOO\RUSDUWLDOO\UHWDLQHGDW\DW\RIDOOVHDODQWVZHUHIXOO\
UHWDLQHGDQGZHUHIXOO\RUSDUWLDOO\UHWDLQHGDIWHU\

* 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 215

CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

sTable 2. EVIDENCE PROFILE: SEALANTS COMPARED WITH FLUORIDE VARNISHES IN PIT-AND-FISSURE OCCLUSAL SURFACES
IN CHILDREN AND ADOLESCENTS*
QUALITY ASSESSMENT

No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Caries incidence (follow-up: range 2-3 y) ‡

3 5DQGRPL]HGWULDOV 6HULRXV§ 6HULRXV¶ 1RWVHULRXV 1RWVHULRXV 1RQH

Caries incidence (follow-up: range 4-7 y)**

 5DQGRPL]HGWULDOV 6HULRXV§ 6HULRXV†† 1RWVHULRXV 1RWVHULRXV 1RQH

Caries incidence (follow-up: range 7 y or more)

1 5DQGRPL]HGWULDOV 9HU\VHULRXV§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

Lack of retention (follow-up: range 2-3 y)

 5DQGRPL]HGWULDOV 6HULRXV† 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

PATIENTS (N) EFFECT QUALITY IMPORTANCE

Sealants Fluoride Relative odds ratio Absolute

varnishes† FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
interval)

    #   IHZHUSHU IHZHU /RZ &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

    ‡‡   IHZHUSHU IHZHU /RZ &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

    §§   IHZHUSHU IHZHU /RZ &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

,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.
† The percentages (30% and 70%) indicate the control group baseline risk (caries prevalence).
†† 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).
‡‡ 2 of 2 studies reported being conducted in water-fluoridated communities.
§ Most studies were classified as unclear for the "allocation concealment" and "masking" domains.
§§ 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.

216 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

sTable 3. EVIDENCE PROFILE: GLASS IONOMER SEALANTS COMPARED WITH RESIN-BASED SEALANTS IN PIT-AND-FISSURE
OCCLUSAL SURFACES IN CHILDREN AND ADOLESCENTS *
QUALITY ASSESSMENT

No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Caries incidence (follow-up: range 2-3 y)‡,§

10 5DQGRPL]HGWULDOV 6HULRXV¶ 6HULRXV# 1RWVHULRXV 6HULRXV** 1RQH

Caries incidence (follow-up: range 4-7 y)‡‡

 5DQGRPL]HGWULDOV 6HULRXV§§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶¶ 1RQH

Caries incidence (follow-up: range 7 yr or more) –not reported

—## — — — — — —

Lack of retention (follow-up: range 2-3 yr)

10 5DQGRPL]HGWULDOV 6HULRXV ¶ 6HULRXV*** 1RWVHULRXV 1RWVHULRXV 1RQH

Lack of retention (follow-up: range 4-7 yr) –not reported

 5DQGRPL]HGWULDOV 6HULRXV§§ 1RWVHULRXV 1RWVHULRXV 6HULRXV††† —

Lack of retention–not reported

— — — — — — —

PATIENTS (N) EFFECT QUALITY IMPORTANCE

Glass ionomer Resin-based Relative odds ratio Absolute

sealants sealants† FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
interval)

††
      IHZHUSHU PRUHIHZHU 9HU\ORZ &ULWLFDO
 IHZHUSHU PRUHIHZHU
 IHZHUSHU PRUHIHZHU

      IHZHUSHU IHZHU 9HU\ORZ &ULWLFDO
 IHZHUSHU IHZHU
 IHZHUSHU IHZHU

— — — — — &ULWLFDO

      PRUHSHU PRUH /RZ ,PSRUWDQW

      PRUHSHU PRUHIHZHU /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%).
† The percentages (30% and 70%) indicate the control group baseline risk (caries prevalence).
†† 1 of 10 studies reported being conducted in water-fluoridated communities.
††† 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 non- cavitated 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 217

CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

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

No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Caries incidence (follow-up: range 2-3 y)‡

1 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶ 1RQH

Caries incidence (follow-up: range 4-7 y)–not reported

—** — — — — — —

Caries incidence (follow-up: range 7 y or more)–not reported

— — — — — — —

Lack of retention (follow-up: range 2-3 y)

1 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

Lack of retention (follow-up: range 4-7 y)–not reported

— — — — — — —

Lack of retention (follow-up: range 7 y or more)–not reported

— — — — — — —

PATIENTS (N) EFFECT QUALITY IMPORTANCE

Glass ionomer 5HVLQPRGL¿HG Relative odds ratio Absolute

sealants glass ionomer FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
sealants* interval)

    #   PRUHSHU IHZHUPRUH 9HU\ORZ &ULWLFDO
 PRUHSHU IHZHUPRUH
 PRUHSHU IHZHUPRUH

— — — — — &ULWLFDO

— — — — — &ULWLFDO

      PRUHSHU PRUH 0RGHUDWH ,PSRUWDQW

— — — — — ,PSRUWDQW

— — — — — ,PSRUWDQW

* Source: Pereira and colleages.s9

** Dashes indicate data not available.
† The percentages (30% and 70%) indicate the control group baseline risk (caries prevalence).
‡ 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.

218 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

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

No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

‡
&DULHVLQFLGHQFH IROORZXSUDQJH\

1 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶ 1RQH

&DULHVLQFLGHQFH IROORZXSUDQJH\ QRWUHSRUWHG

—** — — — — — —

&DULHVLQFLGHQFH IROORZXSUDQJH\RUPRUH QRWUHSRUWHG

— — — — — — —

/DFNRIUHWHQWLRQ IROORZXSUDQJH\

1 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV†† 1RQH

/DFNRIUHWHQWLRQ IROORZXSUDQJH\ QRWUHSRUWHG

— — — — — — —

/DFNRIUHWHQWLRQ IROORZXSUDQJH\RUPRUH QRWUHSRUWHG

— — — — — — —

PATIENTS (N) EFFECT QUALITY IMPORTANCE

5HVLQPRGL¿HG Polyacid- Relative odds ratio Absolute

glass ionomer PRGL¿HGUHVLQ FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
sealants sealants† interval)

    #   IHZHUSHU PRUHIHZHU 9HU\ORZ &ULWLFDO
 IHZHUSHU PRUHIHZHU
 IHZHUSHU PRUHIHZHU

— — — —

— — — —

      PRUHSHU IHZHUPRUH 9HU\ORZ ,PSRUWDQW

— — — —

— — — — —

* Source: Pardi and colleagues.s18

** Dashes indicate data not available.
† The percentages (30% and 70%) indicate the control group baseline risk (caries prevalence).
†† 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 219

CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS

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

No. of Studies Study Design Risk of Bias Inconsistency Indirectness Imprecision Other Considerations

‡
&DULHVLQFLGHQFH IROORZXSUDQJH\

 5DQGRPL]HGWULDOV 6HULRXV§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶ 1RQH

&DULHVLQFLGHQFH IROORZXSUDQJH\ QRWUHSRUWHG

—** — — — — — —

&DULHVLQFLGHQFH IROORZXSUDQJH\RUPRUH QRWUHSRUWHG

— — — — — — —

/DFNRIUHWHQWLRQ IROORZXSUDQJH\

 5DQGRPL]HGWULDOV 6HULRXV§ 6HULRXV†† 1RWVHULRXV 6HULRXV‡‡ 1RQH

/DFNRIUHWHQWLRQ IROORZXSUDQJH\ QRWUHSRUWHG

— — — — — — —

/DFNRIUHWHQWLRQ IROORZXSUDQJH\RUPRUH QRWUHSRUWHG

— — — — — — —

PATIENTS (N) EFFECT QUALITY IMPORTANCE

3RO\DFLGPRGL¿HG Resin-based Relative odds ratio Absolute

resin sealants sealants† FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
interval)

#
     WR PRUHSHU IHZHUPRUH 9HU\ORZ &ULWLFDO
 PRUHSHU IHZHUPRUH
 PRUHSHU PRUHIHZHU

— — — — —

— – — — —

      IHZHUSHU IHZHUPRUH 9HU\ORZ ,PSRUWDQW

— — — — —

— — — — —

* Sources: Gungor and colleaguess22 and Pardi and colleagues.s18

** Dashes indicate data not available.
† The percentages (30% and 70%) indicate the control group baseline risk (caries prevalence).
†† 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.

220 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Supplementary references
s1. Bravo M, Llodra JC, Baca P, Osorio E. Effectiveness of
visible light fissure sealant (Delton) versus fluoride varnish
(Duraphat): 24-month clinical trial. Community Dent
Oral Epidemiol 1996;24(1):42-6.
s2. Liu BY, Lo EC, Chu CH, Lin HC. Randomized trial on
fluorides and sealants for fissure caries prevention. J Dent
Res 2012;91(8):753-8.
s3. Mertz-Fairhurst EJ, Fairhurst CW, Williams JE, Della-
Giustina VE, Brooks JD. A comparative clinical study of
two pit and fissure sealants: 7-year results in Augusta, GA.
J Am Dent Assoc 1984;109(2):252-5.
s4. Splieth C, Förster M, Meyer G. Additional caries protection
by sealing permanent first molars compared to fluoride var-
nish applications in children with low caries prevalence:
2-year results. Eur J Paediatr Dent 2001;2(3):133-8.
s5. Bojanini J, Garces H, McCune RJ, Pineda A. Effectiveness
of pit and fissure sealants in the prevention of caries. J Prev
Dent 1976;3(6):31-4.
s6. Richardson AS, Gibson GB, Waldman R. Chemically poly-
merized sealant in preventing occlusal caries. J Can Dent
Assoc 1980;46(4):259-60.
s7. Erdogan B, Alaçam T. Evaluation of a chemically polymer-
ized pit and fissure sealant: Results after 4.5 years. J Paediatr
Dent 1987;3:11-3.
s8. Tagliaferro EP, Pardi V, Ambrosano GM, Meneghim Mde C,
da Silva SR, Pereira AC. Occlusal caries prevention in high
and low risk schoolchildren: A clinical trial. Am J Dent
2011;24(2):109-14.
s9. Pereira AC, Pardi V, Mialhe FL, Meneghim Mde C, Ambrosano
GM. A 3-year clinical evaluation of glass-ionomer cements
used as fissure sealants. Am J Dent 2003;16(1):23-7.
s10. Houpt M, Shey Z. The effectiveness of a fissure sealant
after six years. Pediatr Dent 1983;5(2):104-6.
s11. Chen X, Du MQ, Fan MW, Mulder J, Huysmans MC,
Frencken JE. Caries-preventive effect of sealants produced
with altered glass-ionomer materials, after 2 years. Dent
Mater 2012;28(5):554-60.
CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
s12. Chen X, Du M, Fan M, Mulder J, Huysmans MC, Frencken
JE. Effectiveness of two new types of sealants: retention
after 2 years. Clin Oral Invest 2012;16(5):1443-50.
s13. Chen X, Liu X. Clinical comparison of Fuji VII and a resin
sealant in children at high and low risk of caries. Dent
Mater J 2013;32(3):512-8.
s14. Amin HE. Clinical and antibacterial effectiveness of three
different sealant materials. J Dent Hyg 2008;82(5):45.
s15. Antonson SA, Antonson DE, Brener S, et al. Twenty-four
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.
s16. Arrow P, Riordan PJ. Retention and caries preventive effects
of a GIC and a resin-based fissure sealant. Community Dent
Oral Epidemiol 1995;23(5):282-5.
s17. Baseggio W, Naufel FS, Davidoff DC, Nahsan FP, Flury S,
Rodrigues JA. Caries-preventive efficacy and retention of a
resin-modified glass ionomer cement and a resin-based fis-
sure sealant: a 3-year split-mouth randomised clinical trial.
Oral Health Prev Dent 2010;8(3):261-8.
s18. Pardi V, Pereira AC, Ambrosano GM, Meneghim Mde C.
Clinical evaluation of three different materials used as pit
and fissure sealant: 24-months results. J Clin Pediatr Dent
2005;29(2):133-7.
s19. Guler C, Yilmaz Y. A two-year clinical evaluation of glass
ionomer and ormocer based fissure sealants. J Clin Pediatr
Dent 2013;37(3):263-7.
s20. Dhar V, Chen H. Evaluation of resin based and glass ionomer
based sealants placed with or without tooth preparation: a
two year clinical trial. Pediatr Dent 2012;34(1):46-50.
s21. Haznedaroğlu E, Güner Ş, Duman C, Menteş A. A 48-
month randomized control trial of caries prevention effect
of a one-time application of glass ionomer sealant versus
resin sealant. Dent Mater J 2016;35(3):532-8.
s22. Güngör HC, Altay N, Alpar R. Clinical evaluation of a
polyacid-modified resin composite-based fissure sealant:
two-year results. Oper Dent 2004;29(3):254-60.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 221
CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES

Use of Vital Pulp Therapies in Primary Teeth with

Deep Caries Lesions
Developed by
American Academy of Pediatric Dentistry
 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
Issued with deep caries lesions. Pediatr Dent 2017;39(5):E146-E159. Erratum in
2017 Pediatr Dent 2020;42(1):12-15.

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
The American Academy of Pediatric Dentistry (AAPD) intends
this guideline to aid clinicians in optimizing patient care when
choosing vital pulp therapies to treat children with deep caries
lesions ‡ 1 in vital primary teeth. Carious primary teeth diagnosed
with a normal pulp requiring pulp therapy or with reversible
pulpitis should be treated with vital pulp procedures.2-6 Cur-
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
known as indirect pulp cap;7 (2) direct pulp cap (DPC); and
(3) pulpotomy.2,7
For the purpose of this guideline, various interventions for
vital pulp therapy were evaluated, including indirect pulp treat-
ment using calcium hydroxide and alternates such as bonding
agents/liners; direct pulp cap using calcium hydroxide and
‡ A caries lesion is a detectable change in the tooth structure that results from the
biofilm-tooth interactions occurring due to the disease caries. It is the clinical manifes-
tation (sign) of the caries process.
alternates such as bonding agents, mineral trioxide aggregate
(MTA), or formocresol; and pulpotomies using formocresol,
MTA, ferric sulfate (FS), sodium hypochlorite (NaOCl), lasers,
calcium hydroxide, or tricalcium silicate. In addition to the re-
ported adverse events, the evidence on outcome moderators
such as type of final restorations and use of rubber dam was
reviewed for this guideline.
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. AGREE: Appraisal of
Guidelines Research and Evaluation. CDC: Centers for Disease Control
and Prevention. CH: Calcium Hydroxide. DPC: Direct pulp cap. DQA:
Dental Quality Alliance. EBDC: Evidence-Based Dentistry Committee.
FS: Ferric sulfate. GRADE: Grading of Recommendations Assessment,
Development and Evaluation. IPT: Indirect pulp therapy. M. abscessus:
Mycobacterium abscessus. MTA: Mineral trioxide aggregate. NaOCl:
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.
Department of Health and Human Services. VPT: Vital pulp therapy.

222 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES

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

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

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-
quiring pulp therapy, is one particular therapy (IPT,
DPC, pulpotomy) more successful* than others?
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.
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
treatment (IPT) due to deep caries lesions, does the
choice of medicament affect success*?
The panel found that the success of IPT in vital pri- Moderate (24 mo.) Conditional
mary teeth with deep caries lesions is independent
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
with DPC due to pulp exposure (one mm or less)
encountered during carious dentin removal, does
the choice of medicament affect success*?
The panel found that in vital primary teeth with deep Very Low (24 mo.) Conditional
caries lesions treated with DPC due to pulp exposure
(one mm or less) encountered during carious dentin
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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 225

CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES

Question 3. In vital primary teeth with deep caries lesions
treated with direct pulp cap due to pulp exposure (one mm
or less) encountered during carious dentin removal, does the
choice of medicament affect success?
Recommendation: The panel found that in vital primary
teeth with deep caries lesions treated with DPC due to pulp
exposure (one mm or less) encountered during caries removal,
the success of DPC was independent of the type of medica-
ment (dentin bonding agents, MTA, and formocresol), and
therefore recommends that clinicians choose the medicament
based on individual preferences. (Conditional recommendation,
very-low quality evidence.)
Summary of findings: The systematic review9 of three DPC
studies compared calcium hydroxide versus alternative direct
capping agents after 24-months (dentin bonding agents 16,
MTA18, and formocresol19). At 24-month follow-up, the meta-
analysis showed the capping agent had no effect on success
(RR 1.05, 95% CI=0.89 to 1.25) (P=0.56).9 The quality of the
evidence for whether DPC capping agent affected success at 24
months was assessed as very low because of the high degree of
heterogeneity in the studies (I2=83 percent) and small sample
size. All the three DPC studies involved immediate placement
of the final restoration.9 The summary of findings for DPC is
included in Table 5.
Question 4. In vital primary teeth with deep caries treated
with pulpotomy due to pulp exposure during caries removal,
does the choice of medicament or technique affect success?
Recommendations:
• The panel recommends the use of MTA in vital primary
teeth with deep caries lesions treated with pulpotomy due
to pulp exposure during carious dentin removal. (Strong
recommendation, moderate-quality evidence)
• The panel recommends the use of formocresol in vital pri-
mary teeth with deep caries lesions treated with pulpotomy
due to pulp exposure during carious dentin removal.
(Strong recommendation, moderate-quality evidence)
• The panel recommends the use of FS in vital primary teeth
with deep caries lesions treated with pulpotomy due to
pulp exposure during carious dentin removal. (Conditional
recommendation, low-quality evidence)
• The panel recommends the use of lasers in vital pri-
mary teeth with deep caries lesions treated with pulpotomy
due to pulp exposure during carious dentin removal.
(Conditional recommendation, low-quality evidence)
• The panel recommends the use of NaOCl in vital pri-
mary teeth with deep caries lesions treated with pulpotomy
due to pulp exposure during carious dentin removal.
(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
(74.5 to 95.0) NNT= Not significant

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
(81.1 to 93.2) NNT= Not significant

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.

226 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES

• The panel recommends the use of tricalcium silicate in
vital primary teeth with deep caries lesions treated with
pulpotomy due to pulp exposure during carious dentin
removal. (Conditional recommendation, very low-quality
evidence)
• The panel recommends against the use of calcium hydroxide
in vital primary teeth with deep caries lesions treated with
pulpotomy due to pulp exposure during carious dentin
removal. (Conditional recommendation, low-quality
evidence)
Summary of findings: The systematic review9 suggests that
the overall success rate at 24 months for MTA, formocresol,
FS, NaOCl, calcium hydroxide, and laser was 82.6 percent
(95% CI=75.8 to 87.8). MTA and formocresol success rates
were the highest of all pulpotomy types in this time frame
and were not significantly different (P=0.15). MTA’s success
rate was 89.6 percent (95% CI=82.5 to 94.0), and formocresol’s
was 85.0 percent (95% CI=76.3 to 91.0).9 MTA, formocresol,
and FS success rates were all significantly better than calcium
hydroxide at 24 months (P=<0.001). Other studies showed
NaOCl’s success rate was significantly less than formocresol
at 18 months (P=0.01), and other pulpotomy agents’ success
rates did not differ statistically (FS vs. laser; FS vs. NaOCl; and
calcium hydroxide vs. laser). At 12 months, pulpotomy success
rates for FS vs. laser and MTA vs. tricalcium silicate did not
differ statistically. The summary of findings for pulpotomy
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
success 24 mos.
FC success= 79.0%
(57.7 to 91.2)
CH success= 41.4%
(26.5 to 58.1)
RR 1.76 (1.40 to 2.23) favoring 4 studies Moderate
FC P=<0.001 with 212 teeth
NNT (significant)= 3. On doing three
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,
there were 165 children with 399 teeth.

4. MTA vs. CH overall
success 24 mos.
MTA success= 89.0%
(59.6 to 97.8)
CH success= 46.0%
(35.0 to 57.3)
RR 1.96 (1.52 to 2.53) favoring 3 studies Moderate
MTA by 96% P=<0.001 with 190 teeth
NNT (significant)= 3. On doing three
pulpotomies, one failure would be prevented
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
success 24 mos.
FS success= 82.1%
(68.2 to 90.7)
CH success= 52.8%
(39.5 to 65.8)
RR 1.57 (1.19 to 2.06) favoring 2 studies Low
FS by 57% P=<0.001 with 118 teeth
NNT (significant)= 4. On doing four
pulpotomies, one failure would be prevented
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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 227

CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES

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
success 24 mos.
MTA success= 92.2% RR 1.11 (0.99 to 1.26) favoring 4 studies Moderate
(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,
there were 241 children with 578 teeth.

7. FC vs. NaOCl overall
success 18 mos.
FC success= 98.1% RR 1.20 (1.04 to 1.40) favoring 2 studies Low
(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,
there were 181 children with 220 teeth.

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,
there were 181 children with 220 teeth.

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.

228 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Comparison 4.1. Formocresol vs. MTA pulpotomy (24-
months). The systematic review9 evaluated eight studies20,21,23-28
comparing formocresol to MTA with a follow-up of 24 months,
and the meta-analysis favored neither type of pulpotomy med-
icament (RR 1.04, 95% CI=0.98 to 1.11) (P=0.15). The quality
of the evidence for this outcome at 24 months was assessed to
be high.
Comparison 4.2. Formocresol vs. FS pulpotomy (24-
months). The systematic review9 evaluated four studies20-22,25
comparing formocresol to FS with a follow-up of 24 months,
and the meta-analysis favored neither type of pulpotomy medi-
cament (RR .02, 95% CI=0.93 to 1.13) (P=0.65). The quality
of the evidence for this outcome at 24 months was moderate
due to small sample sizes.
Comparison 4.3. Formocresol vs. calcium hydroxide pulp-
otomy (CH) (24-months). The systematic review9 evaluated four
studies22,23,25,31 comparing formocresol to CH with a follow-up
of 24 months, and the meta-analysis indicated that formocresol
was significantly better than CH (RR 1.76, 95% CI=1.40 to
2.23) (P<0.001). In terms of numbers needed to treat (NNT),
on doing three pulpotomies, one failure would be prevented if
formocresol was used instead of CH. The quality of the evidence
for this outcome at 24 months was moderate due to small
sample sizes.
Comparison 4.4. MTA vs. CH pulpotomy (24-months).
The systematic review9 evaluated three studies23,25,29 comparing
MTA to CH with a follow-up of 24 months, and the meta-
analysis indicated that MTA was significantly better than CH
(RR 1.96, 95% CI=1.52 to 2.53) (P<0.0001). In terms of
NNT, on doing three pulpotomies, one failure could be pre-
vented if MTA was used instead of CH. The quality of the
evidence for this outcome at 24 months was moderate due
to small sample sizes.
Comparison 4.5. FS vs. CH pulpotomy (24-months).
The systematic review 9 evaluated two studies 22,25 comparing
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,
95% CI=1.19 to 2.06) (P<0.001). In terms of NNT, on doing
four pulpotomies, one failure could be prevented if FS was
used instead of CH. The quality of the evidence for this outcome
at 24 months was low due to very small sample sizes.
Comparison 4.6. MTA vs. FS pulpotomy (24-months).
The systematic review9 evaluated four studies20,21,25,30 comparing
MTA to FS with a follow-up of 24 months, with the meta-
analysis nearing significance (P=0.06) favoring MTA (RR 1.13,
95% CI=1.00 to 1.29). In terms of NNT, on doing nine pulp-
otomies, one failure could be prevented if MTA was used
instead of FS. The quality of the evidence for this outcome at
24 months was moderate due to small sample sizes.
Comparison 4.7. Formocresol vs. NaOCl pulpotomy
(18-months). The systematic review9 evaluated two studies21,32
comparing formocresol to NaOCl with a maximum follow-up
of 18 months, and the meta-analysis indicated that formocresol
was significantly better than NaOCl (RR 1.20, 95% CI=1.04
to 1.40) (P=0.01). In terms of NNT, on doing six pulpotomies,
CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES
one failure could be prevented if formocresol was used instead
of NaOCl. The quality of the evidence for this outcome at
18 months was moderate due to small sample sizes.
Comparison 4.8. Comparison 4.8. Formocresol vs. laser
pulpotomy (18-months). The systematic review9 evaluated two
studies22,33 comparing formocresol to laser, and the meta-analysis
favored neither type of pulpotomy technique (RR 1.14, 95%
CI=0.91 to 1.43) (P=0.27). The quality of the evidence for the
outcomes of these agent comparisons at 18 months was low
due to small sample sizes.
Comparison 4.9. Comparison 4.9. FS vs. NaOCl pulpo-
tomy (18-months). The systematic review 9 evaluated two
studies 21,32 comparing FS to NaOCl, and the meta-analysis
favored neither type of pulpotomy medicament (RR 0.99, 95%
CI=0.85 to 1.16) (P=0.88). The quality of the evidence for the
outcomes of these agent comparisons at 18 months was low due
to small sample sizes.
Comparison 4.10. CH vs. laser pulpotomy (18-months).
The systematic review9 evaluated two studies22,33 comparing CH
to laser, and the meta-analysis favored neither type of pulpotomy
technique (RR 1.07, 95% CI=0.91 to 1.25) (P=0.41). The quality
of the evidence for the outcomes of these agent comparisons
at 18 months was low due to small sample sizes.
Comparison 4.11. FS vs. laser pulpotomy (12-months).
The systematic review9 evaluated two studies22,34 comparing FS
to laser, and the meta-analysis favored neither type of pulp-
otomy technique (RR 1.06, 95% CI=0.94 to 1.19) (P=0.34).
The quality of the evidence for this outcome at 12 months
was moderate due to small sample sizes.
Comparison 4.12. MTA vs. tricalcium silicate pulpotomy
(12-months). The systematic review9 evaluated two studies35,36
comparing MTA to tricalcium silicate, and the meta-analysis
favored neither type of pulpotomy medicament (RR 1.01,
95% CI=0.94 to 1.09) (P=0.83). The quality of the evidence
for this outcome at 12 months was very low.
Remarks: The head-to-head analysis of all pulpotomy
comparisons presented a challenge in assessing the evidence.
The validity of the indirect comparison rests on similarity
assumption that the study designs (Population, intervention,
and outcomes) and the methodological quality are not suffi-
ciently different to result in different effects.37 As this assump-
tion is always in some doubt, indirect comparisons always
warrant rating down by one level in quality of evidence.37 The
panel recognized that the findings are of high clinical relevance
and agreed that it will be of value to produce separate recom-
mendation statements for various pulpotomy medicaments/
techniques, even though the quality of evidence had to be
downgraded. Therefore, for recommendations on pulpotomy
medicaments and techniques, the panel decided to downgrade
the quality of evidence by one level (from the highest level
recorded for that intervention), owing to the indirect compari-
sons among various interventions.
The panel decided on a recommendation against the use of
CH pulpotomy, because the data consistently showed inferior
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 229
CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES
success for CH pulpotomy. The strength of evidence was
conditional, since the quality of evidence was downgraded from
moderate to low to account for indirect comparisons.
Research considerations. The panel recognized that to pro-
duce recommendations supported with higher quality evidence,
there is a need for well-designed clinical trials with multiple
arms allowing simultaneous comparisons of more than two
medicaments or techniques.
Practice implications. The indications, objectives, and type
of pulpal therapy depend on whether the pulp is vital or non-
vital, which is based on the clinical diagnosis of normal pulp
(symptom free and normally responsive to vitality testing), re-
versible pulpitis (pulp is capable of healing), symptomatic or
asymptomatic irreversible pulpitis (vital inflamed pulp is in-
capable of healing), or necrotic pulp.2 In order to replicate the
recorded vital pulp therapy success rates, proper case selection,
accurate diagnosis, and utilization of evidence-based technique
are of key importance.
Indirect pulp treatment is a procedure that leaves the
deepest caries adjacent to the pulp undisturbed in an effort to
avoid a pulp exposure. This caries-affected dentin is covered
with a biocompatible material to produce a biological seal.2,7
Direct pulp cap is a technique in which the pulp is covered
with a biocompatible material when caries excavation causes a
pin-point pulp exposure.9 Past reports of DPC in primary teeth
have shown limited success;16,38 therefore, DPC has had limited
acceptance as a technique for management of carious pulp ex-
posures in the primary dentition.
Pulpotomy is a procedure used when the excavation of
carious dentin in primary teeth produces a pulp exposure. In
this technique, the entire coronal pulp is removed, hemostasis
of the radicular pulp is achieved, and the remaining radicular
pulp is treated with one of several different medicaments.3,4,7
Published studies of this procedure have been reported since the
early 1900’s,39 and pulpotomy currently is the most frequently
used vital pulp therapy technique for deep dental caries lesions
in primary teeth.40
AAPD has published this current guideline on vital pulp
therapy in primary teeth to provide evidence-based recommend-
ations on vital pulp therapies in primary teeth with deep caries
lesions. In view of the similar success of all three vital pulp
therapies, the panel suggests clinicians take the most biological/
conservative approach, which considers caries-affected dentin
removal, pulp exposures (if any), reported adverse effects, and
individual preferences. Based on the recommendations, IPT,
DPC, and pulpotomy may all be viable options for treatment of
primary teeth with deep caries lesions. Overall, the panel found
moderate quality evidence supporting IPT, MTA pulpotomy,
and formocresol pulpotomy. For all other interventions, the
quality of evidence was low to very low. The success of IPT and
DPC was found to be independent of the choice of medicament
used. For pulpotomy, the panel found higher evidence supporting
use of MTA and formocresol and evidence against the
use of CH. Treatment choices should be made based on
the scientific evidence presented, clinical expertise, and patients’
230 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
values and preferences. Clinicians should give greater care to
consider individual patient factors where the guideline offers
conditional recommendation.
The use of rubber dam is universally accepted as a gold
standard for pulp therapies. Since it may be of ethical concern to
design studies with a control group treated without using rubber
dam isolation, there is limited research evaluating benefits of
rubber dam use on primary teeth. However, the panel agreed
that it is critical to use rubber dam in order to maintain the
highest standard of care and to ensure patient safety.41
It is also important that clinicians select the best post-
operative restoration using their clinical expertise and individual
patient preferences. Either intra-coronal restoration or a stainless
steel crown (SSC) may be adequate to achieve a good marginal
seal for single surface (occlusal) restorations on a primary tooth
with a life span of two years or less; whereas for multi-surface
restorations, stainless steel crowns are the treatment of choice.2,42
Potential adverse effects
Summary of findings: There have been concerns regarding tox-
icity related to formocresol and discoloration related to MTA,
and more recently about the nontuberculosis mycobacterial
infection linked to pulpotomy procedures.
Formocresol: The panel did not find any reports on toxicity
related to use of formocresol for vital pulp therapies in children.
Milnes42 reviewed the available evidence on formocresol and
concluded that when used judiciously for pulpotomy procedure,
it is unlikely to be genotoxic, immunotoxic, or carcinogenic in
children. The panel did not find sufficient evidence on adverse
events that could influence the quality of evidence.
MTA: The panel found reports of unintended grayish dis-
coloration of teeth treated with MTA (gray and white) pulp-
otomy. 44-48 One study reported that 94 percent of teeth that
received white MTA pulpotomy and composite restoration turned
gray, suggesting it was not an esthetic alternative to SSC.45 The
discoloration, however, had no influence on the success of vital
pulp therapy. The panel, therefore, did not reduce the quality
of evidence owing to the discoloration-related adverse effect of
MTA. Clinicians should be aware of the possibility of coronal
discoloration with MTA, especially while restoring a tooth with
composite for esthetic considerations, and make decisions based
on individual preferences. The panel did not find sufficient
evidence on adverse events that could influence the quality of
evidence.
Nontuberculosis mycobacterial infection: The U.S. Department
of Health and Human Services (USDHHS)/Centers for Disease
Control and Prevention (CDC) published a report on Myco-
bacterium abscessus (M. abscessus) infections among patients
treated with pulpotomies.49 The report identified the cause of
outbreak to be the contaminated water used during pulpo-
tomies, which introduced M. abscessus into the pulp chamber
of the tooth. It was reported that out of 1,386 pulpotomies
performed since January 2014, as of January 2016, a total of 20
patients were identified with confirmed or probable M. abscessus
infections, resulting in a prevalence rate of one percent. All

patients (median age seven years) were severely ill and required
at least one hospitalization (median hospital stay seven days;
range: one-17 days); 17 patients required surgical excision, and 10
received outpatient intravenous antibiotics. As of April 5, 2016,
no deaths had resulted from infection.49 Since M. abscessus is
ubiquitous in the environment, it poses a contamination risk.
To prevent infections associated with waterlines, dental practices
should monitor water quality, disinfect waterlines as per manu-
facturer’s instructions, use point-of-use water filters, and eliminate
dead ends in plumbing where stagnant water can enable biofilm
formation. 49 The panel did not find sufficient evidence on
adverse events that could influence the quality of evidence.
Remarks: The panel did not find sufficient evidence on ad-
verse events related to medicaments used for IPT, DPC, and
pulpotomy that could influence the quality of evidence. However,
the panel recognizes that there may still be parental concerns
regarding formocresol toxicity and discolorations associated
with MTA and recommends that the clinicians should explain
the evidence to parents and make decisions based on individual
preferences. The panel encourages providers to closely monitor
any updates from the CDC on M. abscessus infection related to
pulpotomy procedures for its future implications and possible
impact on the evidence.
Guideline implementation
This guideline, AAPD’s first evidence-based guideline on pulp
therapy, is published in both the journal, Pediatric Dentistry,
and the AAPD’s Reference Manual. By meeting the standards of
the Institute of Medicine regarding the production of clinical
practice guidelines, these recommendations will be submitted
to the National Guidelines Clearinghouse (NGC), a database of
evidence-based clinical practice guidelines and related documents
maintained as a public resource by the Agency for Healthcare
Research and Quality (AHRQ) of the USDHHS. Inclusion in
the NGC guarantees the guidelines will be accessible and dis-
seminated to private and public payors, policy makers, and the
public. Additionally, AAPD members will be notified of the
new guidelines via social media, newsletters, and presentations.
The guidelines are available as an open access publication on the
AAPD’s website. Patient education materials are being developed
and will be offered in the AAPD’s online bookstore.
Practitioners seeking additional support implementing these
guidelines are referred to the following resources:
– Treatment of Deep Caries, Vital Pulp Exposure, and Pulp-
less Teeth, Chapter 13, McDonald and Avery’s Dentistry
for the Child and Adolescent, 10th edition.50
– Pulp Therapy for the Primary Dentition, Chapter 22, Pedi-
atric Dentistry Infancy through Adolescence, 5th edition.51
– Pediatric Endodontics, Chapter 26, Cohen’s Pathways of
the Pulp, 11th edition.52
– Endodontics: Colleagues for Excellence. 53 www.aae.org/
colleagues.
– Preserving Pulp Vitality, Chapter 4, The Principles of
Endodontics.54
– Pediatric Endodontics: Current Concepts in Pulp Therapy
for Primary and Young Permanent Teeth.55
CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES
Cost-effectiveness of recommendation. Cost-effectiveness
of a treatment is based on initial and possible retreatment costs.56
Such a cost-analysis for therapies with proven health benefits
and minimal adverse effects is an important consideration for
clinicians, patients, and third-party payors.56 This is especially
important when different procedures with similar outcomes are
available to treat a specific condition like in the case of vital pulp
therapies. A research brief covering claims data for all children
with private dental insurance lists vital pulpotomy, in primary
or permanent teeth, as one of top 25 most common procedures
performed in children with private dental benefits.57 For ages
one through six years, the spending is estimated to be $257,
ranging from $160 for children in the lowest quartile of spend-
ing to $996 among children in the highest quartile of spend-
ing. 57 Considering the number of pulp therapies performed
on a population level, cost-effective treatment is a public health
issue. However, very limited data exist on cost-effectiveness
of various pulp therapies in the primary dentition. The most
expensive pulp treatments and modalities with regards to initial
costs are MTA and laser.56,58 Interestingly, a German study using
the Markov model followed the first permanent molar with vital
asymptomatic exposed pulp treated with DPC using MTA or
CH over the lifetime of a 20 year old patient and reported that
MTA was more cost-effective than calcium hydroxide despite
higher initial treatment costs because expensive retreatments were
avoided.56
MTA is a suitable medicament for pulpotomy in primary
teeth. The main reason for its underutilization has been its
higher cost.58,59 The price of MTA is particularly elevated due to
the recommendation to use each package for one patient only.
However, new products marketed in a sealed desiccant-lined
bottle quote a shelf life of three years, allowing use for multiple
treatments. This has lowered the price to be competitive with
other alternative materials.60
Third-party reimbursement is another cost issue that may
unintentionally increase utilization of a specific procedure over
others. Pulpotomies are a widely performed procedure57 and
are reimbursed by both private and federally funded insurance
companies. Alternatively, IPT with an overall success rate of 94.4
percent, is often bundled as part of the restoration and, therefore,
not adequately reimbursed or not reimbursed at all. Reimburse-
ment of more conservative, biological approaches of pulp therapy,
such as IPT, will allow clinicians to make conservative choices
based exclusively on efficacy and effectiveness of the specific
procedures.61
Cost of pulp treatment may be contained by use of effec-
tive medicaments as determined by evidence-based research and
detailed in this guideline, but the only way to reduce costs overall
is to establish dental homes for every child and implement pri-
mary prevention by the child’s parents or caregiver. Primary
prevention must start early if treatment costs are to be reduced
and oral health maintained.
Recommendation adherence criteria
Guidelines are used by insurers, patients, and health care prac-
titioners to determine quality of care. Adherence to guideline
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 231
CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES
recommendations is measured, because it is believed following
best practices reduces inappropriate care and improves out-
comes.62 “Self-evaluation will ensure that dentistry as a profession
can provide evidence to the community at large that its
members are responsible stewards of oral health.” 63 While
measurement of oral health care outcomes is in its nascent stage
at both system and practice levels, the Dental Quality Alliance
(DQA) of the American Dental Association in partnership
with the AAPD and other dental organizations has developed
system-level performance measures for some oral health areas.
These measures further the goals of professional accountability,
transparency, and oral health care quality through performance
measurement. Under consideration by the DQA is a pediatric
retreatment measure in relation to crowns and root canal
therapies.64
Workgroup and stakeholders. In December, 2016, the
AAPD Board of Trustees approved a panel nominated by the
Evidence-Based Dentistry Committee (EBDC) to develop a new
evidence-based clinical practice guideline on vital pulp therapies
in primary teeth with deep caries lesions. The panel consisted of
pediatric dentists in public and private practice involved in
research and education; the stakeholders consisted of authors of
the systematic review in addition to representatives from general
dentistry, governmental and non-governmental agencies, and
international and specialty dental organizations.
External stakeholders. External and internal stakeholders
reviewed the document periodically during the process of de-
velopment of the guideline. Stakeholders also participated in
anonymous surveys to determine the scope and outcomes of
the guideline. All stakeholder comments were considered and
addressed in the panel meetings. It is expected that the publica-
tion and dissemination of the guideline will generate additional
dialogue, comments, and feedback from professional, academic,
and community stakeholders.
Intended users. The target audiences for this guideline are
dental team members in private, dental school, or public health
care settings such as pediatric dentists, dental educators, general
dentists, public health practitioners, policy makers, program
managers, third-party insurers, and dental students/residents.
The target populations include children and adolescents with
deep caries lesions in vital primary teeth.
Review and feedback integration. This guideline was
continuously reviewed by external and internal stakeholders
from the beginning of the process until the formulation of the
guidelines. Stakeholders were invited to take part in anonymous
surveys to determine the scope and outcomes of the guideline.
Comment was also sought on the draft guideline. All stake-
holder comments were addressed and acted upon as appropriate
per group deliberation.
Guideline updating process. The AAPD’s EBDC will
monitor the biomedical literature to identify new evidence
that may impact the current recommendations. These recom-
mendations will be updated five years from the time the last
systematic search, unless the EBDC determines that an earlier
revision or update is warranted.
232 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
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Appendix
®
PubMed /MEDLINE—date limit 01/2017
Search #1. 3607 results
(pulp therap* OR pulpotom* OR pulp cap* OR “Dental
Pulp Capping”[MeSH terms] OR “Pulpotomy”[MeSH terms])
Search #2. 23275 results
(“Root Canal Therapy”[Mesh] OR “Root Canal Preparation”[Mesh]
OR “Root Canal Obturation”[Mesh] OR “Root Canal Filling
Materials”[Mesh] OR “Calcibiotic Root Canal Sealer”[Supple-
mentary Concept] OR “Next root canal sealant”[Supplementary
Concept] OR “calcium sulfate, zinc oxide, vinyl acetate, zinc
phosphate root canal filling”[Supplementary Concept] OR
“QMix root canal irrigant”[Supplementary Concept] OR
“Root Canal Irrigants”[Mesh])
Search #3. 3570082 results
(Infant[MeSH] OR infant * OR infancy OR newborn * OR baby
* OR babies OR neonat * OR preterm * OR premature * OR
postmature * OR Child[MeSH] OR child * OR schoolchild * OR
school age * OR preschool * OR Kid OR kids OR toddler * OR
Adolescent[MeSH] OR adolesc * OR teen * OR Boy * OR girl *
OR Minors[MeSH] OR minors * OR Puberty[MeSH] OR
puberty * OR pubescent * OR prepubescent * OR Pediatrics
[MeSH] OR paediatric * OR paediatric * OR paediatric * OR
Schools [MeSH] OR nursery school * OR kinderman * OR pri-
mary school * OR secondary school * OR elementary school * OR
high school * OR high school *)
Search #4. 144 results
(#1 OR #2) AND #3 AND PubMed systematic review filter
applied
CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES
Search #5. 7589370 results
(randomized controlled trial[pt] OR controlled clinical trial[pt]
OR randomized[tiab] OR randomised[tiab] OR randomization
[tiab] OR randomisation[tiab] OR placebo [tiab] OR drug
therapy[sh] OR randomly[tiab] OR trial [tiab] OR groups[tiab]
OR clinical trial[pt] OR “clinical trial”[tw] OR “clinical trials”
[tw] OR “evaluation studies” [publication type] OR “evaluation
studies as topic” [MeSH terms] OR “evaluation study”[tw]
OR evaluation studies [tw] OR “intervention studies”[MeSH
terms] OR “intervention study”[tw] OR “intervention studies”
[tw] OR “cohort studies”[MeSH terms] OR cohort[tw] OR
“longitudinal studies”[MeSH terms] OR “longitudinal”[tw]
OR longitudinally[tw] OR “prospective” [tw] OR prospectively
[tw] OR “follow up”[tw] OR “comparative study”[publication
type] OR “comparative study”[tw] OR systematic[subset] OR
“meta-analysis” [publication type] OR “meta-analysis as topic”
[MeSH terms] OR “meta-analysis”[tw] OR “meta-analyses”[tw])
Search #6. 1906 results
(#1 OR #2) AND #3 AND #5
Search #7. 890576 results
(“Economics”[Mesh] OR “Cost of Illness”[Mesh] OR “Cost
Savings”[Mesh] OR “Cost Control”[Mesh] OR “Cost-Benefit
Analysis”[Mesh] OR “Health Care Costs”[Mesh] OR “Direct
Service Costs”[Mesh] OR “economics”[Sub-heading] OR cost)
Search #8. 78 results
(#1 OR #2) AND #3 AND #7
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 235
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES

Use of Non-Vital Pulp Therapies in Primary Teeth

Developed by
American Academy of Pediatric Dentistry
 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
Purpose. Untreated decay or trauma can cause the nerve of the
tooth to become irreversibly inflamed, abscessed, or dead. The
diagnosis is based on both clinical and radiographic signs and
symptoms, such as a toothache waking the child in the middle
of the night, unprovoked toothache, gum or facial swelling,
or X-rays showing the tooth has bone loss or root resorption.
Treatment options for this condition include extraction, root
canal therapy (pulpectomy), or lesion sterilization tissue repair
(LSTR), which involves the placement of antibiotics inside the
tooth. This manuscript evaluates available treatment options to
save baby (primary) teeth with dying (irreversibly inflamed),
dead (necrotic), or abscessed nerve (pulp) resulting from decay
or trauma and various factors that impact the treatment’s success
(e.g., eliminate pain and swelling or pathology on follow-up X-rays).
Methods. The authors, working with the American
Academy of Pediatric Dentistry, systematically reviewed all the
dental literature up to January 2020 on the subject of non-vital
(irreversibly inflamed, necrotic) primary tooth pulp treatments.
This systematic review used 114 articles published between
1972 and 2020 that included randomized and nonrandom-
ized controlled trials as well as studies done in laboratories. The
authors defined treatment success as the child having no pain
or infection and radiographs showing no signs of pathology.
Results. Pulpectomy has a high success rate and can be used
for the treatment of dead, dying or abscessed primary teeth
with no evident root resorption. In teeth with no root resorp-
tion, pulpectomy should be chosen over LSTR. Follow-up
X-rays should be taken at least every 12 months to monitor the
treatment. LSTR should be chosen over pulpectomy in teeth
with root resorption or to retain teeth for up to 12 months that
otherwise would be extracted. LSTR treatment should be
monitored closely in the first year, and after the first year, with
periodic clinical examinations and X-rays at least every 12 months.
Pulpectomy and LSTR compared to extraction maintain the
tooth in the arch and eliminate any pain and infection, and the
procedure should not cause severe pain after 1-2 days. Root
canal filling materials such as zinc oxide and eugenol (ZOE),
iodoform, or zinc oxide/iodoform/calcium hydroxide (ZO/
iodoform/CH) are used to fill the root canal space after the
infected pulp is removed. For teeth expected to be in the mouth
for 18 months or longer, zinc oxide/iodoform/CH and ZOE
fillers performed better than iodoform fillers. The use of motor-
driven rotary root canal files to instrument the root canals is
faster than hand instrumentation but does not affect treatment
success or quality of filling the root canals. Pulpectomy success
also was not affected by different methods of filling the root
canals (Lentulo spiral, hand pluggers, or syringe), type of tooth
(anterior or posterior), history of trauma, type or timing of final
restoration placement, method of root length determination,
smear layer removal, or number of treatment visits to complete
the pulpectomy. Antibiotic mixtures used in LSTR should not
include tetracycline since evidence shows that alternate anti-
biotic mixtures performed better than tetracyclines. Extraction
is indicated for a nonrestorable tooth whose root(s)and/or
crown has extensive resorption or destruction. In some cases,

236 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


GLOSSARY OF TERMS AND ABBREVIATIONS
95% CI refers to 95 percent confidence interval.
AAPD: American Academy of Pediatric Dentistry.
Alternate 3Mix used in LSTR is an antibiotic modification of traditional 3Mix
in which tetracycline/minocycline is replaced by another antibiotic such as
clindamycin.
CH is a calcium hydroxide pulpotomy.
DPC (Direct pulp treatment) is done for pinpoint pulp exposures after caries
removal and is sealed with a biocompatable material.
FC is a formocresol pulpotomy.
FS is a ferric sulfate pulpotomy.
GRADE (Grading of Recommendations, Assessment, Development, and
Evaluations) provides a framework for specifying health care questions,
choosing outcomes of interest and rating their importance, evaluating the
available evidence, and bringing together the evidence with considerations of
values and preferences of patients and society to arrive at recommendations.
I2 statistic is a measurement of inconsistency of the data included in the
meta-analysis.
Indirect pulp treatment leaves the deepest decay to prevent a pulp expo-
sure and seals it with a biocompatable material.
Iodoform stands for either Vitapex (Neo Dental International Inc, Burnaby,
British Columbia, Canada) or Metapex (Meta Biomed LTD, Cheongju-si,
Chungcheongbuk-do, South Korea) root canal filler, two identical proprietary
brands containing an iodoform and calcium hydroxide.
Irreversible pulpitis and/or necrosis is a tooth that exhibits any one of the
following clinical or radiographic findings: 1. history of unprovoked toothache;
2. sinus tract, soft tissue pathology, or gingival swelling not associated with
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
solely on bleeding that cannot be controlled within five minutes.
Lasers are laser pulpotomies.
LSTR (lesion sterilization tissue repair) is a procedure for necrotic primary
teeth that usually requires no instrumentation of the root canals or filling
of the canals but instead includes placement of an antibiotic mixture in the
pulp chamber to disinfect the root canals.
mm is a millimeter.
MTA is a mineral trioxide aggregate pulpotomy.
NaOCl (sodium hypochlorite) or common household bleach in one to five percent
concentration or as used in the decision tree is a sodium hypochlorite pulpotomy.
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
to the alternate treatment method.
Nonrestorable primary tooth is where the root(s) and or crown has exten-
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.
Normal pulp is a tooth without reversible or irreversible pulpitis.
NRS is a nonrandomized observational study, and NRSs is the plural.
Pulpectomy is a root canal procedure for primary teeth with irreversible
pulpitis or necrotic pulp resulting from caries or trauma in which the root
canals are instrumented with files, irrigated, and filled with a resorbable material.
Pulpotomy is for pulp exposures after caries removal and the entire coronal
pulp is removed and treated with various techiques or medicaments.
RCT is a randomized clinical trial, and RCTs is the plural.
Reversible pulpitis is the pulpal diagnosis for a tooth without signs or
symptoms of irreversible pulpitis but that has provoked pain from eating for
a short duration ( 5-10 minutes).
ROB (risk of bias) is an assessment of any deviations in the estimate of the
intervention’s results.
SR is the AAPD’s systematic review on non-vital pulp therapies.1
SSC is a stainless steel crown, and SSCs is the plural.
Success in this guideline refers to the overall success of teeth that show
both clinical and radiographic success simultaneously after pulp treatment.
The AAPD Workgroup (WG) consisted of seven pediatric dentists nominated
by the AAPD to perform a systematic review.
Traditional 3Mix is typically a mixture of three antibiotics (minocycline,
metronidazole, and ciprofloxacin) blended in a propylene glycol base and used
in LSTR treatment.
ZO/iodoform/CH (zinc oxide/iodoform/calcium hydroxide) root canal filler
stands for Endoflas (Sanlor Laboratories, Miami, Fla., USA), which is a
proprietary brand containing iodoform, zinc oxide, and calcium hydroxide.
ZOE root canal filler stands for a mixture of zinc oxide powder and the
liquid eugenol.
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
due to parent preferences or other reasons determined by the
clinician and parent, extraction may be the best option even
if the tooth is restorable. Regarding the quality of the evidence,
all of the aforementioned recommendations were based on low
or very low levels of evidence except two. The recommenda-
tions regarding rotary versus hand instrumentation of root canals
and LSTR for teeth with root resorption had moderate levels of
evidence. The quality of evidence was not assessed on extractions
of non-restorable teeth. Future trials are needed to further
evaluate which non-vital treatments are effective with follow-up
periods of a minimum of two years.
Exceptions to the guideline recommendations. Regarding
exceptions to the guideline recommendations, treatment plans
may have to be altered from the Figure decision tree’s recommen-
dations due to a child’s ability to cooperate, complex medical
conditions, inability to achieve local anesthesia of the tooth,
limited oral opening, severe gag reflex, facial swelling, oral pain
with an unclear diagnosis, complications from prior pulp ther-
apy, or concurrent periodontal problems. Also, parent and patient
preferences, age, and cost of treatment may alter treatment
decisions that may not conform to this decision tree or guideline.
Scope and purpose
The American Academy of Pediatric Dentistry (AAPD) intends
this guideline to aid clinicians in optimizing patient care when
choosing pulp therapies for treating children with non-vital or
irreversibly inflamed primary teeth. The pulp diagnosis is based
on symptoms as well as clinical and radiographic signs. Carious
or traumatized primary teeth diagnosed with irreversible pulpitis
or necrotic pulp can be treated with non-vital pulp therapies or
extraction. Currently, there are two non-vital pulp therapies for
primary teeth: (1) conventional pulpectomy and (2) lesion steril-
ization tissue repair (LSTR). For this guideline, the overall
(combined clinical and radiographic) success of pulpectomy and
LSTR was evaluated. The influence of various factors, such as
the number of visits, root length determination method, instru-
mentation technique, irrigation, obturation (quality, techniques,
and materials), and removal of the smear layer were evaluated
for the overall success of conventional pulpectomy, which was
also compared to LSTR in primary teeth with and without
preoperative root resorption. In addition, reported adverse
events such as pain were reviewed for this guideline.
The current recommendation supersedes the section on
“Non-vital pulp treatment for primary teeth diagnosed with
irreversible or necrotic pulp” in the AAPD best practices on pulp
therapy for primary and immature permanent teeth2; however,
it does not apply to pulp therapy for immature permanent
teeth or pulp therapy for primary teeth with traumatic injuries.
Clinical questions addressed. The AAPD Workgroup (WG)
used the Population, Intervention, Control, and Outcome
(PICO) formulation to develop the following clinical questions
that will aid clinicians in the use of non-vital pulp therapies
in primary teeth:
1. In primary teeth, how do we diagnose irreversible
pulpitis/pulp necrosis?
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 237
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES

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.

238 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES

5. In primary teeth treated with pulpectomy, does the type
of isolation technique influence success?
6. In primary teeth treated with LSTR, what factors
influence success?
a) When doing LSTR, how does traditional 3Mix
(with tetracycline) compare to alternate 3Mix
(without tetracycline)?
b) When doing LSTR, should the root canals be filed
or broached?
7. What are the adverse events associated with non-vital
pulp therapy in primary teeth?
Methods
The AAPD previously published best practices2 on non-vital
pulp therapy entitled “Pulp Therapy for Primary and Immature
Permanent Teeth,” which was last revised in 2019. Evidence from
a systematic review and meta-analysis of non-vital pulp therapy
for primary teeth,1 published with this guideline, is the basis for
the current guideline’s recommendations.
Search strategy and evidence inclusion criteria. It was
decided a priori to use the AAPD’s systematic review (SR) on
non-vital pulp therapies. 1 The WG used multiple literature
searches in PubMed®/MEDLINE, Embase®, Cochrane Central
Register of Controlled Trials, and trial databases to identify
randomized controlled trials (RCTs) and systematic reviews
addressing peripheral issues not covered by the review, such
as patient preferences and impact of cost. The search strategy
was updated by one of the authors. Title, abstract, and full-text
review of studies was done in duplicate independently by some
WG members. They extracted the data and performed the risk
of bias assessment (ROB) and meta-analyses.
Assessment of the evidence. This guideline is based on
the SR 1 that assessed the quality of the evidence using the
Grades of Recommendation Assessment, Development, and
Evaluation (GRADE)3-5 approach.
Weaknesses of this guideline are inherent to the limitations
found in the SR upon which this guideline is based. Limitations
include failure to review non-English language studies other
than those in Spanish, Portuguese, and Chinese, and the recom-
mendations are based on combined data from studies of different
risks of bias.
Formulation of the recommendations. The WG evaluated
and voted on the level of certainty of the evidence using the
GRADE approach. The GRADE approach recognizes the
evidence quality and certainty as high, moderate, low, and very
low 4,5 based on serious or very serious issues, including the
ROB, imprecision, inconsistency, indirectness of evidence, and
publication bias. To formulate the recommendations, the WG
used an evidence-to-decision framework, including domains
such as priority of the problem, certainty in the evidence, balance
between desirable and undesirable consequences, and patients’
values and preferences. The strength of a recommendation was
assessed to be either strong or conditional, which presents dif-
ferent implications for patients, clinicians, and policy (Table 1).

Table 1. 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 course of action; only a small
proportion would not.
For clinicians Most individuals should receive the recommended
course of action. Adherence to this recommenda-
tion according to the guideline could be used as a
quality criterion or performance indicator. Formal
decision aids are not likely to be needed to help
individuals make decisions consistent with their
values and preferences.
For policymakers The recommendation can be adapted as policy
in most situations, including for the use of
performance indicators.
Most individuals in this situation would want the suggested course of action,
but many would not.
Recognize that different choices will be appropriate for different patients and
that you must help each patient arrive at a management decision consistent with
her or his values and preferences. Decision aids may well be useful in helping
individuals making decisions consistent with their values and preferences.
Clinicians should expect to spend more time with patients when working toward
a decision.
Policymaking will require substantial debates and involvement of many stake-
holders. 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.

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.

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

Table 2. SUMMARY OF CLINICAL RECOMMENDATIONS ON NONVITAL PULP THERAPIES IN PRIMARY TEETH*

Clinical question Recommendation Quality of evidence Strength of

(follow-up duration) recommendation

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-
sorption (external greater than one mm
and/or internal) needing nonvital pulp
therapy, how does the success of LSTR
compare to conventional pulpectomy?
If the clinician decides not to extract the tooth with significant Moderate Conditional
preoperative root resorption, LSTR should be chosen over (12 months)
pulpectomy to save such teeth for up to 12 months and should
be monitored with periodic clinical exams and radiographs
at least every 12 months.

4. In primary teeth treated with pulpectomy what factors influence success?

a) In primary treated with pulpectomy, does
the number of treatment visits influence
success?
In primary teeth treated with pulpectomy the overall success Very low Conditional
after 12 months was not impacted by the number of visits; (12 months)
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,
does the method of root length determina-
tion influence success?
c) In primary teeth treated with pulpectomy,
does the instrumentation (hand instru-
ments versus rotary) technique influence
time of treatment, quality of fill, and
success?
Clinicians may choose any of the methods (tactile, Very low Conditional
radiographs, apex locators) based on their clinical expertise
and individual circumstances.
Rotary instrumentation time was significantly shorter than Moderate Conditional
manual by approximately two minutes, but the two instru-
mentation methods had comparable successes while the
occurrence of flush fills favored rotary. Considering these
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
findings, but there was only one study with root resorption and
one without root resorption. Therefore, a meta-analysis of RCTs
was not computed. A meta-analysis of pulpectomy studies with
24-month follow-up was conducted for combined RCT non-
randomized observational study (NRS) success rates in the SR.1
There was a significant difference between the teeth with or
without preoperative root resorption. Teeth with resorption had
significantly less success (59 percent) compared to teeth without
resorption (88 percent). The quality of the evidence for this
result was very low according to GRADE at 24 months, due
to high ROB and very serious indirectness.

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CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES

Table 2. CONTINUED*

Clinical question Recommendation Quality of evidence Strength of

(follow-up duration) recommendation

f) In primary teeth treated with pulpectomy,
does the choice of obturation material
influence success?
g) In primary teeth treated with nonvital
pulp therapy, does the timing and/or type
of final restoration influence success?
The evidence suggests that ZO/iodoform/CH and ZOE may Very low Conditional
be a better choice for pulpectomy success compared to (18 months)
iodoform at 18 months. The network analysis after 18 months
showed that ZO/iodoform/CH ranked first followed by ZOE
and then iodoform.
The 12-month data showed stainless steel crowns versus fill- Very low Conditional
ings had comparable success unaffected by the timing of
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
3Mix (with tetracycline) compare to alter-
nate 3Mix (without tetracycline)?
Considering the significantly higher success of alternate Very low Conditional
3Mix and the potential adverse effects of tetracycline in
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
and NRS articles, pulpectomy success in teeth without pre-
operative root resorption from the SR1 had higher success (84
to 90 percent) versus teeth with preoperative root resorption
(59 to 69 percent).
Question 3a. In primary teeth with no root resorption needing
non-vital pulp therapy, how does the success of LSTR compare
to conventional pulpectomy?
Recommendation: Pulpectomy success was higher than
LSTR for teeth without preoperative root resorption, indicating
it should be preferred over LSTR in these teeth. (Conditional
recommendation, low quality of evidence.)
Summary of findings: For teeth with no external or internal
root resorption from direct comparison data, LSTR success was
65 percent compared to 92 percent for pulpectomy success.
For this comparison, the meta-analysis favored pulpectomy,
although the difference was not statistically different (relative
risk [RR] equals 0.77; 95 percent confidence interval [95% CI]
equals 0.56 to 1.05).1 The NNT equals five, which means that
after 12 months one failure may be prevented for every five
teeth using pulpectomy instead of LSTR. The quality of the
evidence for this result was low, according to the GRADE at
12 months, due to a serious imprecision seen in the sample sizes
and the serious heterogeneity seen in the I2 statistic (measure-
ment of inconsistency of the data included in the meta-analysis).

242 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Question 3b. In primary teeth with significant root resorption
(external greater than one mm and/or internal) needing non-
vital pulp therapy, how does the success of LSTR compare to
conventional pulpectomy?
Recommendation: If the clinician decides not to extract the
tooth with significant preoperative root resorption, LSTR
should be the choice over pulpectomy to save such teeth for
up to 12 months, but if retained longer should be monitored
with periodic clinical exams and radiographs at least every 12
months after doing LSTR. (Conditional recommendation,
moderate quality of evidence.)
Summary of findings: For teeth with external or internal root
resorption from direct comparison data, the LSTR success rate
was 76 percent compared to the pulpectomy success rate of 47
percent. This included teeth where the canals were filed or not
before antibiotic placement for LSTR. The meta-analysis was
significant (P=0.001), favoring LSTR1 (RR equals 1.65; 95%
CI equals 1.31 to 2.08). The NNT equals four, meaning one
failure would be prevented for every four teeth using LSTR
instead of pulpectomy. The quality of the evidence for this result
was moderate, according to the GRADE at 12 months, due to
the serious imprecision seen in the sample sizes.
Remarks: Qualitative data from prospective8,9 studies showed
the combined 24-month LSTR success was 37 percent in
these studies. The report from Grewal 10 is a 36-month RCT;
it found that LSTR treatment adversely affected the permanent
tooth eruption due to interradicular bone loss and, in one case,
caused an odontogenic keratocyst. Perhaps LSTR should be
used only to save primary molars for up to 12 months to main-
tain space and then be monitored periodically.
Question 4. In primary teeth treated with pulpectomy, what
factors influence success?
Question 4a. In primary teeth treated with pulpectomy, does
the number of treatment visits influence success?
Recommendation: In primary teeth treated with pulpec-
tomy, the overall success after 12 months was not impacted by
the number of visits; therefore, it is suggested that clinicians
may choose either a one-visit or two-visit pulpectomy based on
clinical expertise and individual circumstances. (Conditional
recommendation, very low quality of evidence.)
Summary of findings: The effect of whether one- or two-visit
pulpectomy affected success was tested with meta-analyses in
the SR. 1 For the one-visit group, the pooled success was 74
percent compared to 81 percent for the two-visit group. The
difference between the groups was not significantly different.
The quality of the evidence for this finding was very low due to
the very serious inconsistency in the I2 statistic and the indirect
comparison.
Question 4b. In primary teeth treated with pulpectomy, does
the method of root length determination influence success?
Recommendation: Evidence suggests that clinicians may
choose any of the root length determination methods (tactile,
radiographs, apex locators) based on their clinical expertise
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
and individual circumstances. (Conditional recommendation,
very low quality of evidence.)
Summary of findings: The effect of whether the method
of root length determination altered success was tested with
meta-analyses in the SR.1 For the studies that used an apex locator,
the pooled success was 79 percent compared to 86 percent for
those that used radiographs. The two methods were not signifi-
cantly different (P=0.28). The quality of the evidence for this
finding was very low due to the very serious inconsistency in
the I2 statistic and indirect comparison.
Remarks: There was one in vivo study11 of single-rooted
primary anterior teeth using an apex locator, radiographs, and
tactile feel of the apex in the mouth to the actual length of the
tooth after it was extracted. This article did not evaluate pulpec-
tomy success. Of the 22 teeth without root resorption, the apex
locator and radiographs mean length deviation from the actual
mean length of 15 mm was insignificant while the tactile feel
method was one mm significantly shorter in the same teeth. In
29 teeth with apical root resorption, the mean lengths for tactile
feel, radiographic, and apex locator were 0.1 mm shorter than
the actual length. Two clinical NRSs 12,13 used tactile feel for
their primary tooth pulpectomies. They had success data that
could be computed for 21 months on primary molars (96.6
percent success; 513 out of 531) and 46 months (93.8 percent;
485 out of 517).
Question 4c. In primary teeth treated with pulpectomy, does
the instrumentation (hand instruments versus rotary) technique
influence time of treatment, quality of fill, and success?
Recommendation: Rotary instrumentation time was signifi-
cantly shorter than manual instrumentation time by approxi-
mately two minutes, but the two instrumentation methods
had comparable successes while the occurrence of flush fills (a
root canal filled to the apex) favored rotary. Considering these
findings and the additional resources/training for rotary over
manual instrumentation, clinicians may choose either method
of instrumentation. (Conditional recommendation, moderate
of evidence.)
Summary of findings: manual versus rotary canal preparation
time. The meta-analysis comparing rotary to manual canal filing
showed a significant difference favoring rotary filing, which
was approximately two minutes faster than manual filing
(mean difference [MD] equals -126; 95% CI equals -167 to -85;
P<0.0001). 1 The quality of the evidence for this result was
high according to the GRADE. Although there was hetero-
geneity seen in the I 2 statistic, this was only due to how
much faster rotary canal preparation was compared to manual
preparation. Only one clinical study14 compared manual versus
rotary filing after 24 months, and there was no significant
difference in the two groups’ pulpectomy success. The anti-
bacterial observational study by Subramaniam 15 evaluating
manual versus rotary canal preparation showed no difference in
bacterial reduction.
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CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
Manual versus rotary optimum (flush) filling outcome. The
meta-analysis favored the use of rotary filing compared to
manual root canal filing for achieving a flush apical fill. Although
there was no statistical difference (P=0.07), the use of rotary
filing had 32 percent more flush fills than those using manual
filing. 1 The NNT equals six, meaning that, after doing six
pulpectomies with manual filing, one more flush fill may
have occurred using rotary compared to manual. The quality
of the evidence for this result was moderate according to
the GRADE due to serious heterogeneity seen in the I2 statistic.
Remarks: Rotary instrumentation required less time and
involved less dentin removal and more uniform root canal
preparation.16 Since many primary tooth root canals are ribbon-
shaped and rotary instruments are centered in root canals, rotary
instrumentation may potentially leave behind infected tissue
in unclean areas in fins and isthmuses; also, additional hand
instrumentation with copious irrigation may be needed to
remove the remnant tissues.17 The higher cost of a rotary system
and the need for training to learn the technique are additional
factors to consider.
Question 4d. In primary teeth treated with pulpectomy, does
the removal of the smear layer influence success?
Recommendation: The WG did not find adequate evidence
to make a recommendation on the influence of smear layer
removal on the success of the pulpectomy. In the SR,1 primary
tooth pulpectomy success did not seem to depend on whether
or not the smear layer was removed. Therefore, it is suggested
that the clinician choose either way of managing the smear
layer based on clinical expertise and individual circumstances.
Summary of findings: The effect of smear layer removal
in primary teeth was evaluated in two RCTs in the SR.1 They
could not be evaluated statistically since one was a 24-month
study and the other a 36-month study. The 36-month study
showed, with smear layer removal, a pulpectomy success rate
of 82 percent (14 out of 17) versus 88 percent (15 out of 17)
without smear layer removal, and the 24 months study had
similar success rates that also were not statistically different.
Smear layer removal for pulpectomy in primary teeth does not
seem to alter its success.
Remarks: The smear layer is an accumulation of dentin and
pulpal debris formed on the root canal walls during instrumen-
tation for a pulpectomy by rotary or manual filing. Its removal
possibly allows the root canal filler to adapt better to the canal
walls, but the smear layer may occlude the dentin tubules and
prevent bacteria and toxin penetration.
Question 4e. In primary teeth treated with pulpectomy, does
the choice of irrigants influence success?
Recommendation: The choice of irrigants (sodium hypo-
chlorite one to five percent, water/saline, or chlorhexidine) had
no impact on pulpectomy success. Therefore, the clinicians may
choose any of these irrigation solutions based on their clinical
expertise and individual circumstances. (Conditional recommen-
dation, very low quality of evidence.)
244 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Summary of findings: There were three studies in the SR1
that only used sodium hypochlorite (NaOCl) as the canal
irrigation method. Three other studies used NaOCl and either
saline or distilled water during the canal preparation or as the
final irrigation solution. The effect of whether the type of
irrigation altered success was tested with meta-analyses. For the
studies that used NaOCl, the pooled success was 80 percent
versus 81 percent for those that used NaOCl and saline and/
or distilled water. The difference between the groups was not
significant.1 The quality of the evidence for this result was very
low according to the GRADE due to the serious heterogeneity
in the I2 and the indirectness of the comparisons.
Remarks: The SR 1 investigated irrigation of root canals
using water/saline, NaOCl, and chlorhexidine on pulpectomy
success after 12 months. This data came from a mixture of RCTs
and NRSs with different pulpectomy fillers and methods. The
articles could not be appropriately grouped to conduct direct
comparisons of the irrigation methods. This data could only
compute overall pulpectomy success using the three irrigation
solutions. The water/saline group evaluated eight studies, which
had a pulpectomy success rate of 81 percent (341 out of 421).
The success rate of the pulpectomies from 12 studies in the
NaOCl group was 89 percent (1,370 out of 1,538). For the
three studies in the chlorhexidine group, the success rate of the
pulpectomies was 87 percent (162 out of 186).
Question 4f. In primary teeth treated with pulpectomy, does
the choice of obturation material influence success?
Recommendation: The evidence suggests that zinc oxide/
iodoform/calcium hydroxide (ZO/iodoform/CH) and zinc
oxide eugenol (ZOE) may be a better choices for pulpectomy
success compared to iodoform at 18 months. (Conditional
recommendation, very low quality of evidence.) The network
analysis after 18 months showed that ZO/iodoform/CH ranked
first, ZOE second, and iodoform last.
Summary of findings: pulpectomy root canal fillers—ZOE
versus iodoform pulpectomy success after 18 months. The meta-
analysis showed no significant difference between the success
rates for ZOE (92 percent) and iodoform (71 percent) at 18
months. 1 The ZOE success rate was 14 percent better than
iodoform; the NNT equals 12, indicating that, after doing 12
pulpectomies, one failure may have been prevented using ZOE
compared to iodoform. The quality of the evidence for this
result was very low, according to the GRADE at 18 months,
due to the very serious heterogeneity in the I2 statistic, high
ROB, and sample size issues.
ZOE versus ZO/iodoform/CH success 18 months. The ZO/
iodoform/CH success rate was 93 percent versus 89 percent for
ZOE at 18 months, and the meta-analysis showed no signifi-
cant difference.1 The quality of the evidence for this result was
low, according to the GRADE at 18 months, due to the high
ROB, serious imprecision seen in the sample sizes in each arm.
ZO/iodoform/CH versus iodoform success 18 months. The
ZO/iodoform/CH success rate was 93 percent compared to
63 percent for iodoform at 18 months, and the meta-analysis

showed no significant difference.1 The quality of the evidence
for this result was very low, according to the GRADE at 18
months, due to the high ROB, serious imprecision seen in the
sample sizes in each arm, and the very serious heterogeneity in
the I 2 statistic. The nonsignificant NNT equals seven means
after 18 months, meaning you may prevent one failure after
seven pulpectomies using ZO/iodoform/CH instead of
iodoform.
Remarks: The meta-analysis1 at 18 months showed a signi-
ficant difference (P<0.001) between the success of ZO/
iodoform/CH and the Vitapex brand of iodoform (RR equals
1.73; 95% CI equals 1.34 to 2.33). The Metapex brand of
iodoform showed no significant difference in success compared
to ZO/iodoform/CH (RR equals 1.27; 95% CI equals 0.78
to 1.12).
Network analysis: The objective of a network meta-analysis
is to combine both the direct and indirect evidence across all
studies. The network meta-analysis also ranks the effectiveness
of the studied interventions. The 18-month network analysis
of pulpectomy filler success ranked ZO/iodoform/CH first,
ZOE second, and iodoform worst.1 Regarding the cumulative
probability percentages of rankings, ZO/iodoform/CH and
ZOE were markedly better than iodoform. From the 18-month
direct comparison data, ZO/iodoform/CH or ZOE appeared
to maintain an 18-month success rate near or above 90 percent
over time while iodoform success decreased to 71 percent or
lower.
ZOE and ZO/iodoform/CH versus calcium hydroxide success
12 and 18 months. Two RCTs compared ZOE pulpectomy
success to different CH brands at 12 months. The ZOE success
rate was 99 percent compared to the CH success rate of 74
percent. The meta-analysis showed a nonsignificant difference
between the success rates of ZOE (99 percent) and one CH
brand (74 percent).1 In the SR1 sensitivity analysis, the other
CH brand meta-analysis result was statistically different
(P<0.0001) The NNT equals four, meaning after 12 months one
failure would be prevented using a ZOE pulpectomy instead
of CH. The quality of the evidence for this result was low,
according to the GRADE at 12 months, due to the high ROB
and serious imprecision in the sample sizes.
The SR 1 found only one RCT at 18 months comparing
ZOE to CH. The ZOE success rate was 100 percent (40 out
of 40) compared to the CH success of 85 percent (34 out of
40). The same RCT had different arms of CH compared to ZO/
iodoform/CH success. There was no valid comparison using
these pulpectomy success rates at 12 or 18 months; therefore,
CH was not included in the network analysis.
Question 4g. In primary teeth treated with non-vital pulp
therapy, does the timing and/or type of final restoration in-
fluence success?
Recommendation: The 12-month data showed stainless steel
crowns (SSCs) versus fillings had comparable success unaffected
by the timing of when the final restoration was placed. The
limited 24-month data suggests that teeth restored with SSCs
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
had better success than composites. Therefore, the clinician
may choose the type and timing of restoration placement based
on their clinical preference. (Conditional recommendation,
very low quality of evidence.)
Summary of findings: type of final restoration. The SR1 found
15 studies treated teeth with SSCs and five other studies treated
teeth with a filling (composite or amalgam). A meta-analysis
tested for any 12-month pulpectomy success differences
between the two groups and found no significant difference.
The quality of the evidence for this result was very low,
according to the GRADE, due to the very serious heterogeneity
in the I2 and indirect comparison. The SR1 reported on four
NRSs with 24-month data on the type of restoration and
success using SSCs and two that used composites. These articles
were a mixture of RCTs and observational studies. They showed
24-month pulpectomy success for SSC was 90 percent and for
composite was 77 percent.
Timing of final restoration. The SR1 found 12 studies that
treated the teeth on the same day as the pulpectomy and 10
studies that treated the teeth at a later date. For treatment the
same day, the pulpectomy success after 12 months was 82 per-
cent compared to 83 percent for placing the restoration at a
later date (one day to one or more weeks later). The difference
between the groups was not significant. The quality of the
evidence for this result was very low, according to the GRADE,
due to the very serious heterogeneity in the I 2 and indirect
comparison.
Question 4h. In primary teeth treated with pulpectomy, does
the obturation technique (syringe, Lentulo, hand pluggers)
influence the quality of fill and success?
Recommendation: The quality of the fill (flush fill) and
pulpectomy success using Lentulo spirals, hand pluggers, and
syringes were not statistically different. The clinicians may
choose any of these obturation techniques based on their clin-
ical preference. (Conditional recommendation, very low quality
of evidence.)
Summary of findings: quality of pulpectomy fill. The SR 1
used a forest plot and compared the pulpectomy data on flush
fills (a root canal filled to the apex) from nine studies using
Lentulo spirals, five using hand pluggers, and nine using
syringes. Using a Lentulo spiral resulted in 63 percent flush fills
versus 48 percent with a hand plugger and 62 percent with a
syringe. There was no significant difference for the three
methods of obturation achieving pulpectomy flush fills. This
was a very low quality of evidence due to serious inconsistency
in the I2 statistic and indirectness of evidence.
Obturation method and pulpectomy success. The SR1 used a
forest plot to compare the pulpectomy success using Lentulos
from 12 studies, six using hand pluggers, and seven using
syringes. Using Lentulos resulted in 91 percent success versus
87 percent using hand pluggers and 87 percent with syringes
after 12 months. There was no significant difference in the three
methods of obturation achieving success. The evidence consists
of indirect comparisons from various types of study designs
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 245
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
(RCTs and observational studies) and different follow-up times.
This is a very low quality of evidence due to the very serious
heterogeneity in the I 2 statistic and indirect comparisons of
evidence.
The SR 1 used five RCT studies that directly compared
pulpectomy success using Lentulo fills versus syringe fills after
12 months of follow-up. The meta-analysis showed no signi-
ficant difference in these success rates. This is a very low
quality of evidence due to the high ROB in some studies and
very serious inconsistency in the I2 statistic.
Remarks: The overfilling of the canals appears to be related
to a lower success for pulpectomy. The data from various RCT
and retrospective studies 18-22 show overfilling the root canals
in primary teeth tended to result in lowered success. The type
of obturation technique (hand plugger, Lentulo, syringe
delivery tip) all produce voids when evaluated in vitro and some
techniques may cause more overfills (Lentulo) than others. 23
There were not enough clinical studies to evaluate these effects.
Question 4i. In primary teeth treated with pulpectomy, does
the tooth type (incisor, primary first molar, primary second
molar) influence success?
Recommendation: The WG did not find adequate evidence
to make a recommendation on the influence of tooth type on
success. Pulpectomy success rates from 13 to 36 months do not
seem to be altered if a molar versus an incisor is treated due
to caries. In addition, the pulpectomy success rates for primary
first molars and primary second molars seem to be comparable.
Summary of findings: The SR1 used 10 studies to report the
success rate of the particular primary tooth treated with
pulpectomy and the follow-up time. Three RCTs had a 12- to
36-month follow-up and seven NRSs had a follow-up from
six to 91 months. For teeth treated due to caries and followed
a minimum of 12 months, the incisor success rate was 87
percent (144 out of 166) and the molar success rate was 89
percent (138 out of 155). The success rates for primary first
molars versus second molars were nearly the same (91 percent
[51 out of 56] and 90 percent [69 out of 77], respectively). No
statistical comparison could be made since the evidence con-
sisted of indirect comparisons from various types of study
designs and follow-ups. No GRADE assessment of the quality
of this evidence was possible.
Remarks: The SR1 data indicated tooth type did not appear
to affect the success rates of primary incisor pulpectomies
versus primary molar pulpectomies after 12 months. The suc-
cess rate for primary incisors was 87 percent (144 out of 166)
if treated due to caries versus 89 percent (138 out of 155) for
primary molars.
Question 4J. In incisors that are necrotic as a result of trauma,
is pulpectomy successful?
Recommendation: The WG did not find adequate evidence
to make a recommendation on the influence of trauma on
success. The pulpectomy success rate in incisors treated due to
trauma or caries was comparable. It does not appear that
246 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
pulpectomy success was adversely affected if treated for trauma
or caries unless the tooth was retraumatized.
Summary of findings: The SR1 found 10 studies that assessed
the success of pulpectomy after trauma or caries. The success
rate of traumatized primary anterior teeth pulpectomy after a
minimum of 12 months was 77 percent (122 out of 159) versus
87 percent (144 out of 166) for primary incisors with caries.
No statistical comparison could be made since the evidence
consisted of indirect comparisons from various types of study
designs and follow-ups. No GRADE assessment of the quality
of this evidence was possible.
Remarks: From this data,1 incisor pulpectomy success rates
do not appear to be much different if treated due to trauma or
caries after 12 months. In one RCT study, 24 trauma did not
decrease the success of an incisor pulpectomy unless the incisor
was retraumatized; then pulpectomy success decreased signifi-
cantly to 41 percent.
Question 5. In primary teeth treated with pulpectomy, does
the type of isolation technique influence success?
Recommendation: The WG did not find evidence to make a
recommendation on the type of isolation technique influencing
success. The use of a rubber dam for non-vital procedures is
critical to maintaining isolation from saliva, blood, and other
contaminants.
Summary of findings: All the studies except five used a
rubber dam.1 The five that did not use a rubber dam did not
have usable data to evaluate.
Remarks: The use of a rubber dam is accepted as the stan-
dard of care when performing non-vital pulp therapy. It may
be unethical to perform a study comparing with and without
use of a rubber dam.
Question 6. In primary teeth treated with LSTR what factors
influence success?
Question 6a. When doing LSTR, how does traditional 3Mix
(with tetracycline) compare to alternate 3Mix (without
tetracycline)?
Recommendation: Considering the significantly higher
success of alternate 3Mix and the potential adverse effects of
tetracycline in children, when doing LSTR clinicians should
choose an alternate 3Mix (without tetracycline) over traditional
3Mix. (Conditional recommendation, very low quality of
evidence.)
Summary of findings: The SR 1 reported the 12-month
data of success from nine RCT studies comparing LSTR using
3Mix with minocycline to five LSTR studies using an alternate
antibiotic mixture where a tetracycline was not included. There
was significantly less success statistically (56 percent) using
3-Mix with a tetracycline versus 3-Mix without tetracycline
(76 percent). The quality of the evidence for this result was
very low, according to the GRADE at 12 months due to the
very serious heterogeneity seen in the I 2 statistic, and very
serious indirectness due to the indirect comparison.

Remarks: There also was in vitro evidence on this finding.
Rafatjou25 found that the combination of clindamycin, metro-
nidazole, and ciprofloxacin was as effective as the combination
of minocycline, metronidazole, and ciprofloxacin, with no signi-
ficant difference observed in reducing mean bacterial colony
counts.
Question 6b. When doing LSTR, should the root canals be
filed or broached?
Recommendation: When doing LSTR, clinicians may choose
whether or not to file/broach the canals since the success rate
for each method was not significantly different. (Conditional
recommendation, very low quality of evidence.)
Summary of findings: The SR 1 reported on 11 RCT and
NRS studies of LSTR treatment with 12-month results where
the canals were not filed or broached before placing the anti-
biotic paste. A meta-analysis compared these 11 studies to four
RCT articles on LSTR where the canals were filed and/or
broached before the triple antibiotic paste was placed. There was
no significant difference in success rate when the canals were
filed or broached before the antibiotic paste placement (72
percent) versus when the canals were not filed or broached
before the antibiotic paste was placed (62 percent). The quality
of the evidence for this result was very low, according to the
GRADE at 12 months, due to the serious heterogeneity seen in
the I2 statistic and very serious indirectness due to the indirect
comparison.
Question 7. What are the adverse events associated with
non-vital pulp therapy in primary teeth?
Recommendation: The WG did not find adequate evidence
to make a recommendation on adverse events after pulpectomy.
Moderate to severe pain after 24 hours from a pulpectomy pro-
cedure appears to be rare. Enamel defects in the succedaneous
tooth replacing a tooth with a pulpectomy seems to be rare,
but retained ZOE filler after pulpectomy exfoliation is not an
uncommon occurrence. LSTR treatment after 36 months from
one report 10 described intraradicular bone loss affecting the
permanent tooth. Clinicians should evaluate non-vital pulp
treatments for success and adverse events clinically and radio-
graphically at least every 12 months.
Summary of findings: pulpectomy filler resorption. The qual-
itative data from the SR1 on filler resorption from six RCTs
and NRSs indicated ZOE resorbs slower than the primary
tooth root in some cases. This may cause the permanent tooth’s
path of eruption to be deflected and may result in anterior
crossbite for incisors. The iodoform fillers seemed to resorb at
a faster rate than the root, resulting in the pulpectomy looking
more like a pulpotomy after 12 to 18 months. Seven studies in
the SR1 found that, if the filler is extruded beyond the apex,
iodoform fillers all seem to resorb but ZOE resorbs slowly and
can take years to resorb. The qualitative data reported that
teeth filled with ZOE for the pulpectomy had all or part of the
filler retained in 138 out of 448 teeth (31 percent) based on
data from 13 RCTs and NRSs.
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
Exfoliation after non-vital pulp treatment. The SR1 reported
that, based on Trairatvorakul’s 8 LSTR study, six out of eight
teeth exhibit abnormal exfoliation after a two-year follow-up.
Grewal’s study10 was the longest LSTR follow-up (36 months).
It showed that LSTR-treated teeth did not resorb, unlike
untreated contralateral teeth. The SR1 combined nine studies on
pulpectomy, including RCTs and NRSs showing 76 out of 317
(24 percent) pulpectomy-treated teeth had early exfoliation,
and 29 out of 319 (nine percent) were overretained compared
to contralateral teeth.
Problems from non-vital treatment in primary teeth on the
succedaneous teeth. The SR 1 found only one LSTR study 26
reporting an enamel defect in one out of 71 (one percent) suc-
cedaneous teeth. From the SR,1 qualitative data on pulpectomy
in five NRSsreported on the presence of enamel defects in
succedaneous teeth. The studies indicated the pulpectomy pro-
cedure did not cause enamel defects in the succedaneous tooth.
Instead, defects were related to the age 27 of the child (younger
than 4.6 years) when the tooth became infected, excessive
preoperative root resorption, 28 or trauma. 18 One pulpectomy
study27 involving 103 succedaneous teeth found only seven out
of the 103 (6.8 percent) had a small enamel defect. Grewal10
reported that LSTR teeth followed-up for 36 months were
overretained compared to the conventional pulpectomy treatment
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
interradicular bone loss surrounding the crown of a permanent
successor.
Pain. The SR1 reported that qualitative data on postoper-
ative pain after the first 24 to 48 hours was only associated
when a non-vital treatment failed. The SR1 could only identify
three studies on immediate postoperative pain during the first
24 hours after pulpectomy. Taking the three studies29-31 together,
regardless of the different variables, the SR1 categorized the
results into no pain, mild pain, and moderate to severe pain in
three time intervals: six, 12, and 24 hours posttreatment. The
results at 24 hours showed the following: children having no
pain (80 percent; 208 out of 261); children with mild pain (12
percent; 31 out of 261); and children with moderate to severe
pain (eight percent; 22 out of 261). Severe pain from the
pulpectomy procedure did not appear to be a major occurrence.
Research considerations
For non-vital primary tooth pulp treatment, there are various
criteria used to grade success. The use of a consistent set of stan-
dards to report treatment success would help future systematic
reviewers compare results. A furcation radiolucency should
decrease after six months or totally resolve to be assessed a
success. A static or unchanged radiolucency means the infection
is still present but not causing clinical symptoms.
The WG observed problems with some studies in the
process of compiling the SR.1 Authors should ensure their flow
diagrams match their results and data in their tables. Also,
reviewers of articles should insist that data they are reviewing
matches so that future systematic reviewers can extract valid data
for comparison. Flow diagrams should be made mandatory
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 247
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
for publication by journals, and the flow diagram should match
the CONSORT Flow Diagram for RCTs.
Guideline implementation and recommendation
adherence
This guideline, the AAPD’s first evidence-based guideline on
non-vital pulp therapy, is published in both the journal Pediatric
Dentistry and The Reference Manual of Pediatric Dentistry.
Additionally, AAPD members will be notified of the new
guidelines via social media, newsletters, and presentations. The
guidelines are available as an open-access publication on the
AAPD’s website.
Guidelines are used by insurers, patients, and health care
practitioners to determine the quality of care. Adherence to
guideline recommendations is measured because it is believed
following best practices reduces inappropriate care and improves
outcomes.
Cost-effectiveness of recommendations. The cost-
effectiveness of treatment is based on initial and possible
retreatment costs of an intervention.32 A cost-analysis for therapies
with proven health benefits and minimal adverse effects is an
important consideration for clinicians, patients, and third-party
payors.32 This is especially important when different procedures
with similar outcomes are available to treat a specific condition,
as with non-vital pulp therapies. A research brief covering claims
data for all children with private dental insurance does not list
non-vital pulp therapies in primary teeth as one of top 25
most common procedures performed in children with private
dental benefits, but it lists extractions.33 The few non-vital pulp
therapies performed on a population level compared to extrac-
tion is a cost-effective treatment health issue since extraction
may require a space maintainer to prevent space loss and
malocclusion. However, very limited data exist on the cost-
effectiveness of non-vital pulp therapies in the primary dentition
versus tooth extraction. An extraction alternative may be
determined based on both cost-effectiveness and quality of life,
as maintaining the integrity of the arches has many implications
on function and the development of the occlusion. Pulpectomy
is a procedure reimbursed by both private and federally funded
insurance companies; however, LSTR is not listed as a specifically
coded procedure. Reimbursement of more conservative
approaches of pulp therapy aimed at preserving a tooth, such
as a pulpectomy and LSTR, will allow clinicians to make
conservative choices based exclusively on efficacy and effective-
ness of the specific procedures.34 Clinicians should also make
their decision taking into consideration the age of the child
at the time of treatment, as the longest follow-up times of the
studies used as a basis for these recommendations are 18
months.
In light of the high but relative short-term success of
non-vital tooth therapies, further studies are needed to inves-
tigate the cost-effectiveness of preserving primary molars with
non-vital tooth procedures versus the alternative of extraction and
need for space maintainers before and after the eruption of the
permanent first molar.
248 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
The cost of pulp treatment may be contained by using
effective medicaments, as determined by evidence-based re-
search and detailed in this guideline; however, the only way to
reduce costs overall is to establish dental homes for every child
and implement primary prevention by the child’s parents or
caregiver. Primary prevention must start early if treatment costs
are to be reduced and oral health maintained.
Workgroup and stakeholders. In December 2018, the
AAPD Board of Trustees approved a WG nominated by the
Evidence-Based Dentistry Committee to develop a new
evidence-based clinical practice guideline on non-vital pulp
therapies in primary teeth with deep caries lesions. The WG
consisted of pediatric dentists in public and private practice
involved in research and education; the stakeholders consisted
of representatives from general dentistry, governmental and
nongovernmental agencies, and international and specialty
dental organizations.
External stakeholders. External and internal stakeholders
reviewed the document during the process of development of
the guideline. Internal stakeholders also participated in anony-
mous surveys to determine the scope and outcomes of the
guideline. All stakeholder comments were considered and
addressed in the WG meetings. It is expected that the publica-
tion and dissemination of the guideline will generate additional
dialogue, comments, and feedback from professional, academic,
and community stakeholders.
Intended users. The target audiences for this guideline
are dental team members in private, dental school, or public
health care settings such as pediatric dentists, dental educators,
general dentists, public health practitioners, policymakers, pro-
gram managers, third-party insurers, dental students/residents,
and parents/guardians. The target populations include children
needing non-vital pulp therapy in primary teeth.
Guideline updating process. The AAPD’s Evidence-Based
Dentistry Committee will monitor the biomedical literature
to identify new evidence that may impact the current recom-
mendations. These recommendations will be updated five years
from the time of the last systematic search unless the Evidence-
Based Dentistry Committee determines that an earlier revision
or update is warranted.
References
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3. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines:
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8. Trairatvorakul C, Detsomboonrat P. Success rates of a
mixture of ciprofloxacin, metronidazole, and minocycline
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217-27.
9. Jaya AR, Praveen, Anantharaj A, et al. In vivo evaluation of
lesion sterilization and tissue repair in primary teeth pulp
therapy using two antibiotic drug combinations. J Clin
Pediatr Dent 2012;37(2):189-91.
10. Grewal N, Sharma N, Chawla S. Comparison of resorption
rate of primary teeth treated with alternative lesion steril-
ization and tissue repair and conventional endodontic
treatment: An in vivo randomized clinical trial. J Indian
Soc Pedod Prev Dent 2018;36(3):262-7.
11. Wankhade AD, Kumar R, Singh RK, Chandra A. Root
length determination by different methods in primary
teeth: An in vivo study. Pediatr Dent 2013;35(2):e38-e42.
12. Coll JA, Josell S, Casper JS. Evaluation of a one-
appointment formocresol pulpectomy technique for primary
molars. Pediatr Dent 1985;7(2):123-9.
13. Rawson TH, Rayes S, Strizich G, Salazar CH. Longitudinal
study comparing pulpectomy and pulpotomy treatments
for primary molars of Alaska Native children. Pediatr Dent
2019;41(3):214-20.
14. Moranker R, Goya A, Gauba K, et al. Manual versus
rotary instrumentation for primary molar pulpectomies: A
24-months randomized clinical trial. Pediatr Dent J 2018;
28(2):96-102. Available at: “https://www.semanticscholar.
org/paper/Manual-versus-rotary-instrumentation-for-
primary-A-Morankar-Goyal/fc808b558de6aff5892fd-
2bdd84eb934230cd991”. Accessed September 18, 2020.
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
15. Subramaniam P, Tabrez TA, Girish Babu KL. Microbio-
logical assessment of root canals following use of rotary
and manual instruments in primary molars. J Clin Pediatr
Dent 2013;38(2):123-7.
16. Kummer TR, Calvo MC, Cordeiro MMR, et al. Ex vivo
study of manual and rotary instrumentation techniques
in human primary teeth. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2008;105(4):e84-e92.
17. George S, Anandaraj S, Issac JS, John SA, Harris A. Rotary
endodontics in primary teeth – A review. Saudi Dent J
2016;28(1):12-7.
18. Coll JA, Josell S, Nassof S. et al. An evaluation of pulpal
therapy in primary incisors. Pediatr Dent 1988;10(3):
178-84.
19. Arikan V, Sonmez H, Sari S. Comparison of two base
materials regarding their effect on root canal treatment
success in primary molars with furcation lesions. BioMed
Res Int 2016;2016:1429286.
20. Holan G, Fuks AB. A comparison of pulpectomies using
ZOE and KRI paste in primary molars: A retrospective
study. Pediatr Dent 1993;15(6):403-7.
21. Flaitz CM, Barr ES, Hicks MJ. Radiographic evaluation of
pulpal therapy for primary anterior teeth. ASDC J Dent
Child 1989;56(3):182-5.
22. Sari S, Okte Z. Success rate of Sealapex in root canal treat-
ment for primary teeth: 3-year follow-up. Oral Surg Oral
Med Oral Path Oral Radiol Endod 2008;105(4):e93-e96.
23. Memarpour M, Shahidi S, Meshki R. Comparison of dif-
ferent obturation techniques for primary molars by digital
radiography. Pediatr Dent 2013;35(3):236-40.
24. Rocha MJ, Cardoso M. Survival analysis of endodontically
treated traumatized primary teeth. Dent Traumatol 2007;
23(6):340-7.
25. Rafatjou R, Yousefimashouf R, Farhadian M, Afzalsoltani S.
Evaluation of the antimicrobial efficacy of two combinations
of drugs on bacteria taken from infected primary teeth
(in vitro). Eur Arch Paediatr Dent 2019;20(6):609-15.
26. Hobson P. Pulp treatment of deciduous teeth. 2. Clinical
investigation. Br Dent J 1970;128(6):275-82.
27. Stallaert KM, Sigal MJ, Titley KV, Andrews PB. A retro-
spective study of root canal therapy in non-vital primary
molars. Eur J Paediatr Dent 2016;17(4):295-300.
28. Coll JA, Sadrian R. Predicting pulpectomy success and
its relationship to exfoliation and succedaneous dentition.
Pediatr Dent 1996;18(1):57-63.
29. Panchal V, Jeevanandan G, Subramanian EMG. Comparison
of post-operative pain after root canal instrumentation
with hand K-files, H-files and rotary Kedo-S files in
primary teeth: A randomised clinical trial. Eur Arch
Paediatr Dent 2019;20(5)467-72.
30. Topcuoglu G, Topcuoglu HS, Delikan E, et al. Postoperative
pain after root canal preparation with hand and rotary
files in primary molar teeth. Pediatr Dent 2017;39(3):
192-6.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 249
CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES

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”)

250 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

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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
2022 of examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:253-65.

Abstract
This best practice presents recommendations about anticipatory guidance and timing of other clinical modalities which promote oral health
during infancy, childhood, and adolescence. The guidance, though modifiable to children with special health needs, focuses on healthy,
normal-developing children and addresses comprehensive oral examination, assessment of caries risk, periodontal risk assessment,
professional preventive procedures, fluoride supplementation, radiographic examination, anticipatory guidance, preventive counseling,
sealant placement, treatment of dental disease, trauma, treatment of developing malocclusions, evaluation of third molars, and transition to
adult care. These preventive recommendations may be applied for the following age groups: six to 12 months, 12 to 24 months, 24 months
to six years, six to 12 years, and 12 years and older. The guidance emphasizes the importance of very early professional intervention and
continuity of care based upon theindividualized needs of the child.
The document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding oral health services and counseling for pediatric
dental patients.

KEYWORDS: ANTICIPATORY GUIDANCE, PERIODICITY OF EXAMINATION, PREVENTIVE DENTISTRY, ADOLESCENT DENTISTRY, CARIES-RISK ASSESSMENT,
FLUORIDE SUPPLEMENT, ORAL HYGIENE COUNSELING, DENTAL REFERRAL

Purpose
The American Academy of Pediatric Dentistry (AAPD)
intends these recommendations to help practitioners make
clinical decisions concerning preventive oral health inter-
ventions, including anticipatory guidance and preventive
counseling, for infants, children, and adolescents.
Methods
This document was developed by the Clinical Affairs
Committee, adopted in 19911, and last revised by the Council
on Clinical Affairs in 2018 2. This update used electronic
database and hand searches of articles in the medical and dental
literature using the terms: periodicity of dental examinations,
dental recall intervals, preventive dental services, anticipatory
guidance and dentistry, caries-risk assessment, early childhood
caries, dental caries prediction, dental care cost effectiveness
and children, periodontal disease and children and adolescents
United States (U.S.), pit-and-fissure sealants, dental sealants,
fluoride supplementation and topical fluoride, dental trauma,
dental fracture and tooth, nonnutritive oral habits, treatment of
developing malocclusion, removal of wisdom teeth, removal of
third molars; fields: all; limits: within the last 10 years, humans,
English, and clinical trials; birth through age 18. From this
search, 2,502 articles matched these criteria and were evaluated
by title and/or abstract. When data did not appear sufficient or
were inconclusive, recommendations were based upon expert
and/or consensus opinion by experienced researchers and
clinicians.
Background
Professional dental care is necessary to maintain oral health.3
The AAPD emphasizes the importance of initiating profes-
sional oral health intervention in infancy and continuing
through adolescence and beyond.4 The periodicity of profes-
sional oral health intervention and services is based on a
patient’s individual needs and risk indicators.5-10 Each age
group, as well as each individual child, has distinct develop-
mental needs to be addressed at specific intervals as part of a
comprehensive evaluation.4,11-13 Continuity of care is based on
the assessed needs of the individual patient and assures appro-
priate management of all oral conditions, dental disease, and
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. BMI: Body mass
index. CRA: Caries-risk assessment. ECC: Early childhood caries.
HPV: Human papilloma virus. PRA: Periodontal-risk assessment.
SHCN: Special health care needs. U.S.: United States.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 253

BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE / COUNSELING AND TREATMENT
injuries.14-20 The early dental visit to establish a dental home
provides a foundation upon which a lifetime of preventive
education and oral health care can be built.21 The early estab-
lishment of a dental home has the potential to provide more
effective and less-costly dental care when compared to dental
care provided in emergency care facilities or hospitals.21-25
Anticipatory guidance and counseling are essential components
of the dental visit.4,11,12,21,24-29 The dental home also can influ-
ence general health by instituting additional practices related
to general health promotion, disease prevention, and screening
for non-oral health related concerns. For example, oral health
professionals can calculate and monitor body mass index
(BMI) to help identify children at risk for obesity and provide
appropriate referral to pediatric or nutritional specialists.28
Collaborative efforts and effective communication between
medical and dental homes are essential to prevent oral disease
and promote oral and overall health among children. Medical
professionals can play an important role in children’s oral
health by providing primary prevention and coordinated care.
Equally, dentists can improve the overall health of children
not only by treating dental disease, but also by proactively
recognizing child abuse, preventing traumatic injuries through
anticipatory guidance, preventing obesity by longitudinal
dietary counseling, and monitoring of weight status.30 In addi-
tion, dentists can have a significant role in assessing immuni-
zation status and developmental milestones for potential
delays, as well as making appropriate referral for further
neurodevelopmental evaluations and therapeutic services.31
The unique opportunity that dentists have to help address
overall health issues strengthens as children get older since
frequency of well-child medical visits decreases at the same
time the frequency of dental recall visits increases. Research
shows that children aged six- to 12-years are, on average, four
times more likely to visit a dentist than a pediatrician.32,33
Recommendations
This document addresses periodicity and general principles of
examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for children who have no
contributory medical conditions and are developing normally.
Accurate, comprehensive, and up-to-date medical, dental, and
social histories are necessary for correct diagnosis and effective
treatment planning. Recommendations may be modified to
meet the unique requirements of patients with special health
care needs (SHCN).34
Clinical oral examination
The first examination is recommended at the time of the
eruption of the first tooth and no later than 12 months of
age.4,21,24,25 The developing dentition and occlusion should be
monitored throughout eruption at regular clinical examina-
tions.29 Evidence-based prevention and early detection and
management of caries/oral conditions can improve a child’s
oral and general health, well-being, and school readiness.7,26,35-38
The number and cost of dental procedures among high-risk
254 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
children is less for those seen at an earlier age versus later,
confirming the fact that the sooner a child is seen by a dentist,
the less treatment needs they are likely to have in the future.39
On the other hand, delayed diagnosis of dental disease can
result in exacerbated problems which lead to more extensive
and costly care.10,35,40-43 Guidance of eruption and development
of the primary, mixed, and permanent dentitions contributes
to a stable, esthetic, and functional occlusion.11,29
Components of a comprehensive clinical examination
include:
• general health/growth assessment (e.g., height, weight,
BMI calculation, vital signs);
• pain assessment;
• extraoral soft tissues examination;
• temporomandibular joint assessment;
• intraoral soft tissues examination;
• oral hygiene and periodontal-risk assessment;
• intraoral hard tissue examination;
• assessment of the developing occlusion;
• radiographic assessment, if indicated;
• caries-risk assessment; and
• assessment of cooperative potential/behavior of child.44
Based upon the visual examination, the dentist may employ
additional diagnostic aids (e.g., photographs, pulp vitality
testing, laboratory tests, study casts).10,15,44-46
The interval of examination should be based on the child’s
individual needs or risk status/susceptibility to disease; some
patients may require examination and preventive services at
more or less frequent intervals, based upon historical, clinical,
and radiographic findings.8-10,18,20,26,47-49 While the prevalence
of caries has decreased in primary teeth, the prevalence of
having no caries in the permanent dentition remains un-
changed; caries remains a health problems facing infants,
children, and adolescents in America. 37 Caries lesions are
cumulative and progressive and, in the primary dentition, are
highly predictive of caries occurring in the permanent denti-
tion.6,50 Reevaluation and reinforcement of preventive activities
contribute to improved instruction for the caregiver of the
child or adolescent, continuity of evaluation of the patient’s
health status, and potentially allaying anxiety and fear for the
apprehensive child or adolescent. 51 Individuals with SHCN
may require individualized preventive and treatment strategies
that take into consideration the unique needs and disabilities
of the patient.34
Caries-risk assessment (CRA)
Risk assessment is a key element of contemporary preventive
care. CRA should be performed as soon as the first primary
tooth erupts and be reassessed periodically by dental and
medical providers.6,27 The goal is to prevent disease by identi-
fying patients at high risk for caries and developing individual-
ized preventive measures and caries management, as well as
determining appropriate periodicity of services.27,52,53 Given
that the etiology of dental caries is multifactorial and complex,

current caries-risk assessment models entail a combination of
factors including diet, fluoride exposure, host susceptibility,
and microflora analysis and consideration of how these factors
interact with social, cultural, and behavioral factors. More
comprehensive models that include social, political, psycho-
logical, and environmental determinants of health also are
available.54-57 CRA forms and caries management protocols
aim to simplify and clarify the process.6,27,58,59
Sufficient evidence demonstrates certain groups of children
at greater risk for development of early childhood caries
(ECC) would benefit from infant oral health care.60-64 Infants
and young children have unique caries-risk factors such as
ongoing establishment of oral flora and host defense systems,
susceptibility of newly erupted teeth, and development of
dietary habits. Because the etiology of ECC is multifactorial
and significantly influenced by health behaviors,65 preventive
messages for expectant parents and parents of very young
children should target factors known to place children at a
higher risk for developing caries (e.g., early Mutans strepto-
cocci transmission, poor oral hygiene habits, nighttime feeding,
high frequency of sugar consumption).26,36,57,66 Motivational
problems may develop when parents/patients are not interested
in changing behaviors or feel that the changes require excessive
effort. Parental attitude, self-efficacy, and intention have a
strong correlation to oral hygiene practices in preschoolers.67
Therefore, health care professionals should utilize preventive
approaches based on psychological and behavioral strategies.
Moreover, they should communicate their recommendations
effectively so parents/patients perceive them as behaviors worth
pursuing. Motivational interviewing and self-determination
theory are examples of effective motivational approaches for
caries prevention that share similar psychological philoso-
phies.68-74
Studies have reported caries experience in the primary
dentition as a predictor of future caries.75,76 Early school-aged
children are at a transitional phase from primary to mixed
dentition. These children face challenges such as unsupervised
toothbrushing and increased consumption of cariogenic foods
and beverages while at school, placing them at a higher risk
for developing caries.77-79 Therefore, special attention should
be given to school-aged children regarding their oral hygiene
and dietary practices. The use of newer technology including
cellular telephones (e.g., text messaging, apps) may provide
an additional intervention to improve adherence to oral hygiene
protocols in children and adolescents.80
Adolescence can be a time of heightened caries activity due
to an increased number of tooth surfaces in the permanent
dentition and intake of cariogenic substances, as well as low
priority for oral hygiene procedures.11,55,56 Risk assessment can
assure preventive care (e.g., water fluoridation, professional
and home-use fluoride and antimicrobial agents, frequency
of dental visits) is tailored to each individual’s needs and direct
resources to those for whom preventive interventions provide
the greatest benefit.11,81,82 Because a child’s risk for developing
dental disease can change over time due to changes in habits
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT
(e.g., diet, home care), oral microflora, or physical condition,
risk assessment must be documented and repeated regularly
and frequently to maximize effectiveness.13,27
Periodontal-risk assessment (PRA)
Periodontal-risk assessment is an important component of the
routine examination of pediatric patients. The gingival and
periodontal tissues are subject to change due to normal growth
and development. PRA identifies risk factors that place
individuals at increased risk of developing gingival and
periodontal diseases and pathologies, as well as factors that in-
fluence the progression of the disease. Risk factors for peri-
odontal disease may be biological, environmental (social), and
behavioral.83 Probing assessments should be initiated after the
eruption of the first permanent molars and incisors as tolerated
by the child.49 Probing of primary teeth may be indicated
when clinical and radiographic findings indicate the presence
of periodontal pathology. Bleeding on probing primary teeth
during early childhood, even at a low number of sites, is
indicative of high susceptibility to periodontal diseases due to
the age-dependent reactivity of the gingival tissues to plaque.84
PRA can improve clinical decision making and allow the
implementation of individualized treatment planning and
proactive targeted interventions.85 Maintenance of gingival
and periodontal health during childhood and adolescence can
help assure periodontal health as an adult.49
Prophylaxis and professional topical fluoride treatment
The interval for frequency of professional preventive services is
based upon assessed risk for caries and periodontal disease.5,8-10,
12,13,27,49,58-60
Prophylaxis aids in plaque, stain, and calculus re-
moval, as well as in educating the patient on oral hygiene
techniques and facilitating the clinical examination.12 Gingivitis
is common in children and adolescents and usually responds
to the implementation of therapeutic measures and routine
maintenance.49 Hormonal fluctuations, including those occur-
ring during the onset of puberty and pregnancy, can modify
the gingival inflammatory response to dental plaque.86 There-
fore, recognizing modifying factors that may result in the
development of periodontal disease is important.49
Children who exhibit higher risk of developing caries or
periodontal disease would benefit from recall appointments
at greater frequency than every six months (e.g., every three
months).5,8,10,12,13,27,49,59 This allows increased professional fluoride
therapy application, professional assessment of oral hygiene,
and opportunity to foster improvement of oral health by
demonstrating proper oral hygiene techniques, in addition to
microbial monitoring, antimicrobial therapy reapplication, and
reevaluating behavioral changes for effectiveness.5,12,59,87-90 An
individualized preventive plan increases the probability of good
oral health by demonstrating proper oral hygiene methods/
techniques and removing plaque, stain, and calculus.8,90
Fluoride contributes to the prevention, inhibition, and
reversal of caries.91-93 Professional topical fluoride treatments
should be based on caries-risk assessment.21,27,92,94 Plaque and
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 255
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE / COUNSELING AND TREATMENT
the enamel pellicle are not a barrier to topical fluoride uptake.12
Consequently, patients who receive rubber cup dental prophy-
laxis or a toothbrush prophylaxis before fluoride treatment
exhibit no differences in caries rates.94,95 Precautionary measures
should be taken to prevent swallowing of any professionally-
applied topical fluoride. Children at high caries risk should
receive greater frequency of professional topical fluoride appli-
cations (e.g., every three months).91,94,96-98 Ideally, this would
occur as part of a comprehensive preventive program in a
dental home.21
Fluoride supplementation
The AAPD encourages optimal fluoride exposure for every
child, recognizing community water fluoridation as the most
beneficial and cost-effective preventive intervention.91 Fluoride
supplementation should be considered for children at moder-
ate to high caries risk when fluoride exposure is not optimal.27
Determination of dietary fluoride sources (e.g., drinking water,
toothpaste, foods, beverages) before prescribing supplements
is required and can help reduce intake of excess fluoride.91 In
addition, supplementation should be in accordance with the
guidelines recommended by the AAPD91 and the American
Dental Association99,100.
Radiographic assessment
Radiographs are a valuable adjunct in the oral health care of
infants, children, and adolescents to diagnose and monitor oral
diseases and evaluate dentoalveolar trauma, as well as monitor
dentofacial development and the progress of therapy.47,48
Timing of initial radiographic examination should not be based
on the patient’s age, but upon each child’s individual circum-
stances.47,48 The need for dental radiographs can be determined
only after consideration of the patient’s medical and dental
histories, completion of a thorough clinical examination, and
assessment of the patient’s vulnerability to environmental
factors that affect oral health.47 Every effort must be made to
minimize the patient’s radiation exposure by applying good
radiological practices (e.g., use of protective aprons, thyroid
collars, rectangular collimation) and by following the as low
as reasonably achievable (ALARA) principle.47,101
Anticipatory guidance/counseling
Anticipatory guidance is the process of providing practical
and developmentally-appropriate information about children’s
health to prepare parents for significant physical, emotional, and
psychological milestones.4,11,21,102,103 Individualized discussion
and counseling should be an integral part of each visit. Topics
should include oral hygiene practices, oral/dental development
and growth, speech/language development, nonnutritive habits,
diet and nutrition, injury prevention, tobacco/nicotine product
use, substance misuse, and intraoral/perioral piercing and oral
jewelry/accessories.4,11,17,21,29,102-111
Anticipatory guidance regarding the characteristics of a
normal healthy oral cavity should commence during infant
oral health visits and continue throughout follow-up dental
256 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
visits. This allows parents to quantify any changes such as, but
not limited to, growth delays, traumatic injuries, and poor
oral hygiene or presence of caries lesions. Educating parents
regarding tooth development and chronology of eruption can
help them better understand the implications of delayed or
accelerated tooth emergence. Parents also need to be informed
about the benefits of topical fluorides for newly erupted teeth
which may be at greater risk of developing caries, especially
during the posteruption maturation process.102 Assessment of
each child’s developmental milestones (e.g., fine/gross motor
skills, language, social interactions) is crucial for early recog-
nition of potential delays and appropriate referral to therapeutic
services.31 Speech and language are integral components of a
child’s early development.108 Abnormal delays in speech and
language production can be recognized early with referral made
to address these concerns. Communication and coordination
of appliance therapy with a speech and language professional
can assist in the timely treatment of speech disorders.108
Oral habits (e.g., nonnutritive sucking: digital and pacifier
habits; bruxism; tongue thrust swallow and abnormal tongue
position; self-injurious/self-mutilating behavior) may apply
forces to teeth and dentoalveolar structures. Although early
use of pacifiers and digit sucking are considered normal,
pacifier use beyond 18 months can influence the developing
orofacial complex.112 Increased overjet and Class II malocclu-
sion are more strongly associated with a finger habit versus a
pacifier habit.113,114 Children having a nonnutritive sucking
habit beyond age three have a higher incidence of maloc-
clusions.29,112 Early dental visits provide an opportunity to
counsel parents to help their children stop sucking habits before
malocclusion or skeletal dysplasias occur.29,112 For school-aged
and adolescent patients, counseling regarding any existing
habits (e.g., fingernail biting, clenching, bruxism), including the
potential immediate and long-term effects on the craniofacial
complex and dentition, is appropriate.29 Management of an
oral habit can include patient/parent counseling, behavior
modification techniques, appliance therapy, or referral to
other providers including, but not limited to, orthodontists,
psychologists, or otolaryngologists.29
Oral hygiene counseling involves the parent and patient.
Initially, oral hygiene is the responsibility of the parent. As the
child develops, home care can be performed jointly by parent
and child. When a child demonstrates the understanding and
ability to perform personal hygiene techniques, the health
care professional should counsel the child. The effectiveness of
home care should be monitored at every visit and includes a
discussion on the consistency of daily oral hygiene preventive
activities, including adequate fluoride exposure.5,8,11,27,91,115
The development of dietary habits and childhood food
preferences appears to be established early and may affect the
oral health as well as general health and well-being of a
child.116 The establishment of a dental home no later than
12 months of age allows dietary and nutrition counseling to
occur early. This helps parents to develop proper oral health
habits early in their child’s life, rather than trying to change

established unhealthy habits later. During infancy, counseling
should focus on breastfeeding, bottle or no-spill cup usage,
concerns with nighttime feedings, frequency of in-between
meal consumption of sugar-sweetened beverages (e.g., sweet-
ened milk, soft drinks, fruit-flavored drinks, sports drinks)
and snacks, as well as special diets.28,117 Excess consumption of
carbohydrates, fats, and sodium contribute to poor systemic
health.118-120 Dietary analysis and the impact of dietary choices
on oral health, malnutrition, and obesity121,122, as well as
quality of life, should be addressed through nutritional and
preventive oral health.28,123 The U.S. Departments of Health
and Human Services and Agriculture provide dietary guide-
lines for Americans two years of age and older every five years
to promote a healthy diet and help prevent chronic diseases.123
Traumatic dental injuries in the primary and permanent
dentition occur with great frequency with a prevalence of
one-third of preschool children and one-fourth of school-age
children.20,124 Facial trauma that results in fractured, displaced,
or lost teeth can have significant negative functional, esthetic,
and psychological effects on children.125 Practitioners should
provide age-appropriate injury prevention counseling for oro-
facial trauma. 17,103 Initial discussions should include advice
regarding play objects, pacifiers, car seats, and electrical cords. As
motor coordination develops and the child grows older, the
parent/patient should be counseled on additional safety and
preventive measures, including use of protective equipment (e.g.,
athletic mouthguards, helmets with face shields) for sporting
and high-speed activities (e.g., baseball, bicycling, skiing, four-
wheeling). Dental injuries could have improved outcomes not
only if the public were aware of first-aid measures and the need
to seek immediate treatment, but also if the injured child had
access to emergency care at all times. Caregivers report that,
even though their children had a dental home, they have
experienced barriers to care when referred outside of the dental
home for emergency services.126 Barriers faced by caregivers
include availability of providers and clinics for delivery of
emergency care and the distance one must travel for treatment.
Therefore, primary care providers should inform parents about
ways to access emergency care for dental injuries and provide
telephone numbers to access a dentist, including for after-
hours emergency care.110 Teledentistry may serve as an adjunct
with time-sensitive injuries or when unexpected circumstances
result in difficulties accessing care.127
Smoking and smokeless tobacco use almost always are ini-
tiated and established in adolescence. 111,128,129 In 2020, 6.7
percent of middle school students and 23.6 percent of high
school students reported current tobacco product use. 130 The
most common tobacco products used by middle school and
high school students were reported to be e-cigarettes, cigarettes,
cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis
(unfiltered cigarettes from India).130 E-cigarette decreased from
27.5 to 19.6 percent among high school students and from
5.3 to 4.7 percent among middle school students from 2019
to 2020.130 The recent decline reversing previous trends may be
attributable to multiple factors including increasing the age of
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT
sale of tobacco products from 18 to 21 years.130 Children may
be exposed to opportunities to experiment with other sub-
stances that negatively impact their health and well-being.
Practitioners should provide education regarding the serious
health consequences of tobacco use and exposure to secondhand
smoke.104,130 The practitioner may need to obtain information
regarding tobacco use and alcohol/drug misuse confidentially
from an adolescent patient.11,107 When tobacco or substance
abuse has been identified, practitioners should provide brief
interventions for encouragement, support, and positive rein-
forcement for avoiding substance use.104,107 If indicated, dental
practitioners should provide referral to primary care providers
or behavioral health/addiction specialists for assessment and/
or treatment of substance use disorders.107
Human papilloma virus (HPV) is associated with several
types of cancers, including oral and oropharyngeal cancers.131,132
Seventy percent of oropharyngeal cancers in the U.S. are caused
by HPV, and the number of oropharyngeal cancers is increasing
annually.132 Evidence supports the HPV vaccine as a means to
lessen the risk of oral HPV infection.131,133 The vaccine provides
the greatest protection when administered at ages nine through
12. 132 As adolescent patients tend to see the dentist twice
yearly and more often than their medical care provider, this
is a window of opportunity for the dental professional to
counsel patients and parents about HPV’s link to oral cancer
and the potential benefits of receiving the HPV vaccine.134
Complications from intraoral/perioral piercings can range
from pain, infection, and tooth fracture to life-threatening
conditions of bleeding, edema, and airway obstruction.106 Edu-
cation regarding pathologic conditions and sequelae associated
with piercings should be initiated for the preteen child and
parent and reinforced during subsequent periodic visits. The
AAPD strongly opposes the practice of piercing intraoral and
perioral tissues and use of jewelry on intraoral and perioral
tissues due to the potential for pathological conditions and
sequelae associated with these practices.106
Treatment of dental disease/injury
Health care providers who diagnose oral disease or trauma
should either provide therapy or refer the patient to an
appropriately-trained individual for treatment.135 Immediate
intervention is necessary to prevent further dental destruction,
as well as more widespread health problems. Postponed
treatment can result in exacerbated problems that may lead
to the need for more extensive care.24,36,37,42 Early intervention
could result in savings of health care dollars for individuals, com-
munity health care programs, and third-party payors.23,31,32,36
Treatment of developing malocclusion
Guidance of eruption and development of the primary, mixed,
and permanent dentitions is an integral component of com-
prehensive oral health care for all pediatric dental patients.29
Dentists have the responsibility to recognize, diagnose, and
manage or refer abnormalities in the developing dentition as
dictated by the complexity of the problem and the individual
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 257
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE / COUNSELING AND TREATMENT
clinician’s training, knowledge, and experience.135 Early diag-
nosis and successful treatment of developing malocclusions
can have both short-term and long-term benefits, while
achieving the goals of occlusal harmony and function and
dentofacial esthestics.136 Early treatment is beneficial for many
patients, but is not indicated for every patient. When there is
a reasonable indication that an oral habit will result in un-
favorable sequelae in the developing permanent dentition, any
treatment must be appropriate for the child’s development,
comprehension, and ability to cooperate. Use of an appliance
is indicated only when the child wants to stop the habit and
would benefit from a reminder. 29 At each stage of occlusal
development, the objectives of intervention/treatment include:
(1) managing adverse growth, (2) correcting dental and skeletal
disharmonies, (3) improving esthetics of the smile and the
accompanying positive effects on self-image, and (4) improving
the occlusion.29
Sealants
A 2016 systematic review concluded sealants are effective in
preventing and arresting pit-and-fissure occlusal caries lesions
of primary and permanent molars in children and adolescents
and can minimize the progression of noncavitated occlusal
caries lesions.137 They are indicated for primary and permanent
teeth with pits and fissures.137 At-risk pits and fissures should
be sealed as soon as possible. Because caries risk may increase
at any time during a patient’s life due to changes in habits
(e.g., dietary, home care), oral microflora, or physical condi-
tion, unsealed teeth subsequently might benefit from sealant
application. 138 The need for sealant placement should be
reassessed at periodic preventive care appointments. Sealants
should be monitored and repaired or replaced as needed.138-140
Third molars
Panoramic or periapical radiographic assessment is indicated
during late adolescence to assess the presence, position, and
development of third molars.47,48 Impacted third molars are
potentially pathologic; a 2016 study found the incidence of
cysts or tumors associated with impacted mandibular third
molars to be 0.41-0.71 percent in patients younger than 30
years.141 A decision to remove or retain third molars should
be made before the middle of the third decade. 142,143 Con-
sideration should be given to removal when there is a high
probability of disease or pathology or the risks associated
with early removal are less than the risks of later removal.29,
143,144
Treatment should be provided before pathologic condi-
tions adversely affect the patient’s oral or systemic health.142,143
Postoperative complications for removal of impacted third
molars are low when performed at an early age.145A Cochrane
review in 2012 reported no difference in late lower incisor
crowding with removal or retention of asymptomatic im-
pacted third molars.146 When a decision is made to maintain
disease-free impacted wisdom teeth, clinical and radiographic
monitoring is appropriate to prevent undesirable outcomes.147
258 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Referral for regular and periodic dental care
As adolescent patients approach the age of majority, educating
the patient and parent on the value of transitioning to a dentist
who is experienced in adult oral health can help minimize
disruption of high-quality, developmentally-appropriate health
care. At the time agreed upon by the patient, parent, and
pediatric dentist, the patient should be referred to a specific
practitioner in an environment sensitive to the adolescent’s
individual needs.11,148 Until the new dental home is established,
the patient should maintain a relationship with the current
care provider and have access to emergency services. For the
patient with SHCN, in cases where it is not possible or desired
to transition to another practitioner, the dental home can
remain with the pediatric dentist, and appropriate referrals
for specialized dental care should be recommended when
needed.148 Proper communication and records transfer allow
for consistent and continuous care for the patient.44
Recommendations by age
Six to 12 months
1. Complete the clinical oral examination with adjunctive
diagnostic tools (e.g., radiographs as determined by child’s
history, clinical findings, and susceptibility to oral disease)
to assess oral growth and development, pathology, and/or
injuries; provide diagnosis.
2. Complete a caries-risk assessment.
3. Provide oral hygiene counseling for parents, including
the implications of the oral health of the caregiver.
4. Clean teeth and remove supra- and subgingival stains or
deposits as indicated.
5. Assess the child’s exposure to systemic and topical fluorides
(including type of infant formula used) and exposure to
fluoridated toothpaste and provide counseling regarding
fluoride.
6. Assess appropriateness of feeding practices, including
bottle and breastfeeding, and provide counseling as
indicated; provide dietary counseling related to oral
health.
7. Provide age-appropriate injury prevention counseling for
orofacial trauma.
8. Provide counseling for nonnutritive oral habits (e.g.,
digit, pacifiers).
9. Provide required treatment or appropriate referral for any
oral diseases or injuries.
10. Provide anticipatory guidance.
11. Assess overall growth and development, and make appro-
priate referral to therapeutic services if needed.
12. Consult with the child’s physician as needed.
13. Determine the interval for periodic reevaluation.
12 to 24 months
1. Repeat the procedures for ages six to 12 months every
six months or as indicated by the child’s individual needs
or risk status/susceptibility to disease.

2. Assess appropriateness of feeding practices (including
bottle, breastfeeding, and no-spill training cups) and
provide counseling as indicated.
3. Review patient’s fluoride status and provide parental
counseling.
4. Provide topical fluoride treatments every six months or
as indicated by the child’s individual needs or risk
status/susceptibility to caries.
Two to six years
1. Repeat the procedures for 12 to 24 months every six
months or as indicated by the child’s individual needs
or risk status/susceptibility to disease, including peri-
odontal conditions. Provide age-appropriate oral hygiene
instructions.
2. Assess diet and body mass index to identify patterns
placing patients at increased risk for dental caries or
obesity. Provide counseling or appropriate referral to a
pediatric or nutritional specialist as indicated.
3. Scale and clean the teeth every six months or as indicated
by individual patient’s needs.
4. Provide pit-and-fissure sealants for caries-susceptible
anterior and posterior primary and permanent teeth.
5. Provide counseling and services (e.g., mouthguards) as
needed for orofacial trauma prevention.
6. Assess developing dentition and occlusion and provide
assessment/treatment or referral of malocclusion as
indicated by individual patient’s needs.
7. Provide required treatment or appropriate referral for any
oral diseases, habits, or injuries as indicated.
8. Assess speech and language development and provide
appropriate referral as indicated.
Six to 12 years
1. Repeat the procedures for ages two to six years every
six months or as indicated by child’s individual needs.
2. Complete a periodontal-risk assessment that may include
radiographs and periodontal probing with eruption of
first permanent molars.
3. Provide substance abuse counseling (e.g., smoking,
smokeless tobacco) and referral to primary care providers
or behavioral health/addiction specialists if indicated.
4. Provide education and counseling regarding HPV and the
benefits of the HPV vaccine.
5. Provide counseling on intraoral/perioral piercing.
12 years and older
1. Repeat the procedures for ages six to 12 years every six
months or as indicated by the child’s individual needs
or risk status/susceptibility to disease.
2. During late adolescence, assess the presence, position, and
development of third molars, giving consideration to
removal when there is a high probability of disease or
pathology or the risks associated with early removal are
less than the risks of later removal.
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT
3. At an age determined by patient, parent, and pediatric
dentist, refer the patient to a general dentist for continuing
oral care.
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108. American Speech-Language-Hearing Association. How
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BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE / COUNSELING AND TREATMENT
127. American Academy of Pediatric Dentistry. Policy on
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128. Albert DA, Severson HH, Andrews JA. Tobacco use by
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129. U.S. Department of Health and Human Services. Pre-
venting Tobacco Use Among Youth and Young Adults: A
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partment of Health and Human Services, Centers for
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/data_statistics/sgr/2012/index.htm”. Accessed March 2,
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130. Centers for Disease Control and Prevention. Tobacco use
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131. Jiang S, Dong Y. Human papillomavirus and oral squa-
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134. American Academy of Pediatric Dentistry. Policy on
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135. American Academy of Pediatric Dentistry. Policy on ethi-
cal responsibilities in the oral health care management
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136. Dean JA, Walsh JS. Managing the developing occlusion.
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144. Klene CA, Ferneini EM, Bennett JD. Oral surgery in
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risk factors. J Can Dent Assoc 2007;73(4):325.
146. Mettes TD, Ghaeminia H, Nienhuijs ME, Perry J, van
deer Sanden WJ, Plasschaert A. Surgical removal versus
retention for the management of asymptomatic impacted
wisdom teeth. Cochrane Database Syst Rev 2012;13(6):
CD003879. Available at: “https://repository.ubn.ru.nl/
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Accessed March 6, 2022.
147. Ghaeminia H, Toedtling V, Tummers M, Hoppenreijs T,
Van der Sanden W, Mettes T. Surgical removal versus
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epdf/full”. Accessed March 6, 2022.
148. American Academy of Pediatric Dentistry. Policy on
transitioning from a pediatric to an adult dental home
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Academy of Pediatric Dentistry; 2022:172-5.
 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 of this best practice for supporting information and references.

AGE
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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
2022 assessment and management for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:266-72.

Abstract
This best practice reviews caries-risk assessment and patient care pathways for pediatric patients. Presented caries-related topics include
caries-risk assessment, active surveillance, caries prevention, sealants, fluoride, diet, radiology, and non-restorative treatment. Caries-risk
assessment forms are organized by age: 0-5 years and * 6 years old, incorporating three factor categories (social/behavioral/medical,
clinical, and protective factors) and disease indicators appropriate for the patient age. Each factor category lists specific conditions to be graded
yes if applicable, with the answers tallied to render a caries-risk assessment score of high, moderate, or low. The care management
pathway presents clinical care options beyond surgical or restorative choices and promotes individualized treatment regimens dependent
on patient age, compliance with preventive strategies, and other appropriate strategies. Caries management forms also are organized by
age: 0-5 years and * 6 years old, addressing risk categories of high, moderate, and low, based on treatment categories of diagnostics, pre-
ventive interventions (fluoride, diet counseling, sealants), and restorative care. Caries-risk assessment and clinical management pathways
allow for customized periodicity, diagnostic, preventive, and restorative care for infants, children, adolescents, and individuals with special needs.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific
Affairs to offer updated information and recommendations regarding assessment of caries-risk and risk-based management protocols.

KEYWORDS: CARIES-RISK ASSESSMENT, CARIES PREVENTION, CLINICAL MANAGEMENT PATHWAYS, DENTAL SEALANTS, FLUORIDE

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that caries-risk assessment and management proto-
cols, also called care pathways, can assist clinicians with
decisions regarding treatment based upon a child’s age, caries
risk, and patient compliance and are essential elements of con-
temporary clinical care for infants, children, and adolescents.
These recommendations are intended to educate healthcare
providers and other interested parties on the assessment of
caries risk in contemporary pediatric dentistry and aid in
clinical decision making regarding evidence- and risk-based
diagnostic, fluoride, dietary, and restorative protocols.
Methods
This document was developed by the Council on Clinical
Affairs, adopted in 20021, and last revised in 20192. To update
this document, an electronic search was conducted of publi-
cations from 2012 to 2021 that included systematic reviews/
meta-analyses or reports from expert panels, clinical guidelines,
and other relevant reviews using the terms: caries risk assess-
ment AND diet, sealants, fluoride, radiology, non-restorative
treatment, active surveillance, caries prevention. Five hundred
ninety-two articles met these criteria. Papers for review were
chosen from this list and from references within selected
articles. When data did not appear sufficient or were incon-
clusive, recommendations were based upon expert and/or
consensus opinion by experienced researchers and clinicians.
Background
Caries-risk assessment
Risk assessment procedures used in medical practice generally
have sufficient data to accurately quantitate a person’s disease
susceptibility and allow for preventive measures. However, in
dentistry, sufficiently-validated multivariate screening tools to
determine which children are at higher risk for dental caries
are limited.3,4 Two caries risk assessment tools, namely the
Cariogram5 and CAMBRA tools6, have been validated in clinical
trials and clinical outcomes studies. Several other published
caries-risk assessment tools utilize similar components but
have not been clinically validated.5,7 Nevertheless, caries-risk
assessment:
1. fosters the treatment of the disease process instead of
treating the outcome of the disease.
2. allows an understanding of the disease factors for a
specific patient and aids in individualizing preventive
discussions.
3. individualizes, selects, and determines frequency of
preventive and restorative treatment for a patient.
4. anticipates caries progression or stabilization.
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

266 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

Caries-risk assessment is part of a comprehensive treatment
plan approach based on age of the child, starting with the age
one visit. Caries-risk assessment models currently involve a
combination of factors including diet, fluoride exposure, a
susceptible host, and microflora that interplay with a variety of
social, cultural, and behavioral factors.8 Caries-risk assessment
is the determination of the likelihood of the increased inci-
dence of caries (i.e., new cavitated or incipient lesions) during
a certain time period9,10 or the likelihood that there will be a
change in the size or activity of lesions already present. With
the ability to detect caries in its earliest stages (i.e., noncavitated
or white spot lesions), health care providers can help prevent
cavitation.11
Caries risk factors are variables that are thought to cause
the disease directly (e.g., microflora) or have been shown useful
in predicting it (e.g., life-time poverty, low health literacy)
and include those variables that may be considered protective
factors. The most-used caries risk factors include low salivary
flow, visible plaque on teeth, high frequency sugar consump-
tion, presence of appliance in the mouth, health challenges,
sociodemographic factors, access to care, and cariogenic
microflora.11 The presence of caries lesions, either noncavitated
or cavitated, also has been shown in numerous studies to be
a strong indicator of caries risk. Clinical observation of caries
lesions, or restorations recently placed because of such lesions,
are best thought of as disease indicators rather than risk
factors since these lesions do not cause the disease directly or
indirectly but, very importantly, indicate the presence of the
factors that cause the disease. Protective factors in caries risk
include a child’s receiving optimally-fluoridated water, having

Table 1. Caries-risk Assessment Form for 0-5 Years Old

Use of this tool will help the health care provider assess the child’s risk for developing caries lesions. In addition, reviewing specific
factors will help the practitioner and parent understand the variable influences that contribute to or protect from dental caries.

Factors High risk Moderate risk Low risk

Risk factors, social/behavioral/medical

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 Ƚ Yes

Risk factors, clinical

Child has visible plaque on teeth Yes
Child presents with dental enamel defects 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

Disease indicators ß
Child has noncavitated (incipient/white spot) caries lesions Yes
Child has visible caries lesions Yes
Child has recent restorations or missing teeth due to caries Yes

Ƚ Practitioners may choose a different risk level based on specific medical diagnosis and unique circumstances, especially conditions that affect
motor coordination or cooperation.
ß
While these do not cause caries directly or indirectly, they indicate presence of factors that do.

Instructions: Circle YES that corresponds with those conditions applying to a specific patient. Use the circled responses to visualize the balance
among risk factors, protective factors, and disease indicators. Use this balance or imbalance, together with clinical judgment, to assign a caries
risk level of low, moderate, or high based on the preponderance of factors for the individual. Clinical judgment may justify the weighting of one
factor (e.g., heavy plaque on the teeth) more than others.

Overall assessment of the child’s dental caries risk: High ˆModerate ˆLow ˆ

Adapted with permission from the California Dental Association, (Ramos-Gomez et al. ) 33 Copyright © October 2007.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 267

BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

teeth brushed daily with fluoridated toothpaste, receiving
topical fluoride from a health professional, and having regular
dental care.11,12
Some limitations with the risk factors include the
following:
• Past caries experience is not particularly useful in young
children, and activity of lesions may be more important
than number of lesions.
• Low salivary flow is difficult to measure and may not
be relevant in young children.13
• Frequent sugar consumption is hard to quantitate.
• Sociodemographic factors are just a proxy for various
exposures/behaviors which may affect caries risk.
• Predictive ability of various risk factors across the life
span and how risk changes with age have not been
determined.14
• Genome-level risk factors may account for substantial
variations in caries risk.
Risk assessment tools can aid in the identification of
specific behaviors or risk factors for each individual and allow
dentists and other health care professionals to become more
actively involved in identifying and referring high-risk children.
Tables 1 and 2 incorporate available evidence into practical
tools to assist dental practitioners, physicians, and other non-
dental health care providers in assessing levels of risk for
caries development in infants, children, and adolescents. As
new evidence emerges, these tools can be refined to provide

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

(For Dental Providers)
Use of this tool will help the health care provider assess the child’s risk for developing caries lesions. In addition, reviewing specific
factors will help the practitioner and patient/parent understand the variable influences that contribute to or protect from dental caries.

Factors High risk Moderate risk Low risk

Risk factors, social/behavioral/medical

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 uses hyposalivatory medication(s) Yes
Patient has special health care needs Ƚ Yes

Risk factors, clinical

Patient has low salivary flow Yes
Patient has visible plaque on teeth Yes
Patient presents with dental enamel defects Yes
Patient wears an intraoral appliance Yes
Patient has defective restorations Yes

Protective factors
Patient receives optimally-fluoridated drinking water Yes
Patient has teeth brushed daily with fluoridated toothpaste Yes
Patient receives topical fluoride from health professional Yes
Patient has dental home/regular dental care Yes

Disease indicators ß
Patient has interproximal caries lesion(s) Yes
Patient has new noncavitated (white spot) caries lesions Yes
Patient has new cavitated caries lesions or lesions into dentin radiographically Yes
Patient has restorations that were placed in the last 3 years (new patient) or
Yes
in the last 12 months (patient of record)

Ƚ Practitioners may choose a different risk level based on specific medical diagnosis and unique circumstances, especially conditions that affect
motor coordination or cooperation.
ß
While these do not cause caries directly or indirectly, they indicate presence of factors that do.

Instructions: Circle YES that corresponds with those conditions that apply to a specific patient. Use the circled responses to visualize the balance among
risk factors, protective factors, and disease indicators. Use this balance or imbalance, together with clinical judgment, to assign a caries risk level of
low, moderate, or high based on the preponderance of factors for the individual. Clinical judgment may justify the weighting of one factor (e.g.,
heavy plaque on the teeth more than others).

Overall assessment of the dental caries risk: High ˆModerate ˆLow ˆ

Adapted with permission from the California Dental Association, (Featherstone et al.) 34 Copyright © October 2007.

268 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

greater predictably of caries in children prior to disease initia-
tion. Furthermore, the evolution of caries-risk assessment tools
and care pathways can assist in providing evidence for and
justifying periodicity of services, modification of third-party
involvement in the delivery of dental services, and quality of
care with outcomes assessment to address limited resources
and workforce issues.
Care pathways for caries management
Care pathways are documents designed to assist in clinical
decision making; they provide criteria regarding diagnosis and
treatment and lead to recommended courses of action.15 The
pathways are based on evidence from current peer-reviewed
literature and the considered judgment of expert panels, as
well as clinical experience of practitioners. Care pathways for
caries management in children aged 0-2 and 3-5 years old
were first introduced in 2011.16 Care pathways are updated
frequently as new technologies and evidence develop.
Historically, the management of dental caries was based
on the notion that it was a progressive disease that eventually
destroyed the tooth unless there was surgical/restorative inter-
vention. Decisions for intervention often were learned from
unstandardized dental school instruction and then refined by
clinicians over years of practice. It is now known that surgical
intervention of dental caries alone does not stop the disease
process. Additionally, many lesions do not progress, and tooth
restorations have a finite longevity. Therefore, modern manage-
ment of dental caries should be more conservative and includes
early detection of noncavitated lesions, identification of an
individual’s risk for caries progression, understanding of the
disease process for that individual, and active surveillance to
apply preventive measures and monitor carefully for signs of
arrest or progression.
Care pathways for children further refine the decisions
concerning individualized treatment and treatment thresholds
based on a specific patient’s risk levels, age, and compliance
with preventive strategies (Tables 3 and 4). Such clinical path-
ways yield greater probability of success, fewer complications,
and more efficient use of resources than less standardized
treatment.15

Table 3. Example of Caries Management Pathways for 0-5 Years Old

Preventive interventions
Risk category Diagnostics Restorative
Fluoride Dietary Sealants
counseling
interventions

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
– Radiographs every six
to 12 months
– Drink optimally-fluoridated Yes Yes – Active surveillance of non-
water (alternatively, take cavitated (white spot)
fluoride supplements caries lesions
with fluoride-deficient – Restore cavitated or
water supplies) enlarging caries lesions
– Twice daily brushing with
fluoridated toothpaste
– Professional topical treatment
every three months

High risk – Recall every three months
– Radiographs every six
months
– Drink optimally-fluoridated
water (alternatively, take
fluoride supplements
with fluoride-deficient
water supplies)
– Twice daily brushing with
fluoridated toothpaste
– Professional topical treatment
every three months
– Silver diamine fluoride on
cavitated lesions
Yes Yes – Active surveillance of non-
cavitated (white spot)
caries lesions
– Restore cavitated or
enlarging caries lesions
– Interim therapeutic
restorations (ITR) may
be used until permanent
restorations can be
placed

Notes for caries management pathways table:

Twice daily brushing: Parental supervision of a “smear” amount of fluoridated toothpaste for children under age three, pea-size amount
for children ages three through five.
Surveillance: Periodic monitoring for signs of caries progression; active surveillance: 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.
Sealants: The decision to seal primary and permanent molars should account for both the individual-level and tooth-level risks.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 269

BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

Table 4. Example of a Caries Management Pathways for ≥ 6 Years Old

Preventive interventions
Risk category Diagnostics Restorative
Fluoride Dietary Sealants
counseling
interventions

Low risk – Recall every six to – Drink optimally-fluoridated Yes Yes – Surveillance
12 months water
– Radiographs every – Twice daily brushing with
12 to 24 months fluoridated toothpaste

Moderate risk – Recall every six months
– Radiographs every
six to 12 months
– Drink optimally-fluoridated Yes Yes – Active surveillance of non-
water (alternatively, take cavitated (white spot)
fluoride supplements caries lesions
with fluoride-deficient – Restore cavitated or
water supplies) enlarging caries lesions
– Twice daily brushing with
fluoridated toothpaste
– Professional topical treatment
every six months

High risk – Recall every three – Drink optimally-fluoridated Yes Yes – Active surveillance of non-
months water (alternatively, take cavitated (white spot)
– Radiographs every fluoride supplements caries lesions
six months with fluoride-deficient – Restore cavitated or
water supplies) enlarging caries lesions
– Brushing with 0.5 percent – Interim therapeutic
fluoride gel/paste restorations (ITR) may
– Professional topical treatment be used until permanent
every three months restorations can be
– Silver diamine fluoride on placed
cavitated lesions

Notes for caries management pathways table:

Twice daily brushing: Parental supervision of a pea-size amount of fluoridated toothpaste for children six years of age.
Surveillance: Periodic monitoring for signs of caries progression; active surveillance: 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.
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 risks.

Content of the present caries management protocol is
based on results of systematic reviews and expert panel
recommendations that provide better understanding of and
recommendations for diagnostic, preventive, and restorative
treatments. Recommendations for the use of fluoridated
toothpaste are based on four systematic reviews17-20, dietary
fluoride supplements are based on the Centers for Disease
Control and Prevention’s fluoride guidelines21, professionally-
applied and prescription strength home-use topical fluoride are
based on two systematic reviews19,22, the use of silver diamine
fluoride to arrest caries lesions also is based on two systematic
reviews23,24. Radiographic diagnostic recommendations are
based on the uniform guidelines from national organizations.25
Recommendations for pit-and-fissure sealants are based on
two systematic reviews26,27, with only the American Dental
Association/AAPD review addressing sealants for primary
teeth. Dietary interventions are based on a systematic review of
strategies to reduce sugar-sweetened beverages.28 Caries risk is
assessed at both the individual level and tooth level. Treatment
of caries with interim therapeutic restorations is based on
the AAPD policy and recommended best practices.29,30 Active
surveillance (prevention therapies and close monitoring) of
enamel lesions is based on the concept that treatment of
disease may only be necessary if there is disease progression,31
and that caries can arrest without treatment.32
Other approaches to the assessment and treatment of dental
caries will emerge with time and, with evidence of effectiveness,
may be included in future guidelines on caries-risk assessment
and care pathways.
Recommendations
1. Dental caries-risk assessment, based on a child’s age,
social/behavioral/medical factors, protective factors, and
clinical findings, should be a routine component of new
and periodic examinations by oral health and medical
providers.
2. While there is not enough information at present to have
quantitative caries-risk assessment analyses, estimating

270 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


children at low, moderate, and high caries risk by a
preponderance of risk and protective factors and disease
indicators will enable a more evidence-based approach to
medical provider referrals, as well as establish periodicity
and intensity of diagnostic, preventive, and restorative
interventions.
3. Care pathways, based on a child’s age and caries risk,
provide health providers with criteria and protocols for
determining the types and frequency of diagnostic,
preventive, and restorative interventions for patient-
specific management of dental caries.
References
1. American Academy of Pediatric Dentistry. The use of a
caries-risk assessment tool (CAT) for infants, children,
and adolescents. Pediatr Dent 2002;24(7):15-7.
2. 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;
2019:220-4.
3. Cagetti MG, Bonta G, Cocco F, Lingstrom P, Strohmenger
L, Campus G. Are standardized caries risk assessment
models effective in assessing actual caries status and future
caries increment? A systematic review. BMC Oral Health
2018;18(1):123.
4. Moyer V. Prevention of dental caries in children from
birth through age 5 years: U.S. Preventive Services Task
Force recommendation statement. Pediatrics 2014;133
(6):1102-10.
5. Bratthall D, Hansel Petersson G. Cariogram--A
multifactorial risk assessment model for a multifactorial
disease. Community Dent Oral Epidemiol 2005;33(4):
256-64.
6. Featherstone JBD, Domejean-Orliaguet S, Jenson L, et al.
Caries risk assessment in practice for age 6 through adult.
J Calif Dent Assoc 2007;35(10):703-13.
7. Featherstone JDB, Crystal YO, Alston, P, et al. A compar-
ison of four caries risk assessment methods. Front Oral
Health 2021;2:656558. Available at: “https://www.
frontiersin.org/articles/10.3389/froh.2021.656558/full”.
Accessed August 26, 2022.
8. Harrison-Barry L, Elsworthy K, Pukallus M, et al. The
Queensland Birth Cohort Study for Early Childhood
Caries: Results at 7 years. JDR Clin Trans Res 2022;7(1):
80-9.
9. Fontana M, Carrasco-Labra A, Spallek H, Eckert G,
Katz B. Improving caries prediction modeling: A call for
action. J Dent Res 2020;99(11):1215-0.
10. Kirthiga M, Murugan M, Saikia A, Kirubakaran R. Risk
factors for early childhood caries: A systematic meta-
analysis of case control and cohort studies. Pediatr Dent
2019;41(2):95-112.
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11. American Dental Association. Guidance on caries risk
assessment in children, June 2018. Available at: “https:
//www.ada.org/~/media/ADA/DQA/CRA_Report.pdf
?la=en”. Accessed March 11, 2022.
12. Machiulskiene V, Campus G, Carvalho JC, et al. Termi-
nology of dental caries and dental caries management:
Consensus report of a workshop organized by ORCA
and Cariology Research Group of IADR. Caries Res
2020;54(1):7-14.
13. Alaluusua S, Malmivirta R. Early plaque accumulation:
A sign for caries risk in young children. Community
Dent Oral Epidemiol 1994;22(10):273-6.
14. Divaris K. Predicting dental caries outcomes in childhood:
A “risky” concept. J Dent Res 2016;95(3):248-54.
15. Rotter T, Kinsman L, James E, et al. The effects of clini-
cal pathways on professional practice, patient outcomes,
length of stay, and hospital costs: Cochrane systematic
review and meta-analysis. Eval Health Prof 2012;35(1):
3-27.
16. Ramos-Gomez F, Ng MW. Into the future: Keeping
healthy teeth caries free. Pediatric CAMBRA protocols. J
Cal Dent Assoc 2011;39(10):723-32.
17. Santos APP, Nadanovsky P, Oliveira BH. A systematic
review and meta-analysis of the effects of fluoride tooth-
paste on the prevention of dental caries in the primary
dentition of preschool children. Community Dent Oral
Epidemiol 2013;41(1):1-12.
18. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste
efficacy and safety in children younger than 6 years. J
Am Dent Assoc 2014;145(2):182-9.
19. Scottish Intercollegiate Guidelines Network: SIGN 138:
Dental interventions to prevent caries in children, March
2014. Available at: “https://www.sign.ac.uk/assets/sign
138.pdf ”. Accessed March 17, 2022.
20. Walsh T, Worthington HV, Glenny AM, Marinho VCC,
Jeroncic A. Fluoride toothpastes of different concentra-
tions for preventing dental caries. Cochrane Database
Sys Rev 2019;3(3):CD007868. Available at: “https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC6398117/”.
Accessed September 12, 2022.
21. Centers for Disease Control and Prevention. Recommen-
dations for using fluoride to prevent and control dental
caries in the United States. MMWR Recomm Rep 2001;
50(RR14):1-42.
22. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride
for caries prevention: Executive summary of the updat-
ed clinical recommendations and supporting systematic
review. J Am Dent Assoc 2013;144(11):1279-91.
23. 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):135-45.
References continued on the next page.
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24. Slayton R, Araujo M, Guzman-Armstrong S, et al.
Evidence-based clinical practice guideline for non-
restorative management of dental caries. J Am Dent Assoc
2018;149(10):837-49.
25. U.S. Food and Drug Administration, American Dental
Association, Department of Health and Human Services.
Dental Radiographic Examinations for Patient Selection
and Limiting Radiation Exposure, 2012. Available at:
“https://www.ada.org/~/media/ADA/Member%20Center
/FIles/Dental_Radiographic_Examinations_2012.pdf ”.
Accessed March 17, 2022.
26. Wright JT, Tampi MP, Graham L, et al. Sealants for
preventing and arresting pit-and-fissure occlusal caries in
primary and permanent molars. A systematic review of
randomized controlled trials–A report of the American
Dental Association and the American Academy of
Pediatric Dentistry. Pediatr Dent 2016;38(4):282-94.
E1-E4. Erratum in: Pediatr Dent 2017;39(2):100. Avail-
able at: “https://pubmed.ncbi.nlm.nih.gov/27557916/”.
September 12, 2022.
27. Ahovuo‐Saloranta A, Forss H, Walsh T, Nordblad A,
Mäkelä M, Worthington HV. Pit and fissure sealants for
preventing dental decay in permanent teeth. Cochrane
Database Sys Rev 2017;7(7):CD001830. Available at:
“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC63
98117/”. September 12, 2022.
272 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
28. Vercammen KA, Frelier JM, Lawery CM, McGlone ME,
Ebbeling CB, Bleich SN. A systematic review of strategies
to reduce sugar-sweetened beverage consumption among
0-year to 5-year-olds. Obes Rev 2018;19(11):1504-24.
29. American Academy of Pediatric Dentistry. Policy on
interim therapeutic restorations (ITR). The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:78-9.
30. American Academy of Pediatric Dentistry. Pediatric
restorative dentistry. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:401-14.
31. Parker C. Active surveillance: Toward a new paradigm in
the management of early prostate cancer. Lancet Oncol
2004;5(2):101-6.
32. Ekstrand KR, Bakhshandeh A. Martignon S. Treatment
of proximal superficial caries lesions on primary molar
teeth with resin infiltration and fluoride varnish versus
fluoride varnish only: Efficacy after 1 year. Caries Res
2010;44(1):41-6.
33. Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL,
Featherstone JDB. Caries risk assessment appropriate for
the age 1 visit (infants and toddlers). J Calif Dent Assoc
2007;35(10):687-702.
34. Featherstone JBD, Domejean-Orliaguet S, Jenson L, et
al. Caries risk assessment in practice for age 6 through
adult. J Calif Dent Assoc 2007;35(10):703-13.
 BEST PRACTICES: PRESCRIBING DENTAL RADIOGRAPHS

Prescribing Dental Radiographs for Infants,

Children, Adolescents, and Individuals with Special
Health Care Needs
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Prescribing
2021 dental radiographs for infants, children, adolescents, and individuals
with special health care needs. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:273-6.

Abstract
This best practice provides guidance on the proper timing, selection, and frequency of dental radiographs for pediatric dental patients and
endorses the U.S. Food and Drug Administration and American Dental Association’s Recommendations for Prescribing Dental Radiographs.
Recommendations were made according to type of patient encounter and the patient’s age and stage of dental development. Considerations
included clinical findings, medical and dental histories, and risk factors for dental caries. This document highlights the purpose of radiographs
for diagnosing oral diseases and trauma, monitoring growth and development, and assessing treatment outcomes. Emphasis is placed on
the importance of minimizing radiation in the pediatric population, and intraoral radiographs are confirmed as the standard diagnostic
radiographic tool. Special attention is paid to justification for use of cone beam computed tomography, related safety concerns, and need
for comprehensive interpretation of resulting images. Dental providers may reference this document to guide decisions regarding the type
and periodicity of dental radiographs, with aims to improve patient care, limit radiation exposure, and utilize resources appropriately.
This best practice was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding prescribing radiographs for pediatric dental patients.

KEYWORDS: ADOLESCENT, CHILD, CONE BEAM COMPUTED TOMOGRAPHY, GROWTH AND DEVELOPMENT, RADIATION, RADIOGRAPHY, RISK ASSESSMENT,
THYROID GLAND

Purpose has published updates to their recommendations for dental

The American Academy of Pediatric Dentistry (AAPD) intends
these recommendations to help practitioners make clinical
decisions concerning appropriate selection of dental radio-
graphs as part of an oral evaluation of infants, children,
adolescents, and individuals with special health care needs.
The recommendations can be used to optimize patient care,
minimize radiation burden, and allocate health care resources
responsibly.
radiographs.5,6 While continuing to endorse the ADA/FDA’s
recommendations, the AAPD expanded its guidance on dental
radiographs, with the last revision in 2017 7. This review
®
includes a new search of the PubMed /MEDLINE database
using the terms: dental radiology, dental radiographs, dental
radiography, cone-beam computed tomography AND guide-
lines, recommendations; fields: all; limits: within the last 10
years, humans, and English.

Methods
In 1981, the Ad Hoc Committee on Pedodontic Radiology
of the American Academy of Pedodontics developed guidance
on radiographic examination of pediatric dental patients.1 Six
years later, the United States Food and Drug Administration
(FDA) published recommendations2 developed by an expert
dental panel, which included a representative of the AAPD,
convened “to reach a consensus on standardizing dental radio-
graphic procedures”3. In 2002, the American Dental Association
(ADA) initiated a review of that document. The AAPD, along
with other dental specialty organizations, participated in the
review and revision of those guidelines. The FDA accepted
the revision in November 2004,4 and the AAPD endorsed it
the following spring. The ADA Council on Scientific Affairs
Background
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,
evaluate dentoalveolar trauma, as well as monitor dentofacial
development and the progress of therapy. The recommenda-
tions in the ADA/FDA guidelines were developed to serve as
ABBREVIATIONS
AAOMR: American Academy of Oral and Maxillofacial Radiology.
AAPD: American Academy of Pediatric Dentistry. ADA: American
Dental Association. ALARA: As low as reasonably achievable.
CBCT: Cone-beam computed tomography. FDA: U.S. Food and
Drug Administration.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 273

BEST PRACTICES: PRESCRIBING DENTAL RADIOGRAPHS

an adjunct to the dentist’s professional judgment. The timing
of the initial radiographic examination should not be based
upon the patient’s age, but upon each child’s individual cir-
cumstances. Radiographic screening for the purpose of
detecting disease before clinical examination should not be
performed.6 Because each patient is unique, the need for den-
tal radiographs can be determined only after consideration
of the patient’s medical and dental histories, completion of a
thorough clinical examination, and assessment of the patient’s
vulnerability to environmental factors that affect oral health.
AAPD’s recommendations for assessing risk for caries de-
velopment in children ages birth through five years and age
six and above can be found in Caries-Risk Assessment and
Management for Infants, Children, and Adolescents.8 Review of
prior radiographs, when available from within the same practice
or through record transfer, also contributes to the decision of
radiographic necessity.

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
being evaluated for oral exam consisting of selected
diseases. periapical/occlusal views and/
or posterior bitewings if
proximal surfaces cannot be
visualized or probed. Patients
without evidence of disease
and with open proximal con-
tacts may not require a radio-
graphic exam at this time.
Individualized radiographic
exam consisting of posterior
bitewings with panoramic
exam or posterior bitewings
and selected periapical
images.
Individualized radiographic exam consisting of posterior bite-
wings with panoramic exam or posterior bitewings and selected
periapical images. A full mouth intraoral radiographic exam is
preferred when the patient has clinical evidence of generalized
oral disease or a history of extensive dental treatment.

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)
for monitoring of dento-
facial growth and develop-
ment, and/or assessment
of dental/skeletal
relationships.
Clinical judgment as to need for and type of radiographic Clinical judgment as to need for
images for evaluation and/or monitoring of dentofacial and type of radiographic images
growth and development or assessmentof dental and skeletal for evaluation and/or monitor-
relationships. ing of dentofacial growth and
development, or assessment of
dental and skeletal relationships.
Panoramic or periapical exam to
assess developing third molars.
Usually not indicated for
monitoring of growth and
development. Clinical
judgment as to the need
for and type of radio-
graphic image for evalua-
tion of dental and skeletal
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.

* Clinical situations for which radiographs may be indicated include, but are not limited to:
A. Positive Historical Findings B. Positive Clinical Signs/Symptoms

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* * Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0–6 years of age 20 and over 6 years of age 21).

Copyright © 2012 American Dental Association. All rights reserved. Reprinted with permission.

274 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Radiographs should be taken to substantiate a clinical
diagnosis and guide the practitioner in making an informed
decision that will affect patient care. The AAPD recognizes that
there may be clinical circumstances for which a radiograph is
indicated, but a diagnostic image cannot be obtained. When
diagnostic radiographs cannot be obtained due to a lack of
cooperation, technical issues, or a health care facility lacking
in intraoral radiographic capabilities, the practitioner should
inform the patient or guardian of these limitations and docu-
ment these discussions in the patient’s record. The decision to
treat the patient without radiographs will depend upon the
urgency of the treatment needs, availability and appropriateness
of alternative treatment settings, and relative risks and benefits
of the various treatment options for the patient.
Because the effects of radiation exposure accumulate over
time,4,9 every effort must be made to minimize the patient’s
exposure. Good radiological practices are important in mini-
mizing or eliminating unnecessary radiation in diagnostic
dental imaging. Examples of good radiologic practice include:
1) use of the fastest image receptor compatible with the
diagnostic task (F-speed film or digital [photostimulable
phosphor {PSP} plate, charge-coupled device {CCD}]), 2)
collimation of the beam to the size of the receptor whenever
feasible, 10-12 3) proper film exposure and processing tech-
niques, 4) use of protective aprons and thyroid collars, and
5) limiting the number of images to the minimum necessary
to obtain essential diagnostic information.6 The dentist must
weigh the benefits of obtaining radiographs against the
patient’s risk of radiation exposure. Some of the newer
panoramic machines are capable of producing extraoral bite-
wings. The radiation dose is similar to a traditional panoramic
radiograph, although it is three to 11 times more than the
traditional intraoral bitewing. 13 Therefore, the extraoral
bitewing should be prescribed based upon case specific
needs and not as an alternative to intraoral radiographs.14
New imaging technology (i.e., cone beam computed
tomography [CBCT]) has added three-dimensional capabili-
ties that have many applications in dentistry. The use of CBCT
has been valuable as an adjunct diagnostic tool in assessing
periapical pathosis in endodontics, oral pathology, anomalies
in the developing dentition (e.g., impacted, ectopic, or super-
numerary teeth), oral maxillofacial surgery (e.g., cleft palate),
dental and facial trauma, and orthodontic and surgical
preparation for orthognathic surgery. For all procedures using
CBCT, the clinical benefits must be balanced against the
potential risks. Considering the cumulative effect of ionizing
radiation 4,9, and that children are more prone to radiation
induced carcinogenesis than adults, the clinician needs to
be aware of the inherent risks associated with cone beam
tomography and the as low as reasonably achievable (ALARA)
principle in patient selection. 15 The American Academy of
Oral and Maxillofacial Radiology (AAOMR) has published
position statements which summarize the potential benefits
and risks of maxillofacial CBCT use in orthodontic and
endodontic diagnosis, treatment, and outcomes and provides
BEST PRACTICES: PRESCRIBING DENTAL RADIOGRAPHS
clinical guidance to dental practitioners. 16,17 The AAOMR’s
position statements support and affirm the position of the
ADA Council on Scientific Affairs that the selection of CBCT
imaging must be justified based on individual need. 16-18
Because this technology has potential to produce vast amounts
of data and imaging information beyond initial intentions,
it is important to interpret all information obtained, including
that which may be beyond the immediate diagnostic needs
or abilities of the practitioner, and CBCT imaging should
be referred for radiological and diagnostic interpretation.
Recommendations
The recommendations of the ADA/FDA guidelines are
contained within the accompanying Table. “These recom-
mendations are subject to clinical judgment and may not
apply to every patient. They are to be used by dentists only
after reviewing the patient’s health history and completing
a clinical examination. Even though radiation exposure from
dental radiographs is low, once a decision to obtain radio-
graphs is made, it is the dentist’s responsibility to follow the
ALARA principle to minimize the patient’s exposure.”6
Intraoral imaging should be maintained as the standard
diagnostic tool. The use of CBCT should be considered when
conventional radiographs are inadequate to complete diagnosis
and treatment planning and the potential benefits outweigh
the risk of additional radiation dose. It must not be routinely
prescribed for diagnosis or screening purposes in the absence
of clinical indication. Basic principles and guidelines for the
use of CBCT include: 1) use appropriate image size or field
of view, 2) assess the radiation dose risk, 3) minimize patient
radiation exposure, and 4) maintain professional competency
in performing and interpreting CBCT studies. 16-19 When
using CBCT, the resulting imaging is required to be supple-
mented with a written report placed in the patient’s records
that includes full interpretation of the findings.
References
1. American Academy of Pedodontics. Dental radiographs
in children. American Academy Pediatric Dentistry
Reference Manual 1991-1992. Chicago, Ill.: American
Academy of Pediatric Dentistry; 1991:27-8.
2. Joseph LP. The Selection of Patients for X-ray Exam-
inations: Dental Radiographic Examinations. Rockville,
Md.: The Dental Radiographic Patient Selection Criteria
Panel, U.S. Department of Health and Human Services,
Center for Devices and Radiological Health; 1987. HHS
Publication No. FDA 88-8273.
3. American Academy Pediatric Dentistry. Guidelines for
prescribing dental radiographs. Pediatr Dent 1995;17(6):
66-7.
4. American Dental Association, U.S. Department of Health
and Human Services. The selection of patients for dental
radiographic examinations—2004. Available at: “https://
www.fda.gov/media/74704/download”. Accessed August
15, 2021.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 275
BEST PRACTICES: PRESCRIBING DENTAL RADIOGRAPHS
5. American Dental Association Council on Scientific
Affairs. The use of dental radiographs: Update and
recommendations. J Am Dent Assoc 2006;137(9):
1304-12.
6. American Dental Association Council on Scientific
Affairs, U.S. Department of Health and Human Services
Public Health Service Food and Drug Administration.
Dental Radiographic Examinations: Recommendations
for Patient Selection and Limiting Radiation Exposure.
Chicago, Ill.: American Dental Association; 2012:5-7.
Available at: “https://www.ada.org/~/media/ADA/
Member%20Center/FIles/Dental_Radiographic_
Examinations_2012.ashx”. Accessed August 15, 2021.
7. American Academy Pediatric Dentistry. Guidelines on
prescribing dental radiographs for infants, children,
adolescents, and individuals with special health care
needs. Pediatr Dent 2017;39(6):205-7.
8. American Dental Association. Caries-risk assessment and
management for infants, children, and adolescents. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2021:252-7.
9. Hall JD, Godwin M, Clarke T. Lifetime exposure to
radiation from imaging investigations. Can Fam Physician
2006;52(8):976-7. Available at: “https://www.cfp.ca/
content/cfp/52/8/976.full.pdf ”. Accessed August 15,
2021.
10. National Council on Radiation Protection and
Measurements (NCRP) Radiation Protection in Dentistry
and Oral Maxillofacial Imaging, # 177 December 19,
2019:84.
11. Mallya SM. Safety and protection. In: White and
Pharoah’s Oral Radiology Principles and Interpretation.
Mallya SM, Lam EWN, eds. 8th ed. St. Louis, Mo.:
Elsevier, Inc.; 2019:29.
12. Mol A. Digital imaging. In: White and Pharoah’s Oral
Radiology Principles and Interpretation. Mallya SM,
Lam EWN, eds. 8th ed. St. Louis, Mo: Elsevier, Inc.;
2019:40-6.
13. Branets I, Stabulas J, Dauer LT, et al. Pediatric bitewing
exposure to organs of the head and neck through the
use of juvenile anthropomorphic phantoms. J Oral Biol
2014:1(1):5. Available at: “https://pdfs.semanticscholar
.org/6c43/23f1b8f01f6a37c672f37f51370a9dbc0239.
pdf?_ga=2.154639409.88309241.1625333899-67121
359.1625333899”. Accessed August 15, 2021.
14. Wiley D, Yepes J, Sanders B, Jones J, Johnson B, Tang Q.
Pediatric phantom dosimetry evaluation of the extraoral
bitewing. Pediatr Dent 2019;42(1):3-7.
276 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
15. Kutanzi KR, Lumen A, Koturbash I, Miousse IR. Pediatric
exposures to ionizing radiation: Carcinogenic considera-
tions. Int J Environ Res Public Health 2016;13(11):
1057.
16. American Academy of Oral and Maxillofacial Radiology.
Clinical recommendations regarding use of cone beam
computed tomography in orthodontics. Position statement
by the American Academy of Oral and Maxillofacial
Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol
2013;116(2):238-57. Erratum in Oral Surg Oral Med
Oral Pathol Oral Radiol 2013;116(5):661.
17. Special Committee to Revise the Joint AAE/AAOMR
Position Statement on use of CBCT in Endodontics.
AAE and AAOMR joint position statement: Use of cone
beam computed tomography in endodontics 2015/2016
Update. Available at: “https://f3f142zs0k2w1kg84k5p
9i1o-wpengine.netdna-ssl.com/specialty/wp-content/up
loads/sites/2/2017/06/conebeamstatement.pdf ”. Accessed
October 10, 2021.
18. American Dental Association Council on Scientific
Affairs. The use of cone-beam computed tomography
in dentistry. An advisory statement from the American
Dental Association Council on Clinical Affairs. J Am
Dent Assoc 2012;143(8):899-902.
19. SEDENTEXCT Project (2008-2011). Radiation protec-
tion No. 172: Cone beam CT for dental and maxillofacial
radiology. Evidence-based guidelines. European
Commission. Available at: “https://ec.europa.eu/energy/
sites/ener/files/documents/172.pdf ”. Accessed August
15, 2021.
20. American Dental Association. Caries risk form (Ages 0-6
years). ADA Resources: ADA Caries Risk Assessment
Forms. Caries Risk Assessment and Management. Chi-
cago, Ill.: American Dental Association; 2011. Available
at: “http://www.ada.org/~/media/ADA/Member%20
Center/FIles/topics_caries_under6.pdf?la=en”. Accessed
August 15, 2021.
21. American Dental Association. Caries risk form (Over 6
years). ADA Resources: ADA Caries Risk Assessment
Forms. Caries Risk Assessment and Management. Chi-
cago, Ill.: American Dental Association; 2011.
Available at: “https://www.ada.org/~/media/ADA/
Science%20and%20Research/Files/topic_caries_over6.
pdf?la=en”. Accessed October 10, 2021.
 BEST PRACTICES: PERINATAL AND INFANT OHC

Perinatal and Infant Oral Health Care

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Perinatal
2021 and infant oral health care. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:277-81.

Abstract
This best practice presents recommendations regarding perinatal and infant oral health care, including caries risk assessment, anticipatory
guidance, preventive strategies, and therapeutic interventions. Oral healthcare providers play an invaluable role in optimizing the oral health
of infants, particularly through the establishment of a dental home, caries prevention, and management of common oral conditions.
Relevant oral findings including developmental cysts, pathognomonic viral and fungal lesions, cleft lip and palate, natal and neonatal
teeth, ankyloglossia, and tooth eruption are discussed. The document emphasizes the importance of dental visits during pregnancy and
highlights feeding practices and caries risk factors during infancy. Strategies for prevention of early childhood caries, including dietary
modifications and use of fluoride, are encouraged. Additional elements of anticipatory guidance addressed are oral hygiene instruction,
frequency of dental examinations, consequences of nonnutritive sucking habits, and safety practices to avoid orofacial trauma. Providers
may use this document to help frame discussions with expectant and new parents regarding essential aspects of perinatal and infant oral
health.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and recommendations regarding perinatal and infant oral health care.

KEYWORDS: ANTICIPATORY GUIDANCE, INFANT ORAL HEALTH, PERINATAL ORAL HEALTH, ORAL HYGIENE INSTRUCTION, CARIES RISK FACTORS, DENTAL HOME

Purpose not appear sufficient or were inconclusive, recommendations

The American Academy of Pediatric Dentistry (AAPD)
recognizes that perinatal and infant oral health are the
foundations upon which preventive education and dental
care must be built to enhance the opportunity for a child to
have a lifetime free from preventable oral disease. Recognizing
that dentists, physicians, allied health professionals, and com-
munity organizations must be involved as partners to achieve
this goal, the AAPD proposes best practices for perinatal
and infant oral health care, including caries risk assessment,
anticipatory guidance, preventive strategies, and therapeutic
interventions, to be followed by the stakeholders in pediatric
oral health.
Method
Recommendations on perinatal and infant oral health care
were developed by the Infant Oral Health Subcommittee of
the Clinical Affairs Committee and adopted in 1986.1 The
Guideline on Perinatal Oral Health Care was originally devel-
oped by the Infant Oral Health Subcommittee of the Council
on Clinical Affairs and adopted in 2009.2 This document is
an update of the 2016 merger of those guidelines3 utilizing a
®
search of the PubMed /MEDLINE database with the terms:
infant oral health, infant oral health care, early childhood
were based upon expert and/or consensus opinion by experi-
enced researchers and clinicians.
Background
Role of oral health providers in perinatal and infant oral
health care
The perinatal period is the period beginning with the
completion of the 20th to 28th week of gestation and ending
one to four weeks after birth. The infant period extends to the
child’s first birthday. Oral health providers have an important
role in perinatal and infant oral health care, particularly
regarding the establishment of a dental home,4 educating
new parents, and the timing of a child’s first dental visit. Oral
health providers need to be knowledgeable regarding the
perinatal period and first year of a child’s life with respect
to common oral conditions, anticipatory guidance, and early
dental caries preventive care including oral cleaning, dietary
recommendations, and optimal fluoride exposure.
Common oral conditions in newborns and infants
Bohn nodules are small developmental anomalies located along
the buccal and lingual aspects of the mandibular and maxillary

caries, perinatal, perinatal oral health, and early childhood

caries prevention; fields: all; limits: within the last 10 years,
humans, English, and clinical trials. The search resulted in 261
papers that were reviewed by title and abstract. From those,
papers were selected to update this document. When data did
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ECC: Early child-
hood caries. FDA: U.S. Food and Drug Administration. MS: Mutans
streptococci. U.S.: United States.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 277

BEST PRACTICES: PERINATAL AND INFANT OHC
ridges and in the hard palate of the neonate. These lesions arise
from remnants of mucous gland tissue. Dental lamina cysts
may be found along the crest of the mandibular and maxillary
ridges of neonates. These lesions arise from epithelial remnants
of the dental lamina. Epstein pearls are keratin-filled cysts
found in the mid-palatal raphe at the junction of the hard and
soft palates. These three developmental remnants generally
disappear shortly after birth, and no treatment is necessary.5
Fordyce granules are very common aberrant yellow-white
sebaceous glands most commonly on the buccal mucosa or
lips. No management is needed as these lesions are inconse-
quential and resolve on their own.5 Ankyloglossia is charac-
terized by an abnormally short lingual frenum that can hinder
the tongue movement and may interfere with feeding or speech.
The frenum might spontaneously lengthen as the child gets
older. Surgical correction, on an individual basis, may be
indicated for functional limitations and symptomatic relief.6
Oropharyngeal candidiasis appears as white plaques
covering the oropharyngeal mucosa which, if removed, leaves
an inflamed underlying surface. Candidiasis is usually self-
limiting in the healthy newborn infant, but topical application
of nystatin to the oral cavity of the baby and to the nipples
of breast-feeding mothers may have benefit.5 Primary herpetic
gingivostomatitis presents with oral features such as
erythematous gingiva, mucosal hemorrhages, and clusters
of small vesicles throughout the mouth. Somatic signs may
include fever, malaise, lymphadenopathy, and difficulty with
eating and drinking. Usually, symptoms regress within two
weeks, and lesions heal without scarring.5 Fluids should be
encouraged to prevent dehydration, and analgesics may make
the child more comfortable.5 Oral acyclovir may be beneficial
in shortening the duration of symptoms.7 Caution by practi-
tioners and parents is necessary to prevent autoinoculation or
transmission of infection to the eyes, other body parts, and
other individuals. Other less common viral conditions with
oral symptoms in infants are herpangina and hand-foot-mouth
disease.5
The prevalence of cleft lip with or without cleft palate
in 2004-2006 was 10.6 per 10,000 live births in the United
States (U.S.) and for cleft palate alone was 6.4 per 10,000 live
births in the U.S.8 Cleft lip may vary from a small notch in
the vermilion border to a complete separation involving skin,
muscle, mucosa, dentition, and bone. Clefts may be unilateral
or bilateral and may involve the alveolar ridge. Isolated cleft
palate occurs in the midline and may involve only the uvula
or may extend into or through the soft and hard palates to
the incisive foramen. Rehabilitation for the child with a cleft
lip or palate may require years of specialized treatment by a
cleft lip/palate team. Surgical closure of a cleft lip usually is
performed around three months of age; closure of the palate
usually occurs around one year.5
Dental eruption (teething)
Natal teeth are present at birth, whereas neonatal teeth erupt
in the first month of life. Attachment of natal and neonatal
278 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
teeth generally is limited to the gingival margin due to little
root formation or bony support. These teeth may be a super-
numerary or prematurely erupted primary tooth. Natal or
neonatal teeth occasionally result in pain and refusal to feed
and can produce maternal discomfort because of abrasion or
biting of the nipple during nursing. Ulceration, bleeding, and
discomfort of the tongue due to its repetitive rubbing across
a natal tooth during swallowing and movement is called
Riga-Fede disease.5 If the tooth is mobile with a danger of
detachment and aspiration, extraction may be warranted.
Decisions regarding extraction of prematurely erupted primary
teeth and smoothing the incisal edge should be made on an
individual basis.
Eruption of teeth (teething) can lead to intermittent
localized discomfort, irritability, low-grade fever, and excessive
salivation; however, many children have no apparent diffi-
culties. Treatment of symptoms includes oral analgesics and
teething rings for the child to ‘gum’.5 Use of topical anesthetic
or homeopathic remedies to relieve discomfort should be
avoided due to potential harm of these products in infants.
Because of the risk of methemoglobinemia, benzocaine use is
contraindicated in children younger than two years of age.9
Pregnancy and the perinatal period
The perinatal period plays a crucial role for the well-being
of pregnant women and the health and well-being of their
newborn children.10 Mothers’ poor oral health is associated
with poor oral health of their offspring.11 Yet, many women
do not seek dental care during their pregnancy, and those
who do often confront unwillingness of dentists to provide
care.12 A systematic review has shown the efficacy of prenatal
dental education and preventive therapies in reducing Mutans
streptococci (MS) in children.13 Physicians, nurses, and other
health care professionals, when aware of the risk factors for
dental caries, can help new parents make appropriate decisions
regarding timely and effective oral health interventions for
their newborns.14
Some medications may pose a risk to infants during the
perinatal period, lactating mothers, and women and men
of reproductive potential. Current U.S. Food and Drug
Administration (FDA) recommendations can assist health
care providers when using in-office, prescribed, and over-the-
counter medications for these individuals.15 While in 2020
the FDA recommended that dental amalgam should be
avoided in pregnant women, women planning to become
pregnant, women who are nursing, and children under the age
of six16, it is important to emphasize that dental visits during
pregnancy are safe, effective, and should be encouraged17.
Newborns and infants frequently have non-nutritive
habits, such as digit sucking or using a pacifier. Prolonged
digit sucking can cause flaring of the maxillary incisor teeth,
an open bite, and a posterior crossbite.18 However, there
should be little concern about the effects of such oral habit
during infancy.

Diet for newborns and infants
Benefits of breastfeeding in a child’s first year of life are clear19;
however, breastfeeding and baby bottle beyond 12 months,
especially if frequent and/or nocturnal, are associated with
early childhood caries (ECC)20. Allowing a child to drink from
a bottle, transportable covered cup, open cup, or box of juice
throughout the day may be harmful.21 Importantly, frequent
consumption of free sugars (i.e., sugars added to food and
beverages and sugars naturally present in honey, syrups, fruit
juices and fruit juice concentrates) promotes the carious pro-
cess.22 Cohort studies provide evidence that two key charac-
teristics of perinatal/infant dietary practices are critical to
prevent dental caries: the age at which sugar is introduced
to a child and the frequency of its consumption.23,24 The
American Heart Association rec-ommends that sugar in foods
and drink be avoided by children under two years.25 Addi-
tionally, the American Academy of Pediatrics recommends
that 100 percent fruit juice not be introduced before 12
months of age and be limited to no more than four ounces
a day for children between the ages of one and three years.21
Dental caries risk in newborns and infants
ECC is defined as the presence of one or more decayed
(noncavitated or cavitated lesions), missing or filled (due
to caries) surfaces, in any primary tooth of a child under
six years of age.26 ECC, like other forms of caries, is a
bacterial-mediated, sugar-driven, multifactorial, dynamic
disease that results in the phasic demineralization and
remineralization of dental hard tissues.27 Traditional microbial
risk markers for ECC include acidogenic-aciduric bacterial
species, namely MS and Lactobacillus species.28 MS may be
transmitted vertically from caregiver to child through salivary
contact, affected by the frequency and amount of exposure.29
Horizontal transmission (e.g., between other members of a
family or children in daycare) also occurs.30 Dental caries in
primary teeth may lead to chronic pain, infections, and other
morbidities. ECC has major impact on the quality of life of
children and their families and is an unnecessary health and
financial burden to society.27
Prevention for ECC needs to begin in infancy. Physicians,
nurses, and other health care workers may have more
opportunities to educate the parent/caregiver than dental
professionals because of the frequency of contact with the
family in the child’s first year of life.31 Therefore, they need
to be aware of caries risk and protective factors and use this
information to promote primary care preventive messages that
include: limiting sugar intake in foods and drink; avoiding
night-time bottle feeding with milk or drinks containing
sugars; avoiding baby bottle usage and breastfeeding beyond
12 months, especially if frequent and/or nocturnal; and
having the child’s teeth brushed twice daily with a smear of
fluoridated toothpaste.32 Additionally, for children who are
at high risk for dental caries, professionally-applied fluoride
varnish and dietary fluoride supplements (for infants living
in nonfluoridated areas) may be part of an individualized
BEST PRACTICES: PERINATAL AND INFANT OHC
preventive plan.33 However, a growing number of caregivers
are hesitant about professionally-applied topical fluorides.34
Fluoride hesitancy mirrors vaccination hesitancy observed in
pediatric medicine.35 Inaccurate information about fluoride
may be shared among caregivers within online social
networks.36
Anticipatory guidance
Anticipatory guidance in the perinatal and infant period
includes assessment of any growth and development consid-
erations that the parents should be aware of or that need
referral to the child’s medical provider.37 Assessment of caries
risk should be considered when counselling the parents
regarding the child’s fluoride exposure which includes con-
suming optimally-fluoridated water, frequency of brushing
with the appropriate quantity of fluoridated toothpaste, and
need for professional topical fluoride applications.38 Anticipatory
guidance during this infant period also entails oral hygiene
instruction, dietary counselling regarding sugar consumption,
frequency of periodic oral examinations37, and information
regarding nonnutritive habits that, if prolonged, may result
in flaring of the maxillary incisor teeth, an open bite, and a
posterior crossbite.18 Counselling regarding safety and pre-
vention of orofacial trauma would include discussions of play
objects, pacifiers, car seats, electrical cords, and injuries due
to falls when learning to walk.
Recommendations
1. Advise expecting and new parents regarding the
importance of their own oral health and the possi-
ble transmission of cariogenic bacteria from parent/
primary caregiver to the infant.
2. Encourage establishment of a dental home that in-
cludes medical history, dental examination, risk
assessment, and anticipatory guidance for infants by
12 months of age.
3. Provide caries preventive information regarding: high
frequency sugar consumption; brushing twice daily
with an optimal amount fluoridated toothpaste;
safety and efficacy of optimally-fluoridated commu-
nity water; and, for children at risk for dental caries,
fluoride varnish and dietary fluoride supplements
(if not consuming optimally-fluoridated water).
4. Assess caries risk to facilitate the appropriate preventive
strategies as the primary dentition begins to erupt.
5. Provide information to parents regarding common
oral conditions in newborns and infants, nonnutritive
oral habits (e.g., digit sucking, use of a pacifier),
teething (including use of analgesics and avoidance
of topical anesthetics), growth and development, and
orofacial trauma (including play objects, pacifiers, car
seats, electric cords, and falls when learning to walk).
6. When ankyloglossia results in functional limitations
or causes symptoms, the need to surgical intervention
should be assessed on an individual basis.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 279
BEST PRACTICES: PERINATAL AND INFANT OHC
7. When a patient presents with a prematurely erupted
primary tooth (i.e., natal or neonatal tooth), decisions
regarding intervention should be individualized, based
on the interference with feeding, the risk of detach-
ment and aspiration, and any medical or contributing
considerations.
References
1. American Academy of Pediatric Dentistry. Infant oral
health care. American Academy of Pediatric Dentistry,
Colorado Springs, Colorado. 1986.
2. American Academy of Pediatric Dentistry. Guideline on
perinatal oral health. Pediatr Dent 2009;31(special issue):
90-4.
3. American Academy of Pediatric Dentistry. Guideline
on perinatal and infant oral health care. Pediatr Dent
2016;38(special issue):150-4.
4. American Academy of Pediatric Dentistry. Policy on the
dental home. The Reference Manual of Pediatric Den-
tistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2021:43-4.
5. Dhar V. Common lesions of the oral soft tissue. In:
Kliegman RM, St Geme JW, Blum NJ, Tasker RC, Shaw
SS, Wilson KM, eds. Nelson Textbook of Pediatrics, 21st
ed. Philadelphia, Pa.: Elsevier; 2020:1924-5.
6. American Academy of Pediatric Dentistry. Policy on
management of the frenulum in pediatric dental patients.
The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2021:
76-80.
7. Sanatosh ABR, Muddana K. Viral infections of oral
cavity. J Fam Med Prim Care 2020;9(1):36-42.
8. National Institute of Dental and Cranial Facial Research.
Prevalence of cleft lip and cleft palate. Available at:
“https://www.nidcr.nih.gov/research/data-statistics/cranio-
facial-birth-defects/prevalence”. Accessed March 2, 2021.
9. U.S. Food and Drug Administration. Risk of serious
and potentially fatal blood disorder prompts FDA action
on oral over-the-counter benzocaine products used for
teething and mouth pain and prescription local anesthe-
tics. May 31, 2018. Available at: “https://www.fda.
gov/drugs/drug-safety-and-availability/risk-serious-and
-potentially-fatal-blood-disorder-prompts-fda-action
-oral-over-counter-benzocaine”. Accessed July 10, 2021.
10. World Health Organization. Maternal and health. Avail-
able at: “https://www.euro.who.int/en/health-topics/
Life-stages/maternal-and-newborn-health/maternal-and
-newborn-health”. Accessed August 15, 2021.
11. Shearer DM, Thomson WM, Broadbent JM, Poulton
R. Maternal oral health predicts their children’s caries
experience in adulthood. J Dent Res 2011;90(5):672-7.
12. Barzel R, Holt K. Oral Health During Pregnancy: A
Resource Guide. 3rd ed. Washington, D.C.: National
Maternal and Child Oral Health Resource Center; 2020.
280 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Available at: “https://www.mchoralhealth.org/PDFs/
oralhealthpregnancyresguide.pdf ”. Accessed October
29, 2021.
13. Xiao J, Alkhers N, Kopycha-Kedzierawski DT, Billings
RJ, Wu TT. Prenatal oral health care and early childhood
caries prevention: A systematic review and meta-analysis.
Caries Res 2019;53(4):411-21.
14. Frese W, Nowak A, Royston L, et al. Caries risk factors
for primary care providers based on shared determinants
of health. May 11, 2016. Pediatric Oral Health Research
and Policy Center, American Academy of Pediatric
Dentistry. Chicago, Ill. Available at: “https://www.aapd.
org/assets/1/7/DentaQuest-RE.pdf ”. Accessed August 15,
2021.
15. U.S. Food and Drug Administration. Pregnancy and
lactation labeling (drugs) final rule. December 3, 2014.
Available at: “https://www.fda.gov/drugs/labeling-
information-drug-products/pregnancy-and-lactation
-labeling-drugs-final-rule”. Accessed August 15, 2021.
16. U.S. Food and Drug Administration. Recommendations
about the use of dental amalgam in certain high risk
populations: FDA Safety Communication, September 24,
2020. Available at: “https://www.fda.gov/medical-devices
/safety-communications/recommendations-about-use
-dental-amalgam-certain-high-risk-populations-fda-safety
-communication”. Accessed August 15, 2021.
17. National Maternal and Child Oral Health Resource
Center. Oral Health Care During Pregnancy Expert
Workgroup, 2012. Washington, D.C.: Available at:
“https://www.unitedconcordia.com/docs/OralHealth
PregnancyConsensus.pdf ”. Accessed August 15, 2021.
18. Dogramaci ES, Rossi-Fedele G. Establishing the associ-
ation between nonnutritive sucking behavior and
malocclusions: A systematic review and meta-analysis. J
Am Dent Assoc 2016;147(12):926-34.
19. Salone LR, Vann WF, Dee DL. Breastfeeding: An
overview of oral and general health benefits. J Am Dent
Assoc 2013;144(2):143-51.
20. Peres KG, Chaffee BW, Feldens CA. Breastfeeding and
oral health: Evidence and methodological challenges. J
Dent Res 2018;97(3):251-8.
21. Heyman MB, Abrams SA. Fruit juice in infants, children,
and adolescents: Current recommendations. Pediatric
2017;139(6):e20170967.
22. Moynihan PJ, Kelly SA Effect on caries of restricting
sugars intake: Systematic review to inform WHO guide-
lines. J Dent Res 2014;93(1):8-18.
23. Chaffee BW, Feldens CA, Rodrigues PH, Vítolo MR.
Feeding practices in infancy associated with caries
incidence in early childhood. Community Dent Oral
Epidemiol 2015;43(4):338-48.
24. Feldens CA, Rodrigues PH, de Anastácio G, Vítolo MR,
Chaffee BW. Feeding frequency in infancy and dental
caries in childhood: A prospective cohort study. Int
Dent J 2018;68(2):113-21.

25. Voss MB, Kaar JL, Welsh JA, et al. Added sugars and
cardiovascular disease risk in children: American Heart
Association. Circulation 2017;135(19):e1017-e1034.
26. Drury TF, Horowitz AM, Ismail AA, et al. Diagnosing
and reporting early childhood caries for research purposes.
J Public Health Dent 1999;59(3):192-7.
27. Pitts NB, Baez R, Diaz-Guallory C, et al. Early childhood
caries: IAPD Bangkok declaration. Pediatr Dent 2019;
41(3):176-8.
28. Kanasi E, Johansson J, Lu SC, et al. Microbial risk
markers for childhood caries in pediatrician’s offices. J
Dent Res 2010;89(4):378-83.
29. Douglass JM, Li Y, Tinanoff N. Association of mutans
streptococci between caregivers and their children. Pediatr
Dent 2008;30(5):375-87.
30. Berkowitz RJ. Mutans streptococci: Acquisition and
transmission. Pediatr Dent 2006;28(2):106-9.
31. Chi DL, Momany ET, Jones MP, et al. Relationship
between medical well baby visits and first dental exami-
nations for young children in Medicaid. Am J Public
Health 2013;103(2):347-54.
32. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste
efficacy and safety in children younger than 6 years. J
Am Dent Assoc 2014;145(2):182-9.
33. American Academy of Pediatric Dentistry. Caries-risk
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adolescents. The Reference Manual of Pediatric Dentistry.
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2021:252-7.
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34. Chi DL, Basson AA. Surveying dentists’ perceptions of
caregiver refusal of topical fluoride. JDR Clin Trans Res
2018;3(3):314-20.
35. Chi DL. Caregivers who refuse preventive care for their
children: The relationship between immunization and
topical fluoride refusal. Am J Public Health 2014;104
(7):1327-33.
36. Seymour B, Getman R, Saraf A, Zhang LH, Kalenderian
E. When advocacy obscures accuracy online: Digital
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38. American Academy of Pediatric Dentistry. Fluoride
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2021:302-5.
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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,
Ill.: American Academy of Pediatric Dentistry; 2022:282-91.

Abstract
This best practice presents general recommendations for managing the distinct oral health care needs of adolescents. Accurate medical,
dental, and social histories are necessary for safe and effective care. Health history forms should allow youth to provide information on
topics such as gender, diet, piercings, and risk-taking behaviors (e.g., tobacco, alcohol, and drug use; sexual activity). Transgender and
gender diverse youth may be at increased risk for oral, physical, and psychosocial conditions (e.g., perimyolysis due to bulimia). The age
and stage of adolescence (early, middle, late) will impact diagnostic, preventive, and restorative treatment decisions. Each adolescent oral
health topic (caries, fluoride use, oral hygiene, diet management, sealants, professional preventive treatment, restorative dentistry, periodontal
disease, malocclusions, third molars, temporomandibular joint disorders, congenitally missing teeth, ectopic eruption, traumatic injuries,
and esthetic concerns) has specific recommendations. Assent is an important aspect of adolescent oral health care that can foster the
patient’s emerging independence. Transition to adult dental care should be discussed as the patient approaches the age of majority and
implemented at a time agreed upon by the patient, parent, and practitioner. Due to the complexity of their unique needs and psychosocial
influences, creating and maintaining trust and confidentiality are important when providing oral health care for adolescents.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding the management of oral health care for adolescents.
KEYWORDS: ADOLESCENT, ORAL HEALTH, ORAL SUBSTANCE ABUSE, RISK HEALTH BEHAVIOR, TONGUE PIERCING, TRANSITION TO ADULT CARE

Purpose marriage, parenthood), and the effect of unprecedented social

The American Academy of Pediatric Dentistry (AAPD)
recognizes that the adolescent patient has unique needs. This
best practice addresses these unique needs and proposes general
recommendations for their management. This best practice
serves as a summary document; more detailed information
regarding these topics is provided in referenced AAPD oral
health policies and clinical practice guidelines.
Methods
This best practice was developed by the Clinical Affairs Com-
mittee and adopted in 1986.1 This document by the Council
on Clinical Affairs is a revision of the previous version, last
revised in 2015.2 The update includes an electronic search
using the term adolescent combined with: dental, gingivitis,
oral piercing, sealants, oral health, caries, tobacco use, dental
trauma, orofacial trauma, periodontal, dental esthetics, smoke-
less tobacco, nutrition, and diet; fields: all; limits: humans,
English, clinical trials. The reviewers agreed upon the inclusion
of 105 electronic and hand searched articles that met the
defined criteria. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/
or consensus opinion by experienced researchers and clinicians.
forces such as social media. 3 Rather than age 10-19 years,
it has been defined as the period between 10 and up to 24
years.3 The American Academy of Pediatrics divides adoles-
cence into three age groups including early (ages 11-14),
middle (ages 15-17), and late (ages 18-21).4
The adolescent patient is recognized as having distinctive
needs5 due to: (1) a potentially high caries rate; (2) a tendency
for poor oral hygiene, nutritional habits, and routine 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-
matic injury; (6) dental phobia; (7) potential use of tobacco,
nicotine, alcohol, and other recreational drugs; (8) desire for
oral piercings; (9) increased risk of pregnancy or sexually
transmitted infections; (10) eating disorders; and (11) unique
social and psychological needs.6-11
Treatment of the adolescent patient can be multi-faceted
and complex. Accurate, comprehensive, and up-to-date medi-
cal, dental, and social histories are necessary for correct
diagnosis and effective treatment planning. Familiarity with
the patient’s medical history is essential for decreasing the
risk of aggravating a medical condition while rendering dental

Background
Adolescence refers to the period of accelerated biological
growth, changes, and social role transitions that bridges the
gap from childhood to adulthood.3 The definition of adoles-
cence has changed due to accelerated onset of puberty, delayed
timing of role transitions (e.g., completion of education,
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. HPV: Human papil-
loma virus. NaF: Sodium fluoride OHRQoL: Oral health-related
quality of life. SHCN: Special health care needs. TMJ: Temporo-
mandibular joint.

282 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


care. In some cases, the parent or family members are unaware
of certain conditions affecting/facing the adolescent patient.
The dental practitioner needs to assure the adolescent patient
of trust and confidentiality in certain situations. If the parent
is unable to provide adequate details regarding a patient’s
medical history, consultation with the medical health care
provider may be indicated.12
There is a growing number of adolescents who experi-
ence gender dysphoria and may be considering or undergoing
gender identity-related medical and health care services.13,14
The current prevalence of transgender and non-conforming
youth is about two percent. 15 Health history forms should
allow youth to provide information on gender, legal and pre-
ferred name, and preferred pronouns.16 Dental office staff
should determine preferences, and terminology used should be
consistent by all staff. Transgender and gender diverse youth
may be at increased risk for eating disorders or substance use
disorders.17,18 Special attention should be given to identifying
dental and systemic conditions that may be linked to such
disorders.
Recommendations
This best practice addresses some of the special needs within the
adolescent population and proposes general recommendations
for their management.
Caries
Adolescence marks a period of significant caries activity for
many individuals. Research suggests that the overall caries
rate is declining, yet remains highest during adolescence.19
Immature permanent tooth enamel,20 a total increase in sus-
ceptible tooth surfaces, and environmental factors such as diet,
independence to seek care or avoid it, a low priority for oral
hygiene, and additional social factors also may contribute to
the upward slope of caries during adolescence.21-25 Untreated
dental caries and missing teeth have been shown to have a neg-
ative impact on oral health-related quality of life (OHRQoL),
however, restored teeth were not associated with worse
OHRQoL.26 It is important for the dental provider to empha-
size the positive effects that fluoridation, professional topical
fluoride treatment, routine professional care, patient education,
and personal hygiene can have in counteracting the changing
pattern of caries in the adolescent population.6-8
Management of caries
Primary prevention
Fluoride: Fluoridation has proven to be safe and highly effective
in prevention and control of caries.27 The adolescent can benefit
from fluoride throughout the teenage years and into early
adulthood.8 Although the systemic benefit of fluoride incor-
poration into developing enamel is not considered necessary
past 16 years of age, topical benefits can be obtained through
optimally-fluoridated water, professionally-applied and pre-
scribed compounds, and fluoridated dentifrices.28,29
BEST PRACTICES: ADOLESCENT OHC
Recommendation: The adolescent should receive maximum
fluoride benefit dependent on risk assessment:29,30
• brushing teeth twice a day with a fluoridated dentifrice
is recommended to provide continuing topical benefits.27
• professionally-applied fluoride treatments should be
based on the individual patient’s caries-risk assessment,
as determined by the patient’s dental provider.27,29
• home-applied prescription strength topical fluoride prod-
ucts (e.g., 0.4 percent stannous fluoride gel, 0.5 percent
fluoride gel or paste, 0.2 percent sodium fluoride [NaF]
rinse) may be used when indicated by an individual’s
caries pattern or caries risk status.27
• systemic fluoride intake via optimal fluoridation of
drinking water or professionally-prescribed supplements
is recommended to 16 years of age. Supplements should
be given only after all other sources of fluoride have been
evaluated.27
Oral hygiene: Adolescence can be a time of heightened caries
activity and periodontal disease due to an increased intake of
cariogenic substances and inattention to oral hygiene proce-
dures.21 Adolescents become more independent and tooth-
brushing may become less of a priority. Adolescent patients
need encouragement and motivation to brush with fluoridated
toothpaste and floss regularly. Discussions regarding oral
hygiene can highlight the benefit of the topical effect of
fluoride, removal of plaque from tooth surfaces, and also
decrease halitosis and improve esthetics.8,31
Recommendations:
1. Adolescents should be educated and motivated to main-
tain personal oral hygiene through daily plaque removal,
including flossing, with the frequency and technique
based on the individual’s disease pattern and oral hygiene
needs.31
2. Professional removal of plaque and calculus is recom-
mended highly for the adolescent, with the frequency
of such intervention based on the individual’s assessed
risk for caries/periodontal disease as determined by the
patient’s dental provider.31,32
Diet management: Many adolescents are exposed to and con-
sume high quantities of refined carbohydrates and acid-
containing beverages in the form of soda, high-energy sports
drinks, and junk food and with introduction of coffee.8,22,23,25,33
The adolescent can benefit from diet analysis and modification.
Recommendation: Diet analysis, along with professionally-
determined recommendations for maximal general and dental
health, should be part of an adolescent’s dental health man-
agement.34
Sealants: Sealant placement is an effective caries-preventive
technique that should be considered on an individual basis.
Sealants have been recommended for any tooth, primary or
permanent, that is judged to be at risk for pit and fissure car-
ies.7,23,36-38 Caries risk may increase due to changes in patient
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 283
BEST PRACTICES: ADOLESCENT OHC
habits, oral microflora, or physical condition, and unsealed
teeth subsequently might benefit from sealant applications.37
Recommendations: Adolescents at risk for caries should
have sealants placed. An individual’s caries risk may change
over time; periodic reassessment for sealant need is indicated
throughout adolescence.37
Secondary prevention
Professional preventive care: Professional preventive dental
care, on a routine basis, may prevent oral disease or disclose
existing disease in its early stages. The adolescent patient
whose oral health has not been monitored routinely by a
dentist may have advanced caries, periodontal disease, or other
oral involvement urgently in need of professional evaluation
and extensive treatment.
Recommendations:
1. Timing of periodic oral examinations should take into
consideration the individual’s needs and risk indicators
to determine the most cost-effective, disease-preventive
benefit to the adolescent.30
2. Initial and periodic radiographic examination should be
part of a clinical evaluation. The type, number, and fre-
quency of radiographs should be determined only after
an oral examination and history taking. Previously ex-
posed radiographs should be available, whenever possible,
for comparison. Currently accepted recommendations
for radiographic exposures (i.e., appropriate films based
upon medical history, caries risk, history of periodontal
disease, and growth and development assessments) should
be followed.38
Restorative dentistry: There is data to suggest arrest or reversal
of noncavitated caries lesions using sealants, five percent NaF
varnish, 1.23 percent acidulated phosphate fluoride (APF) gel,
and 5000 parts per million fluoride toothpaste for specific sites
in primary and permanent teeth and, in advanced cavitated
carious lesions on primary teeth, the use of 38 percent silver
diamine fluoride (SDF).39 In cases where remineralization of
non-cavitated, demineralized tooth surfaces is not successful, as
demonstrated by progression of carious lesions, dental restora-
tions are necessary. Preservation of tooth structure, esthetics,
and each individual patient’s needs must be considered when
selecting a restorative material.40 Molars with extensive caries
or malformed, hypoplastic or hypomineralized enamel for
which traditional amalgam or composite resin restorations are
not feasible may require full coverage restorations.37 Small
noncavitated interproximal carious lesions and facial post
orthodontic white spot lesions may be treated by resin
infiltration.37,41,42
Recommendation: Each adolescent patient and restoration
must be evaluated on an individual basis. Preservation of non-
carious tooth structure is desirable. Referral should be made
when treatment needs are beyond the treating dentist’s scope
of practice.37
284 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Periodontal diseases
Adolescence can be a critical period for the human being’s
periodontal status. Epidemiologic and immunologic data sug-
gest that irreversible tissue damage from periodontal disease
begins in late adolescence and early adulthood.10,43 Gingival
disease becomes prevalent in adolescence.44,45 Dental caries,
mouthbreathing, crowding, and eruption of teeth predispose
adolescents to gingivitis.44 Hormonal changes during adoles-
cence are suspected to be a cause of the increased prevalence45,
with studies suggesting that the increase in sex hormones
during puberty affects the composition of the subgingival
microflora by modifying the gingival inflammatory response
and causing exaggerated gingival inflammation, even in the
presence of a small amount of plaque.44 Other studies suggest
circulating sex hormones may alter capillary permeability and
increase fluid accumulation in the gingival tissues, and this
inflammatory gingivitis is believed to be transient as the body
accommodates to the ongoing presence of the sex hormones.46
Conditions affecting the adolescent include, but are not
limited to, dental plaque biofilm gingivitis, nondental plaque-
induced gingival disease, periodontitis (including chronic
and aggressive forms), necrotizing periodontitis, periodontitis
as a manifestation of systemic disease, periodontal abscess,
endodontic-periodontal lesions, mucogingival deformities (i.e.,
gingival recession), occlusal trauma, and peri-implant dis-
eases.44,45 The severity of periodontal conditions are assessed
by clinical and radiographic examination and can be further
characterized by staging and grading the clinical presentation.47
Early diagnosis of periodontal disease in children is important,
especially when there are systemic risk factors (e.g., poorly-
controlled diabetes, leukemia, smoking, malnutrition). Refer
to AAPD’s Classification of Periodontal Diseases in Infants,
Children, Adolescents and Individuals with Special Health Care
Needs for further information. 44 Personal oral hygiene and
regular professional intervention can help minimize occur-
rence of these conditions and prevent irreversible damage.
Recommendations: The adolescent will benefit from an in-
dividualized preventive dental health program, which includes
the following items aimed specifically at periodontal health:
• patient education emphasizing the etiology, character-
istics, and prevention of periodontal diseases as well as
self-hygiene skills.45,48,49
• a personal, age-appropriate oral hygiene program in-
cluding plaque removal, oral health self-assessment, and
diet. Sulcular brushing and flossing should be included
in plaque removal, and frequent follow-up to determine
adequacy of plaque removal and improvement of gingival
health should be considered.48-50
• periodontal assessment during initial and routine dental
examinations with professional intervention, the fre-
quency of which should be based on individual needs
and should include evaluation of personal oral hygiene
success, periodontal status, and potential complicating
factors such as malocclusion, medical/systemic conditions
or habits that predispose to periodontal disease.

Comprehensive periodontal examination includes an
assessment of gingival topography; probing depth; reces-
sion; attachment levels; bleeding on probing; suppuration;
furcation; presence and degree of plaque, calculus, and
gingival inflammation; mobility of teeth; periodontal
charting; and radiographic periodontal diagnosis should
be a consideration when caring for the adolescent. The
extent and nature of the periodontal evaluation should be
determined professionally on an individual basis. Those
patients with progressive periodontal disease should be
referred when the treatment needs are beyond the treating
dentist’s scope of practice.44,45,48,49
• appropriate evaluation for procedures to facilitate or-
thodontic treatment including, but not limited to, tooth
exposure, frenectomy, fiberotomy, gingival augmentation,
and implant placement.45
Occlusal considerations
Malocclusion can be a significant treatment need in the adoles-
cent population as both environmental and/or genetic factors
come into play. Although the genetic basis of much maloc-
clusion makes it unpreventable, numerous methods exist to
treat the occlusal disharmonies, temporomandibular joint
dysfunction, periodontal disease, and disfiguration which may
be associated with malocclusion. Within the area of occlusal
problems are several tooth/jaw-related discrepancies that can
affect the adolescent. Third molar malposition and temporo-
mandibular disorders require special attention to avoid
long-term problems. Congenitally missing teeth present complex
problems for the adolescent and often require combined
orthodontic, restorative, and prosthodontic care for satisfactory
resolution.
Malocclusion: Any tooth/jaw positional problems that present
significant esthetic, functional, physiologic, or emotional dys-
function are potential difficulties for the adolescent. These can
include single or multiple tooth malpositions, tooth/jaw size
discrepancies, and craniofacial disfigurements. Malocclusion
can affect the oral health quality of life for adolescents. Ado-
lescents with Class II and III malocclusions or anterior overjet
greater than six millimeters reported a significant impact on
their oral health related quality of life.51-55
Recommendations:
1. Malposition of teeth, malrelationship of teeth to jaws,
tooth/jaw size discrepancy, skeletal malrelationship, or
craniofacial malformations or disfigurement that presents
functional, esthetic, physiologic, or emotional problems
for the adolescent should be referred for evaluation when
the treatment needs are beyond the treating dentist’s
scope of practice.
2. Treatment of malocclusion by a dentist should be based
on professional diagnosis, available treatment options,
patient motivation and readiness, and other factors to
maximize progress.56 Optimal oral hygiene and routine
dental examinations are important to prevent deminer-
alization during orthodontic treatment.
BEST PRACTICES: ADOLESCENT OHC
Third molars: Third molars can present acute and chronic
problems for the adolescent. Impaction or malposition leading
to such problems as pericoronitis, caries, cysts, or periodontal
problems merits evaluation for removal.57-59 The role of the
third molar as a functional tooth also should be considered.
Recommendations: Evaluation of third molars, including
radiographic diagnostic aids, should be an integral part of the
dental examination of the adolescent.31 Refer to AAPD’s
Management Considerations for Pediatric Oral Surgery and Oral
Pathology.57 Referral should be made if treatment needs are
beyond the treating dentist’s scope of practice.
Temporomandibular joint (TMJ) problems: Disorders of the
TMJ can occur at any age, but symptoms appear more prev-
alent in adolescence.60,61 A recent study reported that adolescent
females had more TMJ disorders than males.52
Recommendations: Evaluation of the TMJ and related
structures should be a part of the examination of the adoles-
cent. An adolescent comprehensive dental examination should
incorporate a screening evaluation of the TMJ and surrounding
area to include a screening history for symptoms, clinical
examination and evaluation of jaw movements and, if
indicated, radiographic imaging. Referral should be made
when the diagnostic and/or treatment needs are beyond the
treating dentist’s scope of practice.57,60,61
Congenitally missing teeth: The impact of a congenitally miss-
ing permanent tooth on the developing dentition can be
significant.62 When treating adolescent patients who are con-
genitally missing teeth, many factors (e.g., esthetics; patient
age; growth potential; orthodontic, periodontal, and oral
surgical needs) must be taken into consideration.56,62-64
Recommendations: Evaluation for patients who are
congenitally missing permanent teeth should include both
immediate and long-term management. Referral should be
made when the treatment needs are beyond the treating
dentist’s scope of practice. Due to the complexity of the
growing adolescent, a team approach may be indicated.62,65
Ectopic eruption: Abnormal eruption patterns of the adoles-
cent’s permanent teeth can contribute to root resorption, bone
loss, gingival defects, space loss, and esthetic concerns. Early
diagnosis and treatment of ectopically erupting teeth can re-
sult in a healthier and more esthetic dentition. Prevention and
treatment may include extraction of deciduous teeth, surgical
intervention, and/or endodontic, orthodontic, periodontal,
and/or restorative care.66-68
Recommendations: The dentist should be proactive in diag-
nosing and treating ectopic eruption and impacted teeth in
the young adolescent.57 Early diagnosis, including appropriate
radiographic examination,38 is important. Referral should be
made when the treatment needs are beyond the treating den-
tist’s scope of practice.65
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BEST PRACTICES: ADOLESCENT OHC
Traumatic injuries
Epidemiological studies have shown up to 25 percent of adol-
escents and adults experienced dental trauma, with most of
these injuries involving maxillary central incisors from falls,
collisions, playing sports, accidents, violence, or recreational
activities.69-71 The prevalence of injuries reported from studies
around the world shows a wide range from six percent to 59
percent, depending on the country and type of injury.70 Dental
traumatic injuries are associated mostly commonly with falls
or collisions, and males are more frequently injured across all
age groups.69 All sporting activities have an associated risk of
orofacial injuries due to falls, collisions, and contact with hard
surfaces.72 The administrators of youth, high school, and col-
lege organized sports have demonstrated that dental and facial
injuries can be reduced significantly by introducing mandatory
protective equipment such as face guards and mouthguards.73
Additionally, youth participating in leisure activities such as
skateboarding, roller skating, trampolining, and bicycling also
benefit from appropriate use of mouthguards and protective
equipment.8,74,75 Long-term sequelae of traumatic injuries
can affect well-being, speech, need for complex care, and oral
health-related quality of life.8
Recommendations: Timely management of traumatic dental
injuries is very important. There is a need for greater aware-
ness of and education regarding the importance of timely
management of dental trauma.69 Dentists should introduce a
comprehensive trauma prevention program to help reduce the
incidence of traumatic injury to the adolescent dentition. This
prevention plan should consider assessment of the patient’s
sport or activity, including level and frequency of activity.73
Once this information is acquired, recommendation and
fabrication of an age-appropriate, sport-specific, and properly-
fitted mouthguard/faceguard can be initiated.73 Players should
be warned about altering the protective equipment that will
disrupt the fit of the appliance. In addition, players and
parents must be informed that injury may occur even with
properly-fitted protective equipment.73
Additional considerations in oral/health care of the adolescent
The adolescent can present particular psychosocial character-
istics that impact the health status of the oral cavity, care
seeking, and compliance. The self-concept development pro-
cess, emergence of independence, and the influence of peers
are just a few of the psychodynamic factors impacting dental
health during this period.6,9,28
Esthetic concerns: Desire to improve esthetics of the dentition
by tooth whitening and removal of stained areas or defects can
be a concern of the adolescent. Indications for the appropriate
use of tooth-whitening methods and products are dependent
upon correct diagnosis and consideration of eruption pattern
of the permanent dentiton.76 The dentist must determine the
appropriate mode of treatment. Use of bleaching agents,
microabrasion, placement of an esthetic restoration, or a com-
bination of treatments all can be considered.77,78
286 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Recommendations: For the adolescent patient, judicious
use of bleaching can be considered part of a comprehensive,
sequenced treatment plan that takes into consideration the
patient’s dental developmental stage, oral hygiene, and caries
status. A dentist should monitor the bleaching process, ensur-
ing the least invasive, most effective treatment method. Dental
professionals also should consider possible side effects when
contemplating dental bleaching for adolescent patients.78-80
Tobacco, nicotine, alcohol, and recreational drug use: Signifi-
cant oral, dental, and systemic health consequences and death
are associated with all current forms of tobacco use. These
include the use of products such as cigars, cigarettes, snuff,
hookahs, smokeless tobacco, pipes, bidis, kreteks, dissolvable
tobacco, and electronic cigarettes.81 Smoking and smokeless
tobacco use are initiated and established primarily during
adolescence.82-85 There is increased risk in oral cancer from
chewing tobacco and an increased risk of lung and pancreatic
cancers, cardiovascular disease, stroke, and risk-taking behav-
iors with use of nicotine, e-cigarettes, vaping, alcohol, and
recreational drugs.86 In addition, use of these substances can
have effects such as halitosis, extrinsic staining, and negative
outcomes in sports performance.8
Recommendations: The oral and systemic consequences of
all current forms of tobacco use should be part of each pa-
tient’s oral health education.87-89 For those adolescent patients
who use tobacco products, the practitioner should provide or
refer the patient to appropriate educational and counseling
services.90 Questions regarding tobacco use should be added to
the adolescent dental record.91 When associated pathology is
present, referral should be made if the treatment needs are
beyond the treating dentist’s scope of practice. This is further
discussed in AAPD’s tobacco use, nicotine delivery systems,
and substance abuse.87-89
Oral piercing: Intraoral and perioral piercing can have local
and systemic adverse effects.92,93 Risks include, but are not
limited to, pain, bleeding, swelling, hematoma, delayed healing,
nerve damage, abscess, blood-borne infections (hepatitis B or
C, human immunodeficiency virus [HIV], Epstein-Barr virus
[EBV], tetanus, tuberculosis), endocarditis, metal hypersensi-
tivity, choking from loose jewelry, enamel fractures, gingival
trauma, periodontal recession, speech impediment, and swal-
lowing difficulties or aspiration.8,93-95
Recommendations: Piercing and the use of jewelry on
intraoral and perioral tissues should be discouraged due to
potential for pathologic conditions and sequelae.93 Prevention
of complications begins with oral health education regarding
these adverse effects.95
Pregnancy: The pregnant adolescent can be affected by
physiological changes to the oral cavity (e.g., gingivitis,
pregnancy-associated dry mouth, pyogenic granuloma).96
Recommendations: Proper screening for pregnancy is part
of care of the adolescent female patient. Comprehensive care

during pregnancy should involve assessment of caries and
periodontal disease risks along with discussion of the import-
ance of a healthy diet, fluoride, and oral hygiene.96
Sexually-transmitted infections: There is a growing concern
and increase in the prevalence of sexually transmitted disease in
adolescents, specifically in the ages of 15-19 years.11 Screening
and examination for oral signs of sexually transmitted infections
and appropriate management or referral by the provider are
important. Because human papilloma virus (HPV) has shown
a relationship with oral and oropharyngeal cancers, dentists
are in a unique position to discuss the HPV vaccination with
patients and their parents.97
Recommendations: Screening and examination for oral
signs of sexually transmitted diseases should be part of com-
prehensive care delivered to the adolescent patient. The
examination should include identifying oral manifestations of
sexually-transmitted diseases as well as education on the risk
of transmission during unprotected oral sex and adoption of
barrier techniques (e.g., condoms, dental dams) for prevention;
referral for counseling and treatment is recommended when
indicated.11 Patients also should be educated on HPV and
available vaccination to prevent risk of infection.97
Psychosocial and other considerations: Behavioral considerations
when treating an adolescent may include anxiety, phobia, and
intellectual dysfunction.21 Some psychosocial considerations
may result in oral problems (e.g., perimyolysis/severe enamel
erosion in patients with bulimia).98
The impact of psychosocial factors relating to oral health
must include consideration of the following:
• changes in dietary habits (e.g., fads, freedom to snack,
increased energy needs, access to carbohydrates).
• use of tobacco, alcohol, and drugs.
• risk-taking or risk-seeking behavior.
• motivation for maintenance of good oral hygiene.
• adolescent as responsible for care.
• lack of knowledge about periodontal disease.
Physiologic changes also can contribute to significant oral
concerns in the adolescent. These changes include: (1) loss of
remaining primary teeth; (2) eruption of remaining perma-
nent teeth; (3) gingival maturity; (4) facial growth; and (5)
hormonal changes.
Although new studies show that neurologic maturation
continues into the third decade of life, seeking assent from
adolescents for intervention can foster the moral growth and
development of autonomy in young patients. 99,100 Refer to
AAPD’s Informed Consent for further information.101
Recommendations:
1. An adolescent’s oral health care should be provided by a
dentist who has appropriate training in managing the
patient’s specific needs. Referral should be made when
the treatment needs are beyond the treating dentist’s
scope of practice. This may include both dental and
BEST PRACTICES: ADOLESCENT OHC
nondental problems. 102 Consultation with nondental
professionals or a team approach may be indicated.
2. Supplemental medical history topics regarding questions
on pregnancy, alcohol and drug use, oral piercings,
tobacco use, sexual activity, and eating disorders should
be included in the adolescent dental record.91
3. Attention should be given to the particular psychosocial
aspects of adolescent dental care. Other issues such as
assent, confidentiality, and compliance should be ad-
dressed in the care of these patients.101,103
4. A complete oral health care program for the adolescent
requires an educational component that addresses the
particular concerns and needs of the adolescent patient
and focuses on:
a. specific behaviorally- and physiologically-induced
oral manifestations in this age group;31
b. shared responsibility for care and health by the
adolescent, parent, and provider;31 and
c. consequences of adolescent behavior on oral health.8
Transitioning to adult care: As adolescent patients approach
the age of majority, it is important to educate the patient and
parent on the value of transitioning to a dentist who is knowl-
edgeable in adult oral health care. The adult’s oral health
needs may go beyond the scope of the pediatric dentist’s
training. The transitioning adolescent should continue pro-
fessional oral health care in an environment sensitive to his/
her individual needs. Many adolescent patients independently
will choose the time to seek care from a general dentist and
may elect to seek treatment from a parent’s primary care
provider. In some instances, however, the treating pediatric
dentist will be required to suggest transfer to adult care.
Pediatric dentists are concerned about decreased access
to oral health care for individuals with special health care
needs (SHCN)104 as they reach the age of majority. Pediatric
hospitals, by imposing age restrictions, can create a barrier
to care for these patients. Transitioning to a dentist who is
knowledgeable and comfortable with adult oral health care
needs is important and, in some instances, difficult due to a
lack of trained providers willing to accept this responsibility.
Successful transitioning from pediatric to adult special needs
dentistry involves the patient and his caregiver(s), adequate
preparation, and understanding of the complex situations
relating to care.105
Recommendations: At a time agreed upon by the patient,
parent, and pediatric dentist, the patient should be transitioned
to a dentist knowledgeable and comfortable with managing
that patient’s specific oral care needs. For the patient with
SHCN, in cases where it is not possible or desired to transition
to another practitioner, the dental home can remain with
the pediatric dentist and appropriate referrals for specialized
dental care should be recommended when needed.103
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 287
BEST PRACTICES: ADOLESCENT OHC
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consent. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:470-3.
102. Larson RW. Toward a psychology of positive youth
development. Am Psychologist 2000;55(1):170-83.
103. American Academy of Pediatric Dentistry. Management
of dental patients with special health care needs. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2020:275-80.
104. American Academy of Pediatric Dentistry. Record-
keeping. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:462-9.
105. Borromeo GL, Bramante G, Betar D, Bhikha C, Cai YY,
Cajili C. Transitioning of special needs paediatric patients
to adult special needs dental services. Aust Dent J 2014;
59(3):360-5.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 291
BEST PRACTICES: PREGNANT ADOLESCENT PATIENT

Oral Health Care for the Pregnant Pediatric

Dental Patient
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Oral health
2021 care for the pregnant pediatric dental patient. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:292-301.

Abstract
This best practice provides recommendations regarding preventive, diagnostic, and therapeutic oral health care for pregnant youth. Recom-
mendations emphasize the benefits of a non-cariogenic diet and nutritious foods essential to proper fetal development. The safety of
prescription and over-the-counter medications is reviewed, and oral health care providers are advised to maintain awareness of benefits,
risks, and side effects of pharmacotherapeutic agents for pregnant patients. Likewise, providers should understand the effects of smoke,
tobacco, and illicit substances during pregnancy and counsel patients regarding the negative consequences of exposure. Common oral
conditions associated with pregnancy, such as dental erosion, dental caries, xerostomia, gingivitis, and pyogenic granulomas, are reviewed.
Components of dental care that require special considerations for the pregnant patient include history intake, assessment of risk for caries
as well as periodontal diseases, screening for hypertension, and timing of preventive, restorative, and emergency care. Radiation safety, with
emphasis on the as low as reasonably achievable (ALARA) principle, is addressed. The document highlights educating the pregnant patient
and providing anticipatory guidance to improve oral health during and after pregnancy. Lastly, oral health care providers are encouraged
to review state laws and regulations pertaining to consent of pregnant minors and minor confidentiality. Dental visits are encouraged as
part of safe and effective prenatal care.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and recommendations regarding oral health care for the pregnant pediatric dental patient.
KEYWORDS: PREGNANCY, PRENATAL CARE, TOBACCO COUNSELING, ORAL HYGIENE INSTRUCTION, INFORMED CONSENT

Purpose trials, systematic reviews, or meta-analysis yielding 56 articles.

The American Academy of Pediatric Dentistry (AAPD), as
the oral health advocate for infants, children, adolescents, and
individuals with special health care needs, recognizes that
adolescent pregnancy remains a significant social and health
issue in the United States (U.S.) These recommendations
are intended to address management of oral health care
particular to the pregnant adolescent rather than provide
specific treatment recommendations for oral conditions.
Methods
Recommendations on oral health care for the pregnant
adolescent were developed by the Council on Clinical Affairs
Committee on the Adolescent and adopted in 2007.1 This
document by the Council on Clinical Affairs is a revision
of the previous version, last revised in 20162. The revision
®
included a search of the PubMed /MEDLINE database
using the terms: (“pregnancy”[MeSH] OR “pregnancy in
adolescence”[MeSH] OR “teen pregnancy”[Text word] OR
“pregnant teen”[Text word] OR “pregnant adolescent”[Text
word] OR “adolescent pregnancy”[Text word]) AND (“Oral
Health”[MeSH] OR “oral health”[Text word] OR “dental
health”[Text word] OR “dental care”[MeSH]); filters: 10 years,
Humans, English. This search yielded 434 articles that met
the defined criteria to update this document. The search then
was narrowed to include articles that were limited to clinical
Additional strategies such as Google Scholar and hand searches
were employed. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/
or consensus opinion by experienced researchers and clinicians.
Background
General considerations
Teen birth rate is defined by the Centers for Disease Control
and Prevention (CDC) as the number of births per 1000
females aged 15-19 years.3 In 2018, the overall teen birth rate
was 17.4 births per 1,000 females, which was a seven percent
decline from 2017.3 However, racial disparities exist, with the
teen birth rates being higher for non-Hispanic Black teenagers
(26.3 births per 1000 females) and Hispanic Black teenagers
(26.7 births per 1000 females) compared to non-Hispanic
White teenagers (12.1 births per 1000 females).3 Although
the U.S. has seen the lowest rates of teen pregnancy in
seven decades, the U.S. is still ranked highest among developed
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. CDC: Centers for
Disease Control and Prevention. FASDs: Fetal alcohol spectrum
disorders. FDA: U.S. Food and Drug Administration. MS: Mutans
streptococci. NAS: Neonatal abstinence syndrome. U.S.: United
States.

292 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


countries.4 The declines in teen birth rates reflect a number of
behavioral changes, including decreased sexual activity and in-
creased use of contraception.5 Why adolescents have become
more effective contraceptive users is unclear; involvement in
school activities, educational and career aspirations, mentoring
programs, economic fluctuations, childbearing norms, contra-
ceptive coverage under the Affordable Care Act, and the
availability of health information via internet or television all
may have contributed.5 The American College of Obstetricians
and Gynecologists supports access for adolescents to all U.S.
Food and Drug Administration (FDA) approved contraceptive
methods.5 The prevalence of unplanned pregnancies in adoles-
cents worldwide ranges from 33 to 82 percent.6 In the United
States, 75 percent of adolescent pregnancies (age 15-19 years)
are not planned.7 Women living below the federal poverty
level had unintended pregnancy rates two to three times the
national average.8
Adolescent pregnancy (or childbearing) is a complex issue
and more likely among socioeconomically disadvantaged ado-
lescents.5 Adolescent childbearing may present unfavorable
consequences (e.g., not completing high school) for mothers
and imposes high public sector costs. Nearly two-thirds of
teenage mothers receive public assistance and have increased
risk for living in poverty as they enter adulthood.9 Furthermore,
the challenges of teen pregnancy may last generations with
children of teen mothers more like to perform poorly in school
or drop out, and daughters of teen mothers to become teen
mothers themselves.9
Recommendations
General considerations
Proper prenatal care is essential. Oral health care providers are
in a position to encourage pregnant pediatric dental patients
to seek routine care with their obstetrician and other primary
care providers throughout their pregnancy. Likewise, obstetric
care providers are able to counsel patients regarding good
oral health habits, including the importance of professional oral
health care during pregnancy. Dental visits during pregnancy
are safe, effective, and encouraged.10,11
Recommendations: Health care providers should counsel
patients on the safety and benefits of prenatal medical and
dental care. Recommendations for adolescent oral health care
can be found in AAPD’s Adolescent Oral Health Care.12
Diet considerations during pregnancy
The diet of the pregnant adolescent can affect the health of the
child. A healthy diet is necessary to provide adequate amounts
of nutrients to the mother-to-be and the unborn child.
Nutrients of particular importance include folic acid, iron,
calcium, vitamin D, choline, omega-3 fatty acids, B vitamins,
and vitamin C.13 Vitamin D works with calcium to help the
bones and teeth of the fetus develop.13 Folic acid, a B vitamin,
plays an important role in the production of cells and helps
in the development of the neural tube, the brain, and spinal
BEST PRACTICES: PREGNANT ADOLESCENT PATIENT
cord.14 Folic acid supplementation has been shown to decrease
the risk of isolated cleft lip with or without cleft palate.15,16
A healthy diet during pregnancy is encouraged. Studies
have shown that improving the nutritional status of women
prior to and during pregnancy can substantially reduce the
risk of low-birth-weight babies. 17 In addition, diabetes
during pregnancy has been associated with cleft lip and palate
in fetuses.18 An expectant female may modify food choices due
to morning sickness and/or taste aversions, but appropriate
nutrition for the health of the mother and fetus is crucial.
Nausea and vomiting, which are common symptoms during
the first trimester, may cause a woman to avoid routine oral
health practices such as toothbrushing and flossing. In addition,
avoidance of certain foods may lead to an increased cariogenic
diet, putting the individual at risk for dental caries.
Recommendation: Oral health care providers should
encourage pregnant patients to consume noncariogenic,
nutrient-dense foods to promote the general and oral health
of the mother and developing fetus.
Pharmacotherapy during pregnancy
Availability of current information on the potential effects
of medications during pregnancy is important for improving
health care providers’ prescribing practices and patient safety.19
In 2014, the FDA updated its requirements for labeling
of human prescription drugs and biological products via the
Pregnancy and Lactation Labeling Rule (PLLR).20 Labeling
must include usage information (e.g., risks of the medication,
clinical considerations, fertility effects) for specific populations
including pregnancy, lactation, and females and males of re-
productive potential.20 Searchable information on prescription
medication labeling can be found at DailyMed, the official
provider of FDA label information.21 Some prescription medi-
cations such as doxycycline and tetracycline (both antibiotics),
as well as alprazolam and diazepam (both anxiolytics), should
be avoided.22 Certain anticonvulsants (e.g., topiramate, valproic
acid) during pregnancy have been associated with cleft lip
and palate in fetuses. 18 Federal regulations require labeling
for over-the-counter (OTC) medications to include specific
warnings such as contraindications, when to consult a doctor
or pharmacist, and considerations with pregnancy/breast-
feeding. 23 Some OTC medications to be avoided by preg-
nant patients include medications for gastrointestinal upset/
diarrhea that contain bismuth subsalicylate, decongestants
(e.g., phenylephrine, pseudoephedrine), cough and cold
medicines that contain guaifenesin, and pain medications
such as ibuprofen, naproxen, and aspirin.22 When in doubt,
consultation with thepatient’s obstetrician is warranted.
Recommendations: Oral health care providers should be
aware of different medications and their effects on pregnant
patients. Oral health care providers should be aware of and
recommend that pregnant patients avoid medications that
cross the placenta and pose a risk to the developing fetus.
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BEST PRACTICES: PREGNANT ADOLESCENT PATIENT
Effects of smoke, tobacco, alcohol, and illicit substance
exposure during pregnancy
Education on the serious health consequences of tobacco use
and fetal exposure to tobacco and other environmental smoke
is an important component of prenatal counseling. Women who
have higher exposure levels to polycyclic aromatic hydrocarbons
(PAHs) produced by the burning of coal, oil, gas, or garbage,
smoke from gas/garbage/cigarette/cigar/pipe, or charbroiling
meat also were more likely to have babies with cleft lip with or
without cleft palate.24 Prenatal exposure to secondhand smoke
has been associated with cognitive deficits.25 Dental health
care providers can discourage the use of tobacco and educate
individuals on the serious health consequences of tobacco
use and exposure to environmental tobacco smoke (ETS).26
No amount of alcohol, nor time to drink alcohol, during
pregnancy is safe. 27,28 Alcohol using during pregnancy is
known to cause miscarriage, stillbirth, and lifelong birth
defects and developmental disabilities.29 Children with fetal
alcohol spectrum disorders (FASDs) may present with ab-
normal facial features (e.g., smooth philtrum), small head
size, shorter than average height, low body weight, poor
coordination, hyperactive behavior, difficulty with attention,
poor memory, difficulty in school, learning disabilities, speech
and language delays, intellectual disabilities, poor reasoning
and judgement skills, sleeping and sucking problems as baby,
vision or hearing problems, and problems with heart, kidney,
or bones. 27 Determining the number of individuals with
FASDs is difficult, but the CDC estimates 0.2 to 1.5 infants
with fetal alcohol syndrome are born for every 1,000 live
births in certain areas of the U.S.30 In addition, a 2019 report
from the CDC found that one in nine pregnant women
reported drinking alcohol in the past 30 days.30 Screening for
alcohol use and providing counseling may help decrease the
risk of FASDs and harm to the infant.30.31 Early recognition,
diagnosis, and prevention can reduce negative outcomes and
lifelong consequences for the child.28
Individuals with substance (e.g., opioids) misuse issues
may misuse these substances regularly or only occasionally.32
Sexually active adolescents who misuse substances have high
rates of sexual risk behaviors, unintended pregnancy, and
repeated unplanned pregnancy.33-36 Therefore, substance mis-
use among pregnant adolescents represents a major public
health problem.
Substance misuse during pregnancy is associated with an
increased risk for stillbirths and neonatal abstinence syndrome
(NAS).37,38 NAS occurs with a sudden discontinuation of fetal
exposure to licit or illicit substances that were used or misused
by the mother during or after pregnancy.39,40 The American
Academy of Pediatrics recommends important prevention
measures such as a focus on preventing unintended pregnan-
cies, universal screening for drugs in women of childbearing
age, knowledge and informed consent of maternal drug testing
and reporting practices, and improved access to comprehensive
obstetric care.41,42
294 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Recommendations: Oral health care providers should be
aware of and recommend that pregnant patients avoid sub-
stances that cross the placenta and pose a risk to the developing
fetus. Pregnant pediatric dental patients should be encouraged
to avoid smoking, exposure to smoke, and use of alcohol
and drugs. Dentists should counsel pregnant patients on the
increased risk of negative consequences to the developing fetus
if exposed to these substances.
Common oral conditions associated with pregnancy
Physiologic changes in the oral cavity during pregnancy are
well documented. 43 These include alterations in both the
hard and soft tissues. Nausea and vomiting are common
during the first trimester and occur in up to 70 percent of
women.44 Acid from vomitus can cause demineralization and
erosion of enamel, known as perimyolysis. A sodium bicar-
bonate rinse can neutralize the acidic challenge.45 Immediate
toothbrushing, however, can cause erosion/loss of the weak-
ened enamel.46 When erosion is established, fluoride may be
used to minimize hard tissue loss and control sensitivity; a
daily neutral sodium fluoride mouth rinse or gel to may be
prescribed.47 Some physicians advocate frequent snacking or
eating multiple small meals throughout the day to help
relieve morning sickness. 48 Sipping ginger ale or sucking
ginger lollipops also has been recommended. 48 However,
frequent exposure to cariogenic substances may increase the
risk of developing caries.
Pregnancy-associated hormonal changes may cause
dryness of the mouth. Approximately 44 percent of pregnant
participants in one study reported persistent xerostomia.49 A
palliative approach to alleviate dry mouth may include
increased water consumption or chewing sugarless gum to
increase salivation.49
Signs of gingivitis (e.g., bleeding, redness, swelling,
tenderness) are evident in the second trimester and peak in
the eighth month of pregnancy, with anterior teeth affected
more than posterior teeth.50 These findings may be exacer-
bated by poor plaque control and mouth breathing. 51 From
a periodontal perspective, the effects of hormonal levels on
the gingival status of pregnant women may be accompanied
by increased levels of progesterone and estrogen which
contribute to increased vascularity, permeability, and possible
tissue edema.52,53
Periodontal disease has been associated with adverse
pregnancy outcomes such as pre-term birth54-56, fetal growth
restriction54, low birthweight54.55, pre-eclampsia54, and gesta-
tional diabetes54. True cause-and-effect relationships between
periodontal disease and poor fetal outcomes cannot be de-
termined. The development of more interventional trials
would be beneficial56 as some recent studies have shown that
the treatment of periodontal disease does not eliminate adverse
pregnancy outcomes57-59 and may actually put some women at
a higher risk for pre-term delivery59.

Poor plaque control coupled with hormonal changes may
lead to the development of a pyogenic granuloma (i.e., preg-
nancy tumor or granuloma gravidarum). This benign vascular
lesion appears as a deep red to purple gingival nodule in the
second or third trimester of pregnancy.51,60 Although the lesion
may regress postpartum, surgical excision may be necessary.60
Recommendations: Oral health care providers should
council pregnant patients experiencing morning sickness or
gastroesophageal reflux to rinse with a cup of water containing
a teaspoon of sodium bicarbonate, and toothbrushing should
be avoided for about one hour after vomiting to minimize
dental erosion. Pregnant patients who alter their diet to
combat morning sickness should be counseled on the negative
effects of frequent exposures to sugary substances and the
increased risk for developing caries with these practices.
Pregnant patients should be encouraged to have routine dental
examinations to be evaluated for commonly associated oral
lesions. Oral health care providers should encourage pregnant
patients to practice good oral hygiene, including brushing
twice daily with fluoridated toothpaste and flossing, to min-
imize periodontal insult.
Oral health care during pregnancy
The most significant predictor of not receiving routine dental
care during pregnancy was a woman’s lack of routine dental
care when not pregnant.46 Improving the oral health of preg-
nant women reduces complications of dental diseases to both
the mother and the developing fetus.61 Despite this, the preva-
lence of dental services usage during pregnancy ranges from
16-83 percent.62 A recent systematic review indicated facili-
tators and barriers to dental care during pregnancy include
physiological conditions, low importance of oral health, nega-
tive stigma regarding dentistry, fear or anxiety towards dental
treatment, mobility and safety, financial barriers, employment,
time constraints, lack of information, health professionals’
barriers, family and friends’ advice, and beliefs and myths
regarding the safety of dental treatment.63
Routine dental care is encouraged in order to achieve
optimal oral health for pregnant adolescents. A pregnant adol-
escent who does not already have a dental home and receive
regular preventive and therapeutic care is encouraged to seek
professional oral health care during the first trimester. The
initial visit would entail thorough review of medical, dental,
and social histories and a comprehensive evaluation. The dental
history addresses diet and fluoride use, preexisting oral con-
ditions, current oral hygiene practices and preventive home
care, previous radiographic exposures, and tobacco and other
substance use.64-68 Historical and clinical findings can be used
to determine the patient’s risks for caries and periodontal disease
and to develop an individualized treatment plan. Blood pressure
readings taken at each visit can help identify hypertension
which increases the risk of bleeding during procedures. Of
note, adolescents are at a higher risk than average mothers for
pregnancy-related high blood pressure (preeclampsia) and its
complications.69 If an abnormal elevation in blood pressure
BEST PRACTICES: PREGNANT ADOLESCENT PATIENT
is noted during a dental visit, consultation with the patient’s
physician is warranted. Blood pressure greater than or equal
to 140/90 mmHg is considered mild hypertension, whereas
values greater than or equal to 160/110 mmHg are considered
severe.70 Acute-onset, severe hypertension that persists for 15
minutes or more is considered an emergency. Untreated severe
hypertension can have significant morbidity (e.g., hemorrhagic
stroke) or mortality.71
Preventive services are critical components of oral health
care for the adolescent pregnant patient. Ideally, a dental pro-
phylaxis would be performed during the first trimester and
again during the third trimester if oral home care is inadequate
or periodontal conditions warrant professional care. During
pregnancy, elevation in sex steroid hormones occurs which
may modify the gingival inflammatory response and result in
an exaggerated gingival inflammation in the presence of even
relatively small amounts of plaque.72 Referral to a periodontist
may be necessary in the presence of progressive periodontal
disease.50,73 While fluoridated dentifrice and professionally-
applied topical fluoride treatments can be effective caries
preventive measures for the expectant adolescent, evidence
not support the use of fluoride supplements (tablets, drops,
lozenges, chewing gum) to benefit the fetus.74
Because the pregnant uterus is below the umbilicus, a
pregnant woman generally is more comfortable for treatment
during the second trimester. Pregnant women are considered
to have a full stomach due to delayed gastric emptying and,
therefore, are at increased risk for aspiration, particularly
during the last trimester.75 In general, non-emergency dental
treatment needed during the third trimester would be post-
poned until after birth due to the risk of premature labor and
discomfort from lying on one’s back for an extended period
of time.76
Common invasive dental procedures may require certain
precautions during pregnancy, particularly during the first tri-
mester. Performing elective restorative and periodontal ther-
apies during the second trimester may prevent any dental
infections or other complications from occurring in the third
trimester.77 A pregnant patient experiencing dental pain or
infection requires immediate treatment. When contemplating
therapeutic agents for local anesthesia, infection, postoperative
pain, or sedation, consideration is given to the potential benefits
of the dental therapy versus the risks to the pregnant patient
and the fetus. Selecting the safest medication, limiting the
duration of the drug regimen, and minimizing dosage78
promote patient safety.
Nitrous oxide/oxygen analgesia/anxiolysis may facilitate the
delivery of dental care for a pregnant adolescent when topical
and local anesthetics alone are inadequate. Consultation with
the prenatal medical provider is indicated prior to its use, and
precautions are needed during treatment to prevent hypoxia,
hypotension, and aspiration.78 Due to the increased risk of
pregnancy loss, use of nitrous oxide may be contraindicated
in the first trimester of pregnancy.78 If more advanced be-
havior guidance regimens such as moderate sedation or general
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BEST PRACTICES: PREGNANT ADOLESCENT PATIENT
anesthesia are needed, post-menarchal patients who have not
disclosed a pregnancy may be subjected to a pregnancy test
prior to treatment. Pregnancy testing has been recommended
for female patients of childbearing age when the results would
alter the patient’s medical management.79
The FDA, in 2020, encouraged practitioners to avoid using
dental amalgam in pregnant women, women planning to be-
come pregnant, women who are nursing, and children under
the age of six.80 However, the American Dental Association
(ADA) has reaffirmed amalgam is a durable, safe, effective
restoration and that the FDA warning did not present any
new information.81 The ADA recommends dentists discuss all
restorative options with their patients, including the risks and
benefits to amalgam use.81
Dental bleaching is known to have side effects (e.g., tooth
sensitivity, tissue irritation) in the general population82 and has
not been studied in pregnant patients. The lack of evidence
regarding safety has led other organizations to recommend that
bleaching be avoided during pregnancy.83 For more informa-
tion regarding bleaching, refer to AAPD’s Policy on the Use
of Dental Bleaching for Child and Adolescent Patients.82 In
general, deferring elective dental treatment that is not med-
ically necessary should be postponed until after delivery to
help minimize risk to patient and fetus.76
The American College of Obstetricians and Gynecologists
affirms that, with shielding of the abdomen and thyroid,
dental x-rays are safe during pregnancy.11 Radiographs are an
integral component of a comprehensive dental examination
and can help the oral health care provider in assessment of
dental disease and pathology and development of a treatment
plan. However, because the effects of ionizing radiation accu-
mulate over time, the oral health care provider must weigh the
risks and benefits of taking radiographs in a pregnant patient.84
The decision to obtain radiographic imaging is based on the
patient’s history and clinical examination.84 During dental
radiographic examination of all patients, including pregnant
patients, optimizing techniques, shielding the thyroid and
abdomen, choosing the fastest available image receptor (e.g.,
high-speed film, digital radiography), collimation of beam to
size of receptor, and avoiding retakes help minimize radiation
exposure.11,84,85 When a radiographic examination is conducted
properly, the amount of radiation striking a patient’s abdomen
is negligible.84 For diagnostic radiology outside of the abdomen
and pelvis, including the head and neck, the amount of radia-
tion to which a fetus is exposed to is a very low dose and, when
standard precautions are taken, it does not pose a significant
risk to the fetus.86 Following the as low as reasonably achievable
(ALARA) principle helps dentists minimize the patient’s expo-
sure.84 The use of cone-beam computed tomography (CBCT)
is not addressed in this document, and consultation with a
patient’s obstetrician/gynecologist is indicated prior to its use.
The vertical transmission of bacteria associated with dental
caries from caregiver to child is well documented.87,88 Suppres-
sion of the mother’s reservoirs of Mutans streptococci (MS) by
dental rehabilitation and antimicrobial treatments may prevent
296 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
or at least delay infant acquisition of these cariogenic micro-
organisms.89 Transmission of cariogenic bacteria from mother
to infant is increased when the mother has poor oral health
with untreated dental caries.90
Education is an important component of prenatal oral
health care and may have a significant effect on the oral health
of both the mother and the child. Counseling for the pregnant
adolescent includes topics directed toward all adolescent pa-
tients (e.g., dietary habits, injury prevention, third molars),
as well as oral changes that may occur during pregnancy and
infant oral health care. Since the pregnant adolescent may be
receptive to information that will improve the infant’s health,
anticipatory guidance can be introduced to focus on the needs
of the child at each stage of life. Studies have documented
that early oral health promotion starting during pregnancy
can lead to a sustained and long-term improvement of the
oral health of children.91,92 Programs that promote oral health
must continue to inform pregnant women and care providers
about the importance of dental care before, during, and after
pregnancy. Oral health counseling during pregnancy and
dental cleanings are recommended.93 Counseling may include:
• relationship of maternal oral health with fetal health88
(e.g., possible association of periodontal disease with
preterm birth and pre-eclampsia, developmental
defects in the primary dentition94);
• an individualized preventive plan including oral
hygiene instructions, rinses, and/or xylitol products
to decrease the likelihood of MS transmission post-
partum;95-97
• dietary considerations (e.g., maintaining a healthy
diet, avoiding frequent exposures to cariogenic foods
and beverages, overall nutrient and energy needs88,98)
and vitamin supplements14,15,94;
• anticipatory guidance for the infant’s oral health in-
cluding the benefits of early establishment of a dental
home;91,92
• anticipatory guidance for the adolescent’s oral health
to include injury prevention, oral piercings, tobacco
and substance abuse, sealants, and third molar assess-
ment;12
• oral changes (e.g., xerostomia, shifts in oral flora) that
may occur secondary to pregnancy;50,73 and
• individualized treatment recommendations based upon
the specific oral findings for each patient.
Recommendations: Oral health care providers should
recommend that pregnant pediatric dental patients continue
with routine dental care during pregnancy, including preventive
services such as in-office dental examinations, prophylaxis, and
fluoride treatments. Pregnant pediatric dental patients should
be encouraged to maintain good home care, including brushing
two times daily with fluoridated toothpaste and daily flossing.
If dental treatment must be deferred until after delivery, radio-
graphic assessment also should be deferred. All radiographic
procedures should be conducted in accordance with radiation

safety practices. Restorative and periodontal therapies may be
completed during the second trimester to prevent any dental
infections or other complications from occurring in the third
trimester. However, elective dental procedures should be post-
poned until after delivery. Consultation with the patient’s
obstetrician or primary care provider may be warranted before
the use of local anesthesia, nitrous oxide analgesia, over-the-
counter pain medications, or prescriptions are utilized. Oral
health care providers should evaluate a pregnant pediatric
dental patient’s blood pressure at every dental visit. A referral
to obstetrician or primary care provider is warranted if blood
pressure is elevated.
Legal considerations
Dental practitioners should be familiar with federal and state
statutes that govern consent for care for a pregnant patient
less than the age of majority. Statutes and case law concerning
consent involving pregnant patients less than 18 years of age
vary from state to state. In some states, dentists are required
to obtain parental consent for non-emergency dental services
provided to a child 17 years of age or younger who remains
under parental care.99 This would involve obtaining consent
from the parent who must be aware of the pregnancy in order
to understand the risks and benefits of the proposed dental
treatment.77 However, if the parent is unaware of the pregnancy,
the pregnant adolescent may be entitled to confidentiality
regarding health issues such as the pregnancy.100 In other states,
there are mature minor laws that allow minors to consent
for their own health care when a dentist deems the minor
competent to provide informed consent. In addition, some
states emancipate minors who are pregnant or by court order.
Practitioners are obligated to be familiar with and abide by
the laws specific to where they practice and where the patient
resides. If a pregnant adolescent’s parents are unaware of the
pregnancy, and state laws require parental consent for dental
treatment, the adolescent is encouraged to inform them so
appropriate informed consent for dental treatment can occur.
The Health Insurance Portability and Accountability Act
(HIPAA) specifically addresses minor confidentiality.101
Recommendation: Oral health care providers should be
aware of their state’s regulations on consent and caring for a
pregnant pediatric dental patient.
References
1. American Academy of Pediatric Dentistry. Guideline
on oral health care for the pregnant adolescent. Pediatr
Dent 2007;29(suppl):93-7.
2. American Academy of Pediatric Dentistry. Guideline on
oral health care for the pregnant adolescent. Pediatr Dent
2016;38(special issue):163-70.
3. Martin JA, Hamilton BE, Osterman MJK. Births in the
United States, 2018. NCHS Data Brief, no 346. Hyatts-
ville, Md.: National Center for Health Statistics. 2019.
Available at: “https://www.cdc.gov/nchs/data/databriefs/
db346-h.pdf ”. Accessed August 15, 2021.
BEST PRACTICES: PREGNANT ADOLESCENT PATIENT
4. Centers for Disease Control and Prevention. Health Care
Providers and Teen Pregnancy Prevention. Available at:
“https://www.cdc.gov/teenpregnancy/health-care-providers/
index.htm”. Accessed August 15, 2021.
5. Committee on Adolescent Health Care of the American
College of Obstetricians and Gynecologists. Adolescent
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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
2021 of dental patients with special health care needs. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:302-9.

Abstract
This best practice presents recommendations regarding the management of oral health care for dental patients with special health care needs
(SHCN) rather than treatment for oral conditions. SHCN are defined as any physical, developmental, mental, sensory, behavioral, cognitive,
or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services
or programs. Nearly one in five U.S. children has a SHCN. The more severe their health conditions, the more likely they are to have unmet
dental needs. Barriers to care are discussed. Without professional preventive and therapeutic dental services, children with SHCN may
exacerbate systemic medical conditions and increase the need for costly care. Each oral health topic (e.g., dental home, scheduling appoint-
ments, patient assessment, planning dental treatment, informed consent, behavior guidance, preventive strategies) includes specific
recommendations. The document addresses patients with developmental or acquired orofacial conditions as a special cohort of children
with SHCN. Consultation and coordination of care with medical and other dental providers may be necessary for safe delivery of care and
to improve long term outcomes for these patients. As children with SHCN approach adulthood, planning and coordinating their successful
transition to an adult dental home ensures no disruption in the continuity of oral health care.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and guidance on the management of dental patients with special health care needs.

KEYWORDS: DENTAL CARE FOR DISABLED, DISABLED CHILD, DENTAL CARE FOR CHILDREN, PEDIATRIC DENTISTRY

Purpose or were inconclusive, recommendations were based on expert

Providing both primary and comprehensive preventive and
therapeutic oral health care to individuals with special health
care needs (SHCN) is an integral part of the specialty of pedi-
atric dentistry.1 The American Academy of Pediatric Dentistry
(AAPD) values the unique qualities of each person and the
need to ensure maximal health attainment for all, regard-
less of developmental disability or other special health care
needs. These recommendations are intended to educate health
care providers, parents2, and ancillary organizations about the
management of oral health care needs particular to individuals
with SHCN rather than provide specific treatment recom-
mendations for oral conditions.
Methods
Recommendations on the management of dental patients with
SHCN were developed by the Council on Clinical Affairs,
adopted in 20043, and last revised in 20164. This update is
based on a review of the current dental and medical literature
related to individuals with SHCN. A search was conducted via
®
PubMed /MEDLINE using the terms: special needs, disabil-
ity, disabled patients/persons/children, handicapped patients,
dentistry, dental care, and oral health; fields: all; limits: within
the last 10 years, human, and English. Papers for review were
chosen from the resultant list of articles and from references
within selected articles. When data did not appear sufficient
and/or consensus opinion by experienced researchers and
clinicians.
Background
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
management, health care intervention, and/or use of specialized
services or programs. The condition may be congenital,
developmental, or acquired through disease, trauma, or envi-
ronmental cause and may impose limitations in performing
daily self-maintenance activities or substantial limitations in
a major life activity. Health care for individuals with special
needs requires specialized knowledge, as well as increased
awareness and attention, adaptation, and accommodative
measures beyond what are considered routine.”5
Children with SCHN may include those with behavioral
(e.g., anxiety, attention deficit hyperactivity disorder, autism
spectrum disorder), congenital (e.g., trisomy 21, congenital
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. AwDA: Ameri-
cans with Disabilities Act. HIPAA: Health Insurance Portability
and Accountability Act. SHCN: Special health care needs.

302 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


heart disease), developmental (e.g., cerebral palsy) or cognitive
(e.g., intellectual disability) disorders, and systemic diseases
(e.g., childhood cancer, sickle cell disesase).6 In some instances,
the condition primarily affects the orofacial complex (e.g.,
amelogenesis imperfecta, dentinogenesis imperfecta, cleft lip/
palate, oral cancer). While these individuals may not expe-
rience the same limitations as other patients with SHCN,
their needs are unique, affect their overall quality of life, and
require specialized, multidisciplinary oral health care. These
individuals may be at an increased risk for oral diseases
throughout their lifetime.6-11 Oral health conditions associated
with SHCN11 include:
• build-up of calculus resulting in increased gingivitis
and risk for periodontal disease.
• enamel hypoplasia.
• dental caries.
• oral aversion and behavior problems.
• dental crowding.
• malocclusion.
• anomalies in tooth development, size, shape, eruption,
and arch formation.
• bruxism and wear facets.
• fracture of teeth or trauma.
Oral diseases can have a direct and devastating impact on
the general health and quality of life. Individuals with certain
systemic health problems or conditions such as compromised
immunity (e.g., malignancies, human immunodeficiency
virus, history of organ transplantation) or cardiac conditions
at a high risk for infective endocarditis may be especially
vulnerable to the effects of oral diseases.12 Patients with
cognitive, developmental, or physical disabilities that impact
their ability to understand, assume responsibility for, or co-
operate with preventive oral health practices are susceptible
as well.13 Oral health is an inseparable part of general health
and well-being.14
According to the National Survey of Children’s Health in
2017-2018, approximately 13.6 million children (18.5 percent)
had a special health care need.15 One in four children with
SHCN (26.6 percent) had functional limitations, one in five
(19.9 percent) were consistently or significantly impacted by
their health condition(s), and nearly half (46.0 percent) were
sometimes/moderately impacted by their health condition(s).15
The Surgeon General’s Call to Action to Improve the Health
and Wellness of Persons With Disabilities included a call to
double efforts in preventing disease and promoting the overall
health and well-being of persons with disabilities.14 Because of
improvements in medical care, patients with SHCN are liv-
ing longer and require extended medical and oral health care.11
Many of the formerly acute and fatal diagnoses have become
chronic and manageable conditions.11 Oral health care is as
important as the provision of medical services.
Unmet dental needs are associated with SHCN status and
complexity.16 Children affected with more severe conditions
have increased risk of having unmet dental needs.11,16,17 Barriers
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
to care for children with SHCN may range from limitations
in access to a dentist willing to provide care, access to a pro-
fessional with experience and expertise, child’s cooperation,
and transportation issues. Because of these unmet dental care
needs, a dental home with comprehensive, coordinated services
should be established.18,19
Optimal health of children is more likely to be achieved
with access to comprehensive health care benefits.20 Common
barriers for medically necessary oral health care include finan-
cial constraints.21-25 Insurance plays an important role for
families with children who have SHCN, but it still provides
incomplete protection.23-25 Many individuals with SHCN rely
on government funding to pay for medical and dental care
and lack adequate access to private insurance for health care
services.26 Lack of preventive and timely therapeutic care may
increase the need for costly care and exacerbate systemic health
issues.27
Nonfinancial barriers such as language and psychosocial,
structural, and cultural considerations may interfere with
access to oral health care.25 Effective communication is essential
and, for hearing impaired patients/parents, can be accom-
plished through a variety of methods including interpreters,
written materials, and lip-reading. Psychosocial factors associ-
ated with access for patients with SHCN include oral health
beliefs, norms of caregiver responsibility, and past dental
experience of the caregiver. Structural barriers include trans-
portation, school absence policies, discriminatory treatment,
and difficulty locating providers who accept Medicaid.21
Priorities and attitudes can serve as impediments to oral
care. The caregiver’s oral health promotion efforts and interest
in oral health-related education have been positively correlated
with the level of function, capabilities, and independence of
an individual with SHCN.28 Parental and physician lack of
awareness and knowledge in the management of children with
SHCN may hinder an individual with SHCN from seeking
preventive dental care.28,29 Other health conditions may seem
more important than dental health, especially when the re-
lationship between oral health and general health is not well
understood.30
Persons with SHCN may express a greater level of anxiety
about dental care than those without a disability, which may
adversely impact the frequency of dental visits and, subse-
quently, oral health.31 An assessment of anxiety or dental fear
is challenging in this population and, in some cases, an
estimation through parent or caregiver report is helpful.
Patients with SHCN require additional considerations for be-
havior guidance including the patient’s development, education
level, cognitive ability, cooperation in medical settings, triggers
for uncooperative behavior, soothing strategies, adherence to
schedule or routine, current therapies, and other beneficial
accommodations32 as these can complicate the delivery of care.
The use of basic and advanced behavior guidance techniques33,34
allows the dentist to recognize the complexities of managing
patients with SHCN.
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BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
Managing patients with SHCN includes proper coordination
and transition into adult care. Pediatric dentists are concerned
about decreased access to oral health care for patients with
SHCN as they transition beyond the age of majority.35 Finding
a dental home for nonpediatric patients with SHCN can be
challenging. Pediatric hospitals, by imposing age restrictions,
can create another barrier to care for these patients. This presents
difficulties for pediatric dentists providing care to adult patients
with SHCN patients who have not yet transitioned to adult
primary care. Outpatient surgery centers and in-office general
anesthesia may be alternatives, although they may not be appro-
priate for patients with medically complex special needs.36 The
Commission on Dental Accreditation requires dental schools
to ensure that curricular efforts focus on educating students
on assessment of treatment needs of patients with SHCN.37
Recommendations
Reducing the risk of developing oral disease is an integral
part of the comprehensive oral health care for children with
SHCN. The goals of care include: (1) establishing dental
home at an early age, (2) obtaining thorough medical, dental,
and social patient histories, (3) creating an environment con-
ducive for the child to receive care, (4) providing compre-
hensive oral health education and anticipatory guidance to
the child and caregiver, and (5) providing preventive and
therapeutic services including behavior guidance and a multi-
disciplinary approach when needed.6 Attention to detail is
important for all aspects of care including scheduling appoint-
ments, assessment, treatment planning, consent, education
and anticipatory guidance, treatment, recalls, and transition of
care when the patient reaches adulthood.
Dental home
A dental home should be established by 12 months of age,38
especially for children with SHCN. The dental home provides
an opportunity to implement individualized preventive oral
health practices, help establish routine dental care, and reduces
the child’s risk of preventable dental/oral disease.38 Dentists
are obligated to be familiar with the regulations of the Amer-
icans with Disabilities Act18 (AwDA) and ensure compliance.
Regulations require practitioners to provide physical access
to the dental office (e.g., wheelchair ramps, disabled-parking
spaces).
Scheduling appointments
The caregiver’s and patient’s initial contact with the dental
practice allows both parties an opportunity to address the
child’s primary oral health needs and to confirm the appropri-
ateness of scheduling an appointment with that particular
practitioner. Along with the child’s name, age, and chief
complaint, the receptionist should determine the presence
and nature of any SHCN and, when appropriate, the name(s)
of the child’s medical care provider(s). The office staff, under
the guidance of the dentist, should determine the need for an
increased length of appointment and/or additional auxiliary
304 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
staff in order to accommodate the patient in an effective and
efficient manner. The need for increased dentist and team time
as well as customized services should be documented so the
office staff is prepared to accommodate the patient’s unique
circumstances at each subsequent visit. 39 Consideration for
length of time, time of the appointment (e.g., morning, first
appointment of the day, limited patients in the waiting room)
or need for introductory visits helps to ensure a positive
experience.6
When scheduling patients with SHCN, familiarity and
compliance with Health Insurance Portability and Account-
ability Act (HIPAA) and AwDA regulations applicable to
dental practices are imperative.18,50 HIPAA insures that the
patient’s privacy is protected, and AwDA prevents
discrimination on the basis of a disability.
Patient assessment
Familiarity with the patient’s medical history is essential. An
accurate, comprehensive, and up-to-date medical history is
necessary for correct diagnosis, effective treatment planning,
and decreasing the risk of aggravating a medical condition
while rendering care. The intake interview should address the
chief complaint, history of present illness, medical conditions
and/or illnesses, medical care providers, hospitalizations/surgeries,
anesthetic experiences, current medications, allergies/sensitivi-
ties, immunization status, review of systems, and family, social
and dental histories.41,42 The interview should include patient’s
development, education level, and cognitive ability to help
predict cooperation.32 Many children with SHCN may have
sensory considerations or limitations to communication that
can make the dental experience challenging; the dentist should
include such concerns during the history intake and be pre-
pared to modify the traditional delivery of oral care to address
the child’s unique needs. If the patient/parent is unable to
provide accurate information, consultation with the caregiver
or with the patient’s physician may be required.
At each patient visit, the dental team should consult and
verbally update the patient’s medical history, noting any recent
medical attention for illness or injury, change in health status,
newly diagnosed medical conditions, allergies/sensitivities, and
changes in medications. Obtaining a written update at each
recall visit enhances documentation and awareness of the
patient’s history and health status. The patient’s record should
identify any significant medical conditions.
A comprehensive clinical examination includes evaluation
of the head, neck, and oral structures, along with caries- and
periodontal-risk assessment.43,44 Caries-risk assessment pro-
vides a means of classifying caries risk at a point in time and,
therefore, should be applied periodically to assess changes in
an individual’s risk status.43 The examination also should in-
clude assessments of occlusion, habits, and traumatic injuries.
The dentist should review all available adjunctive diagnostic
aids such as radiographs, photographs, or blood tests.
A summary of the oral findings and specific treatment
recommendations should be provided to the patient and parent.

When appropriate, the patient’s other health care providers
(e.g., physicians, nurse practitioners, therapists) and caretakers
should be informed of any significant findings. An individ-
ualized preventive program, including a dental recall schedule,
should be recommended after evaluation of the patient’s caries
risk, oral health needs, and capabilities.
Medical consultations
The dentist should coordinate care via consultation with the
patient’s other care providers. When appropriate, the physician
should be consulted regarding medications, sedation, general
anesthesia, and special restrictions or preparations that may
be required to ensure the safe delivery of oral health care. A
multidisciplinary approach may be necessary in complex case
management. The dentist and staff always should be prepared
to manage a medical emergency.
Planning dental treatment
The goals of oral health care for individuals with SHCN align
with those for all children with careful consideration of the
risks, benefits, and prognosis of the proposed plan to the indi-
vidual’s condition. Understanding the patient’s cognitive level,
sensitivities, oral aversion, and triggers to negative behavior
will help improve delivery of care and communication. Den-
tists should communicate with patients with SHCN at a level
appropriate for their cognitive development.32 The dentist
should not assume that patients with impaired communica-
tion have associated intellectual disability, unless specified.32
Patients with hearing or visual impairment may require non-
verbal communication and cues with the help of the caregiver.
Other considerations include treating active disease prior to
any major medically-necessary procedures (e.g., cardiac surgery,
initiation of oncology treatment), deferring all elective dental
treatment during active phases of medical care if a child is
immunocompromised or at hematologic risk6, and prescribing
antibiotic prophylaxis if risk for infective endocarditis or
distant site infection (e.g., in the presence of uncontrolled
systemic disease, if the individual is immunocompromised) is
high.45 The practitioner should have a thorough knowledge of
indications and contraindications for the use of pharmacol-
ogic agents (e.g., antibiotics, analgesics, sedatives, anesthetics)
in relation to the patient’s medical condition. In some situa-
tions (e,g., anatomic airway issues; high risk of complications
with procedures, surgeries, or general anesthesia; the need for
high level specialist care), treatment in a tertiary hospital setting
is indicated. There is anecdotal parental concern for increased
risk of development of neurodevelopmental disorders such as
autism with general anesthesia exposure. Research has shown
that exposure to general anesthesia before the age of two years
and the number of exposures were not associated with the
development of autism,46 however, further research regard-
ing the risks associated with neurodevelopmental disorders is
warranted.47
Indications for an orthodontic evaluation include facial
asymmetry, abnormalities in nasal breathing, malocclusion, and
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
difficulties with chewing, swallowing, speech, and/or oral
functioning. The primary motivation for parents to have
their child with SHCN undergo orthodontic therapy is to
improve the child’s facial attractiveness, oral function, and
quality of life.48,49 The decision to initiate orthodontic treat-
ment should factor in the child’s ability to tolerate treatment
and the expected outcomes of care.
Informed consent
All patients must be able to provide signed informed consent
for dental treatment or have someone present who legally can
provide this service for them. Informed consent/assent must
comply with state laws and, when applicable, institutional
requirements. Informed consent should be well documented
in the dental record through a signed and witnessed form.50
Behavior guidance
Behavior guidance of the patient with SHCN can be challeng-
ing. Communication may be limited due to anxiety, intellectual
disability, or impaired hearing or vision. Because of dental
anxiety, a lack of understanding of dental care, oral aversion, or
fatigue from multiple medical visits and procedures, children
with SHCN may exhibit resistant behaviors. These behaviors
can interfere with the safe delivery of dental treatment. With
the parent’s/caregiver’s assistance, most patients with physical
and intellectual disabilities can receive oral health care in the
dental office. Protective stabilization can be helpful for some
patients (e.g., those with aggressive, uncontrolled, or impulsive
behaviors; when traditional behavior guidance techniques are
not adequate)33,34 for safe delivery of care and with consent.
When non-pharmacologic behavior guidance techniques are
ineffective, the practitioner may recommend sedation or gen-
eral anesthesia to allow completion of comprehensive treatment
in a safe and efficient manner.
Preventive strategies
Individuals with SHCN may be at increased risk for oral
diseases; these diseases further jeopardize the patient’s overall
health.7 Education of parents/caregivers is critical for ensuring
appropriate and regular supervision of daily oral hygiene. The
team of dental professionals should develop an individualized
oral hygiene program that accommodates the unique disabil-
ity of the patient. Assistance from other health professions
(e.g., occupational therapy) may be beneficial. Brushing with
a fluoridated dentifrice twice daily helps prevent caries and
gingivitis. If a patient’s sensory issues cause the taste or texture
of fluoridated toothpaste to be intolerable, a toothpaste with-
out sodium laurel sulfate (SLS) to eliminate foaming nature, a
fluoridated mouthrinse, or an alternative (e.g., casein
phosphopeptide-amorphous calcium phosphate [CPP-ACP])
may be applied with the toothbrush.51 Toothbrushes can be
modified to enable individuals with physical disabilities to
brush their own teeth. Electric toothbrushes and floss holders
may improve patient compliance. Caregivers should provide the
optimal oral care when the patient is unable to do so adequately.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 305
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
Practitioners should encourage a noncariogenic diet for
long term prevention of dental disease.52 When a diet rich in
carbohydrates or the use of high calorie supplements is medi-
cally necessary (e.g., to increase weight gain), the dentist
should provide strategies to mitigate the caries risk by altering
frequency of and/or increasing preventive measures. Medica-
tions and their oral side effects (e.g., xerostomia, gingival
overgrowth) should be reviewed as these can have an impact
on caries and periodontal risk.6
Patients with SHCN may benefit from sealants. Sealants
reduce the risk of caries in susceptible pits and fissures of
primary and permanent teeth.53 Topical fluorides (e.g., sodium
fluoride, silver diamine fluoride)may be indicated when caries
risk is increased. 54 Interim therapeutic restoration (ITR), 55
using materials such as glass ionomers that release fluoride, may
be useful as both preventive and therapeutic approaches in
patients with SHCN.56 In cases of gingivitis and periodontal
disease, chlorhexidine mouthrinse may be useful.57 Use of a
toothbrush to apply the chlorhexidine is an option if caregivers
are concerned about the child’s potentially swallowing the
antiseptic. An increased recall frequency for patients having
severe dental disease is indicated. Patients with aggressive
periodontal disease require referral to a periodontist for eval-
uation and treatment if the treatment needs are beyond the
treating dentist’s scope of practice.
Preventive strategies for patients with SHCN also should
address traumatic injuries. This would include anticipatory
guidance about risk of trauma (e.g., with seizure disorders or
motor skills/coordination deficits), mouthguard fabrication,
and what to do if dentoalveolar trauma occurs. Additionally,
children with SHCN are more likely to be victims of physical
abuse, sexual abuse, and neglect when compared to children
without disabilities.58 Craniofacial, head, face, and neck injuries
occur in more than half of the cases of child abuse.59 Because
of this incidence, dentists need to be aware of signs of abuse
and mandated reporting procedures.58,59
Barriers
Dentists should be familiar with community-based resources
for patients with SHCN and encourage such assistance when
appropriate. While local hospitals, public health facilities,
rehabilitation services, or groups that advocate for those with
SHCN can be valuable contacts to help the dentist/patient
address language and cultural barriers, other community-based
resources may offer support with financial or transportation
considerations that prevent access to care.60
Patients with developmental or acquired orofacial conditions
The oral health care needs of patients with developmental or
acquired orofacial conditions necessitate special considerations,
and management of their oral conditions may present other
unique challenges. Some children with acquired orofacial
conditions may have an oral aversion which can increase
their anxiety and decrease cooperation in the dental setting.
Developmental defects, such as hereditary ectodermal dysplasia
306 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
with clinical manifestations of oligodontia and anomalies in
size or shape, can cause lifetime problems and be devastating
to children and adults.8 From the first contact with the child
and family, every effort must be made to assist the family in
adjusting to and understanding the complexity of the anomaly
and the related oral needs and provide an overview of goals
and progression of treatment.61 The dental practitioner must
be sensitive to the psychosocial well-being of the patient, as
well as the effects of the condition on growth, function, and
appearance. Congenital oral conditions may entail therapeutic
intervention of a protracted nature, timed to coincide with
developmental milestones. Patients with conditions such as
ectodermal dysplasia, epidermolysis bullosa, cleft lip/palate,
and oral cancer may require a multidisciplinary team approach
to their care. Coordinating delivery of services by the various
health care providers can be crucial to successful treatment
outcomes.
Patients with oral involvement of conditions such as osteo-
genesis imperfecta, ectodermal dysplasia, and epidermolysis
bullosa often present with unique financial barriers. Although
the oral manifestations are intrinsic to the genetic and con-
genital disorders, medical health benefits may not provide for
related professional oral health care. The distinction made by
third-party payors between congenital anomalies involving the
orofacial complex and those involving other parts of the body
is often arbitrary and without merit.62 For children with ecto-
dermal dysplasia, hypodontia, or oligodontia, removable or
fixed prostheses (including complete dentures or over-dentures)
and or implants may be indicated. 63 Dentists should work
with the insurance industry to recognize the medical indication
and justification for such treatment in these cases.
Referrals
A patient may suffer progression of his/her oral disease if
treatment is not provided because of age, behavior, inability to
cooperate, disability, or medical status. Postponement or denial
of care can result in unnecessary pain, discomfort, increased
treatment needs and costs, unfavorable treatment experiences,
and diminished oral health outcomes. Dentists have an obli-
gation to act in an ethical manner in the care of patients.64 If
the patient’s needs are beyond the skills of the practitioner,
the dentist should make necessary referrals in order to ensure
the overall health of the patient. In some cases, the complex
nature of disease and/or existing conditions necessitate mul-
tiple referrals and a team (e.g., cleft lip/palate team) approach
to providing comprehensive care.
Transition into adult dentistry
When patients with SHCN reach adulthood, their oral health
care needs may extend beyond the scope of the pediatric
dentist’s practice. The successful transition from pediatric
to adult dental care is integral to continuity of care and im-
proved long-term outcomes of children with SHCN. 65
Education and preparation before transitioning to a dentist
who is knowledgeable and comfortable in both adult oral

health needs and managing SHCN are important. 66,67 Until
the new dental home is established, the patient should main-
tain a relationship with the current care provider and have
access to emergency services. 68 In cases where transitioning
is not possible or desired, the dental home can remain with
the pediatric dentist who should recommend appropriate
referrals for specialized dental care as needed.60 A coordinated
transition from a pediatric to an adult dental home is critical
for extending the level of oral health and health trajectory
established during childhood.36
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//www.fda.gov/drugs/drug-safety-and-availability/fda
-drug-safety-communication-fda-approves-label-changes
-use-general-anesthetic-and-sedation-drugs”. Accessed
October 18, 2021.
48. Abeleira MT, Pazos E, Limeres J, Outumuro M, Diniz M,
Diz P. Fixed multibracket dental therapy has challenges
but can be successfully performed in young persons with
Down syndrome. Disabil Rehabil 2016;38(14):1391-6.
49. Abeleira MT, Pazos E, Ramos I, et al. Orthodontic treatment
for disabled children: A survey of parents’ attitudes and
overall satisfaction. BMC Oral Health 2014;14(98):1-8.
50. American Academy of Pediatric Dentistry. Informed
consent. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:480-3.
51. Awasthi P, Peshwani B, Tiwari S, Thakur R, Shashikiran
ND, Singla S. Evaluation and comparison of the effi-
cacy of low fluoridated and calcium phosphate-based
dentifrice formulations when used with powered and
manual toothbrush in children with autism. Contemp
Clin Dent 2015;6(1):S188-91.
52. American Academy of Pediatric Dentistry. Policy on
dietary recommendations for infants, children, and adol-
escents. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:87-9.

53. Wright JT, Crall JJ, Fontana M, et al. Evidence-based
clinical practice guideline for the use of pit-and-fissure
sealants. American Academy of Pediatric Dentistry,
American Dental Association. Pediatr Dent 2016;38(5):
E120-E36.
54. American Academy of Pediatric Dentistry. Restorative
dentistry. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:386-98.
55. American Academy of Pediatric Dentistry. Fluoride ther-
apy. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2021:302-5.
56. American Academy of Pediatric Dentistry. Policy on
interim therapeutic restorations (ITR). The Reference
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Academy of Pediatric Dentistry; 2021:74-5.
57. McGrath C, Zhou N, Wong, HM. A systematic review
and meta‐analysis of dental plaque control among chil-
dren and adolescents with intellectual disabilities. J Appl
Res Intellect Disabil 2019;32(3):522-32.
58. Giardino AP, Hudson KM, Marsh J. Providing medical
evaluations for possible child maltreatment to children
with special health care needs, Child Abuse and Neglect
2003;27(10):1179-86.
59. Fisher-Owens SA, Lukefahr JL, Tate AR, et al. Oral and
dental aspects of child abuse and neglect. Pediatr Dent
2017;39(4):278-83.
60. Nowak AJ. Patients with special health care needs in
pediatric dental practices. Pediatr Dent 2002;24(3):
227-8.
61. American Cleft Palate-Craniofacial Association. Param-
eters for evaluation and treatment of patients with cleft
lip/palate or other craniofacial differences. Revised ed.
January, 2018. Available at: “https://journals.sagepub.
com/doi/pdf/10.1177/1055665617739564”. Accessed
September 23, 2021.
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62. American Academy of Pediatric Dentistry. Policy on
third-party reimbursement for oral health care services
related to congenital orofacial differences. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2021:147-9.
63. National Foundation for Ectodermal Dysplasias. Param-
eters of oral health care for individuals affected by
ectodermal dysplasias. 2nd revision, 2015. National
Foundation for Ectodermal Dysplasias; 2015:1-39. Avail-
able at: “https://juyhw1n8m4a3a6yng24eww91-wp
engine.netdna-ssl.com/wp-content/uploads/2016/07/
NFEDParametersOfOralHealthCare.pdf ”. Accessed
September 23, 2021.
64. American Academy of Pediatric Dentistry. Policy on 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.: American Academy of
Pediatric Dentistry; 2021:172-3.
65. Borromeo GL, Bramante G, Betar D, Bhikha C, Cai YY,
Cajili C. Transitioning of special needs paediatric pa-
tients to adult special needs dental services. Aust Dent J
2014;59(3):360-5.
66. Woldorf JW. Transitioning adolescents with special
health care needs: Potential barriers and ethical conflicts.
J Spec Pediatr Nurs 2007;12(1):53-5.
67. Casamassimo PS, Seale NS, Ruehs K. General dentists’
perceptions of educational and treatment issues affecting
access to care for children with special health care needs.
J Dent Educ 2004;68(1):23-8.
68. American Academy of Pediatric Dentistry. Periodicity of
examination, preventive dental services, anticipatory
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Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2021:241-51.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 309
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
that manifests in the mouth, so health care professionals
(including dental providers) need to be aware of how to evaluate
and address these concerns. Maltreatment includes physical
and sexual abuse and can include evidence of bite marks and
dental neglect. Bullying and the human trafficking of chil-
dren also occur and can have serious long-term effects. These
issues may be the presenting problem, noticed during a
physical examination, or children or adolescents may disclose
information about experiencing abuse or neglect. It is im-
portant for all health care providers (including dental providers)
to be alert to and knowledgeable about signs and symp-
toms of child abuse and neglect and to know how to respond.
Because different communities have different resources, not
all providers of a certain job specification may be available
everywhere, and thus, job roles may sometimes overlap.
Physical abuse
Craniofacial, head, face, and neck injuries occur in more than
half of child abuse cases. 1-6 All suspected victims of abuse
or neglect, including children in state custody or foster care,
should be examined carefully by the appropriate provider at
some point during the course of the evaluation for signs of
oral trauma, caries, gingivitis, and other oral health problems,
which are more prevalent in maltreated children than in the
general pediatric population.7
Some authorities believe that the oral cavity may be a
central focus for physical abuse because of its significance in
communication and nutrition.8 Oral injuries may be inflicted
with instruments such as eating utensils or a bottle during
forced feedings, hands, fingers, scalding liquids, or caustic sub-
stances. This form of abuse may result in contusions; burns
or lacerations of the tongue, lips, buccal mucosa, palate (soft
and hard), gingiva, alveolar mucosa, or frenum; fractured,
displaced, or avulsed teeth; or facial bone and jaw fractures.
Naidoo9 cited the lips as the most common site for inflicted
oral injuries (54 percent) followed by the oral mucosa, teeth,
gingiva, and tongue. Lacerations to the oral frena in premobile
infants are often the result of physical abuse and are frequently
associated with other findings of serious physical abuse. 10
Trauma to the teeth may result in pulpal necrosis, leaving the
teeth gray and discolored.11,12 Gags applied to the mouth may
result in bruises, lichenification, or scarring at the corners of
the mouth.13 Some serious injuries of the oral cavity, including
posterior pharyngeal injuries and retropharyngeal abscesses,

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.

310 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


may be inflicted by caregivers who fabricate illness in a child14
to simulate hemoptysis or other symptoms requiring medical
care. All findings in cases in which there is reasonable suspi-
cion of abuse or neglect, regardless of mechanism, should be
reported for further investigation. Unintentional or accidental
injuries to the mouth are common and can be distinguished
from abuse by judging whether the history (including the
timing and mechanism of the injury) is consistent with the
characteristics of the injury and the child’s developmental
capabilities. Multiple injuries, injuries in different stages of
healing, or a discrepant history should arouse suspicion for
abuse. Consultation with or referral to a knowledgeable dentist
or child abuse pediatrician may be helpful. The clinical report
from the American Academy of Pediatrics (AAP) entitled
The Evaluation of Suspected Child Physical Abuse provides
additional guidance.15
Sexual abuse
Although the oral cavity is a frequent site of sexual abuse in
children,16 visible oral injuries or infections are rare. When
oral-genital contact is suspected, referral to specialized clinical
settings equipped to conduct comprehensive examinations
is recommended. The AAP clinical report entitled The Eval-
uation of Children in the Primary Care Setting When Sexual
Abuse Is Suspected 17 provides information regarding these
examinations as does the Updated Guidelines for the Medical
Assessment and Care of Children Who May Have Been Sexually
Abused18.
When oral-genital contact is confirmed by history or
examination findings, universal testing for sexually transmitted
infections within the oral cavity is controversial; the clinician
may consider risk factors (e.g., chronic abuse or a perpetrator
with a known sexually transmitted infection) and the child’s
clinical presentation when deciding whether to conduct such
testing. Accuracy to diagnose sexually transmitted infections
of the oral cavity is increased if evidence is collected within
24 hours of exposure in prepubertal children19 and within 72
hours in adolescents. Evidence collection should be repeated as
clinically indicated. Oral and perioral gonorrhea in prepubertal
children (which is diagnosed with appropriate culture techni-
ques and confirmatory testing) is pathognomonic of sexual
abuse but is rare.20,21 Rates are higher in sexually abused adoles-
cents (12 percent with gonorrhea; 14 percent with Chlamydia).22
Pharyngeal gonorrhea frequently is asymptomatic.23 Although
culture has been considered the gold standard, nucleic acid
amplification tests are more commonly used now24 because they
are more sensitive, less invasive, and less expensive.25 Although
they have not been approved by the U.S. Food and Drug Ad-
ministration for the prepubertal age group or for rectal or
oropharyngeal swab specimens, the Centers for Disease Control
and Prevention does cite nucleic acid amplification tests on
vaginal swab specimens or urine as an alternative to cultures
in girls. However, culture remains the preferred method for
testing urethral swab specimens or urine for boys and for
extragenital swab specimens (pharynx and rectum) for all
BEST PRACTICES: CHILD ABUSE AND NEGLECT
children.26,27 Although human papillomavirus infection may
result in oral or perioral warts, the mode of transmission
remains uncertain. Human papillomavirus infections may be
transmitted sexually through oral-genital contact, vertically
from mother to infant during birth, or horizontally through
nonsexual contact from a child or caregiver’s hand to the
genitals or mouth.28,29
Unexplained injury or petechiae of the palate, particularly
at the junction of the hard and soft palate, may result from
forced oral sex.30 As with all suspected child abuse or neglect,
when sexual abuse is suspected or diagnosed in a child, the case
must be reported to child protective services and/or law en-
forcement agencies for investigation. 31-34 A multidisciplinary
child abuse evaluation for the child and family is preferred
when available.
Children who present acutely with a recent history of sex-
ual abuse may require specialized forensic testing for semen
and other foreign materials resulting from assault. Specialized
hospitals and child protection clinics equipped with protocols
and experienced personnel are best suited for collecting such
specimens and maintaining a chain of evidence necessary for
investigations. If a victim provides a history for oral-penile
contact, the buccal mucosa and tongue can be swabbed with
a sterile, cotton-tipped applicator; the swab can be air dried
and packaged appropriately for laboratory analysis.
Bite marks
Acute or healed bite marks may indicate abuse. Dentists
trained as forensic odontologists can assist health care pro-
viders in the detection and evaluation of bite marks related
to physical and sexual abuse.35 Bite marks should be suspected
when ecchymoses, abrasions, or lacerations are found in an
elliptical, horseshoe shaped, or ovoid pattern.36 Bite marks
may have a central area of ecchymoses (contusions) caused by
the following two possible phenomena: (1) positive pressure
from the closing of the teeth with disruption of small vessels
or (2) negative pressure caused by suction and tongue thrust-
ing. Bites produced by dogs and other carnivorous animals
tend to tear flesh, whereas human bites compress flesh and
can cause abrasions, contusions, and lacerations but rarely
avulsions of tissue. An intercanine distance (i.e., the linear
distance between the central point of the cuspid tips) measuring
more than 3.0 cm is suspicious for an adult human bite.37
Bite marks found on human skin are challenging to inter-
pret because of the distortion presented and the time elapsed
between the injury and the analysis.36 Recent investigations
have led to questions about the scientific validity of forensic
patterned evidence (bite mark analysis in particular) and its
role in legal proceedings.38 The pattern, size, contour, and color
of a bite mark ideally can be evaluated by a forensic odon-
tologist; a forensic pathologist can be consulted if a forensic
odontologist is not available. If neither specialist is available,
a medical provider or dental provider experienced in identi-
fying the patterns of child abuse injuries may examine and
document the bite mark characteristics photographically with
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 311
BEST PRACTICES: CHILD ABUSE AND NEGLECT
an identification tag and scale marker (e.g., ruler) in the
photograph. The photograph should be taken such that the
angle of the camera lens is directly over the bite and in the
same plane of the bite to avoid distortion.39 A special photo-
graphic scale was developed by the American Board of Forensic
Odontology (ABFO) for this purpose as well as for docu-
menting other patterned injuries (ABFO No. 2 Reference
Scale). ABFO-certified odontologists and the ABFO bite mark
analysis flow sheet can be found on the ABFO website (www.
abfo.org). In addition to photographic evidence, every bite
mark that shows indentations ideally will have a polyvinyl
siloxane impression made immediately after swabbing the
bite mark for secretions containing DNA. This impression will
help provide a three-dimensional model of the bite mark.
Written observations and photographs should be repeated at
intervals to best document the evolution of the bite.39 Because
each person has a characteristic bite pattern, a forensic
odontologist may be able to match dental models (casts) of
a suspected abuser’s teeth with impressions or photographs
of the bite. (This is the responsibility of the police and not
the health care provider.)
DNA is present in oral epithelial cells and may be depo-
sited in bites. Even if saliva and cells have dried, they can be
collected by using the double-swab technique. First, a sterile
cotton swab moistened with distilled water is used to wipe the
area in question, then dried and placed in a specimen tube. A
second control sample is collected by swabbing the victim’s
buccal mucosa to distinguish his or her DNA from that of
the perpetrator. 39 All evidence should be collected, docu-
mented, and labeled according to standards with a clear chain
of custody and submitted for forensic analysis.39 Questions
regarding the evidentiary procedure should be directed to a
law enforcement agency.
Bullying
Thirty percent of children in the sixth to 10th grades report
having been bullied and/or having bullied others.40 Children
with orofacial or dental abnormalities (including malocclu-
sion) are frequently subjected to bullying41,42 and, as a result,
may suffer serious psychological consequences, including
depression and suicidal ideation.43-45 Children who reported
physical abuse, intimate partner violence, forced sex, and
bullying were found to also report poor oral health.46 Also of
great concern are the more subtle psychosocial consequences
that can be associated with bullying behavior. Health care
providers (including dental providers) can ask patients about
bullying and advocate for antibullying prevention programs
in schools and other community settings. 44 Health care
providers can become familiar with “Connected Kids: Safe,
Strong, Secure,” the primary care violence prevention protocol
from the AAP that offers preventive education, screening
for risk, and linkages to community-based counseling and
treatment resources (https://patiented.solutions.aap.org/
Handout-Collection.aspx?categoryid=32034).47
312 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Human trafficking
Human trafficking is a serious child health issue involving
medical and dental ramifications, among others, but it is
just beginning to be addressed in the United States. The U.S.
Department of State defines human trafficking as “[T]he
recruitment, harboring, transportation, provision, or obtaining
of a person for labor or services through the use of force,
fraud, or coercion for the purpose of subjection to involun-
tary servitude, peonage, debt bondage, or slavery” (22 USC
§7102[9]).48 Of these, children most commonly experience
sex trafficking, “in which a commercial sex act is induced
by force, fraud, or coercion, or in which the person induced
to perform such act has not attained 18 years of age” (22
USC §7102[9]). Sex trafficking is considered “commercial
sexual exploitation of children” as are pornography and sur-
vival sex (defined as the exchange of sexual activity for basic
necessities such as shelter, food, or money).49,50
Precise numbers of children experiencing human or sex
trafficking are difficult to obtain because of the complicated
nature of these definitions and underreporting. However, it is
estimated that >100,000 children are victims of prostitution
each year in the United States51; see the AAP Clinical Report
entitled Child Sex Trafficking and Commercial Sexual Ex-
ploitation: Health Care Needs of Victims for more information
on identifying and serving these patients. 50 The average age
of children who are exploited for sex is 12 years old, and
children as young as 6 years old are targeted.46,51 Children who
are or have been in foster care,49 are homeless,52 are runaways,50
or are incarcerated in juvenile detention facilities50 are more
likely to be victims of human trafficking (particularly if they
are experiencing survival sex); this can include international
abduction, although geographical dislocation is not required
in the definition of trafficking.52
Although children who are victims of human trafficking
are often disenfranchised from most of society, more than
one-quarter of them still will see a health care professional
while in captivity.53 Victims of trafficking have complex psy-
chosocial and physical challenges that affect how they perceive
and respond to a given situation. Rescued victims often have
complex health needs, including infectious diseases, reproduc-
tive health problems, substance abuse, and mental health
problems. Dental problems also rank high in this list: for traf-
ficked women and adolescents in Europe, 58 percent reported
tooth pain.54 In the United States, more than half (54.3 percent)
of women and adolescents reported dental problems, most
commonly tooth loss (42.9 percent).55 Child trafficking victims
have twice the risk for dental problems because they “often
suffer from inadequate nutrition leading to retarded growth
and poorly formed teeth, as well as dental caries, infections and
tooth loss.”56 For older children, dental problems may trace
back to their situation of origin, with limited access to or poor
quality of care. Dental problems may also come from being in
the trafficking situation, during which time children may have
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
women. As many as 50 percent of victims may be boys or
men, 58 although they are not discussed as much in the
literature. For both sexes, a commonality is a history of child
abuse.
Dental neglect
Dental neglect, as defined by the American Academy of Pedi-
atric Dentistry, is the “willful failure of parent or guardian,
despite adequate access to care, to seek and follow through
with treatment necessary to ensure a level of oral health essential
for adequate function and freedom from pain and infection.”59
Dental caries, periodontal diseases, and other oral conditions
can lead to pain, infection, loss of function, and worse if left
untreated. These undesirable outcomes can adversely affect
learning, communication, nutrition, and other activities neces-
sary for normal growth and development.4,60 Some children
who first present for dental care have severe early childhood
caries (formerly termed infant bottle or nursing caries). Care-
givers with adequate knowledge and willful failure to seek
care must be differentiated from caregivers without knowledge
or awareness of their child’s need for dental care when deter-
mining the need to report such cases to child protective services.
Several factors are considered necessary for the diagnosis of
neglect61:
• a child is harmed or at risk for harm because of lack
of dental health care;
• the recommended dental care offers significant net
benefit to the child;
• the anticipated benefit of the dental treatment is signi-
ficantly greater than its morbidity, so parents would
choose treatment over nontreatment;
• access to health care is available but not used; and
• the parent understands the dental advice given.
Failure to seek or obtain proper dental care may result
from factors such as family isolation, lack of finances, trans-
portation difficulty, parental ignorance, or lack of perceived
value of oral health. 62-64 The point at which to consider a
parent negligent and begin intervention occurs after the parent
has been properly alerted by a health care provider about the
nature and extent of the child’s condition, the specific treat-
ment needed, and the mechanism of accessing that treatment.62
Because many families face challenges in accessing dental
care or insurance for their children, the health care provider,
including the dental provider, will evaluate whether dental
services are readily available and accessible to the child when
considering whether negligence has occurred. A child’s social,
emotional, and medical ability to undergo treatment also
should be considered when determining dental neglect.64
To the best of his or her ability, the health care provider
should be certain that the caregiver understands the expla-
nation of the disease and its implications and, when barriers to
the needed care exist, attempt to assist the family in finding
financial aid, transportation, or public facilities for needed
BEST PRACTICES: CHILD ABUSE AND NEGLECT
services. Risks and benefits of dental treatment should be
explained, and parents should be told that appropriate anal-
gesic and anesthetic procedures will be used to ensure the
child’s comfort during dental procedures. If, despite these
efforts, the parent fails to obtain therapy, the case should be
reported to the appropriate child protective services agency.62
Conclusions
It is important for health care providers (including dental
providers) to be aware that physical or sexual abuse may result
in oral or dental injuries or conditions. Health care providers
should be aware of when and how to document suspicious
injuries and how to obtain laboratory evidence, photo docu-
mentation, and/or consultation with experts when appropriate.
Furthermore, injuries that are inflicted by a perpetrator’s
mouth or teeth may leave clues regarding the timing and
nature of the injury as well as his or her identity. Health care
providers should be knowledgeable about such findings, their
significance, and how to meticulously observe and document
them. When questions arise or consultation is needed, a
pediatric dentist or a dentist with formal training in forensic
odontology can ensure appropriate testing, diagnosis, and
treatment.
Pediatric dentists and oral and maxillofacial surgeons,
whose advanced education programs include a mandated
child abuse curriculum, can provide valuable information and
assistance to other health care providers about oral and dental
aspects of child abuse and neglect. The Prevent Abuse and
Neglect through Dental Awareness65 coalition (http://www.
healthy.arkansas.gov/programsServices/oralhealth/Pages/PANDA.
aspx), which has trained thousands of physicians, nurses,
teachers, child care providers, dentists and other dental pro-
viders, is another resource for physicians seeking information
on this issue. Physician members of multidisciplinary child
abuse and neglect teams are encouraged to identify such dental
providers in their communities to serve as consultants for
these teams. In addition, medical providers with experience
or expertise in child abuse and neglect can make themselves
available to dentists and dental organizations as consultants
and educators. Such efforts will strengthen our ability to
prevent and detect child abuse and neglect and enhance our
ability to care for and protect children.
Recommendations
1. Health care providers (including dental providers) are
required to report injuries that are concerning for abuse
or neglect to child protective services in accordance
with local or state legal requirements. Abusive injuries
frequently involve the face and oral cavity and, thus,
may be first encountered by dental providers.
2. Similarly, sexual abuse may involve the mouth, even
without overt signs, and thus, health care providers
(including dental providers) should know how to collect
a history to elicit this information as well as how to
appropriately collect laboratory tests to support forensic
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 313
BEST PRACTICES: CHILD ABUSE AND NEGLECT
investigations. The general provider is encouraged to
become aware of and consult with appropriate special-
ists in his or her area for specialized forensic interviews
and specimen collection.
3. Bite marks found on human skin are challenging to
interpret because of the distortion presented and the
time elapsed between the injury and the analysis. Ideally,
the pattern, size, contour, and color of the bite mark
should be evaluated by a forensic odontologist, when
one is available.
4. Health care providers (including dental providers) are
encouraged to ask their patients about bullying and
advocate for antibullying prevention programs in
schools and other community settings.
5. Health care providers (including dental providers)
should be aware of the risk factors for human traf-
ficking, identify these in their patients (both girls and
boys), safely connect the patients to resources, and
advocate for anti-trafficking efforts.
6. If parents fail to obtain therapy after barriers to care
have been addressed, the case should be reported to
the appropriate child protective services agency as
concerning for dental neglect.
7. Providers are encouraged to work with colleagues
(including psychological and educational resources)
to provide support to families if any of the aforemen-
tioned maltreatment has occurred.
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15. Christian CW; American Academy of Pediatrics, Com-
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17. Jenny C, Crawford-Jakubiak JE; American Academy
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18. Adams JA, Kellog ND, Farst KJ, et al. Updated guide-
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19. Girardet R, Bolton K, Lahoti S, et al. Collection of
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20. DeJong AR. Sexually transmitted diseases in sexually
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21. Everett VD, Ingram DL, Flick LAR, Russell TA, Tropez-
Sims ST, McFadden AY. A comparison of sexually
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22. Dattel BJ, Landers DV, Coulter K, Hinton J, Sweet RL,
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23. Nelson JD, Mohs E, Dajani AS, Plotkin SA. Gonorrhea
in preschool and school-aged children. Report of the
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24. Hammerschlag MR, Gaydos CA. Guidelines for the
use of molecular biological methods to detect sexually
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25. Black CM, Driebe EM, Howard LA, et al. Multicenter
study of nucleic acid amplification tests for detection of
Chlamydia trachomatis and Neisseria gonorrhoeae in
children being evaluted for sexual abuse. Pediatr Infect
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26. Workowski KA, Bolan GA; Centers for Disease Control
and Prevention. Sexually transmitted diseases treatment
guidelines, 2015. MMWR Recomm Rep 2015;64(RR-
03):1-137.
27. Centers for Disease Control and Prevention. Recommeda-
tions for the laboratory-based detection of Chlamydia
trachomatis and Neisseria gonorrhoeae–2014. MMWR
Recomm Rep 2014;63(RR-02):1-19.
28. Stevens-Simon C, Nelligan D, Breese P, Jenny C, Douglas
JM Jr. The prevalence of genital human papillomavirus
infections in abused and nonabused preadolescent girls.
Pediatrics 2000;106(4):645-9.
29. Bussen S, Sutterlin U, Schmidt U, Bussen D. Anogenital
warts in childhood – Always a marker for sexual abuse?
Geburtshilfe Frauenheilkd 2012;72(1):43-8.
30. Schlesinger SL, Borbotsina J, O’Neill L. Petechial hemor-
rhages of the soft palate secondary to fellatio. Oral Surg
Oral Med Oral Pathol 1975;40(3):376-8.
31. Mouden LD, Bross DC. Legal issues affecting dentistry’s
role in preventing child abuse and neglect. J Am Dent
Assoc 1995;126(8):1173-80.
32. Schwartz S, Woolridge E, Stege D. The role of the dentist
in child abuse. Quintessence Int Dent Dig 1976;7(10):
79-81.
33. Sognnaes RF, Blain SM. Child abuse and neglect, I.
Diagnostic criteria of special interest to dentists [IADR
abstract 1104]. J Dent Res 1979;58(1 Suppl 1):367.
34. Donly KJ, Nowak AJ. Maxillofacial, neck, and dental
lesions of child abuse. In: Reece RM, ed. Child Abuse:
Medical Diagnosis and Management. Philadelphia, Pa.:
Lea & Febiger; 1994:150-66.
35. Sperber ND. Bite marks, oral and facial injuries –
Harbingers of severe child abuse? Pediatrician 1989;16
(3-4):207-11.
36. Silva RHA, de Oliveira Musse J, Melani RFH, Oliveira
RN. Human bite mark identification and DNA tech-
nology in forensic dentistry. Braz J Oral Sci 2006;5(19):
1193-7.
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37. Wagner GN. Bitemark identification in chid abuse cases.
Pediatr Dent 1986;8(1 Spec No):96-100.
38. Golden GS. Bite-mark and pattern injury analysis: A brief
status overview. J Calif Dent Assoc 2015;43(6):309-14.
39. Hinchliffe J. Forensic odontology, part 4. Human bite
marks. Br Dent J 2011;210(8):363-8.
40. American Academy of Pediatrics Committee on Injury,
Violence, and Poison Prevention. Role of the pediatrician
in youth violence prevention. Pediatrics 2009;124(1):
393-402.
41. Seehra J, Fleming PS, Newton T, DiBiase AT. Bullying
in orthodontic patients and its relationship to maloc-
clusion, self-esteem, and oral health-related quality of
life. J Orthod 2011;38(4):247-56, quiz 294.
42. Al-Bitar ZB, Al-Omari IK, Sonbol HN, Al-Ahmad HT,
Cunningham SJ. Bullying among Jordanian school-
children, its effects on school performance, and the
contribution of general physical and dentofacial features.
Am J Orthod Dentofacial Orthop 2013;144(6):872-8.
43. Hunt O, Burden D, Hepper P, Stevenson M, Johnston C.
Self-reports of psychosocial functioning among children
and young adults with cleft lip and palate. Cleft Palate
Craniofac J 2006;43(5):598-605.
44. Al-Omari IK, Al-Bitar ZB, Sonbol HN, Al-Ahmad HT,
Cunningham SJ, Al-Omiri M. Impact of bullying due
to dentofacial features on oral health-related quality
of life. Am J Orthod Dentofacial Orthop 2014;146(6):
734-9.
45. Seerha J, Newton JT, DiBiase AT. Bullying in school-
children – Its relationship to dental appearance and
psychosocial implications: an update for GDPs. Br Dent
J 2011;210(9):411-5.
46. Kvist T, Annerback EM, Sahlqvist L, Flodmark O, Dahllof
G. Association between adolescents’ self-perceived oral
health and self-reported experiences of abuse. Eur J Oral
Sci 2013;121(6):594-9.
47. American Academy of Pediatrics. Connected Kids: Safe,
Strong, Secure. Available at: “https://patiented.solutions.
aap.org/Handout-Collection.aspx?categoryid=32034”.
Accessed May 13, 2016.
48. U.S. Department of State. Trafficking in Persons Report.
2007. Available at: “http://www.state.gov/j/tip/rls/tiprpt/
2007/”. Accessed May 23, 2016.
49. U.S. Department of Education. Human Trafficking of
Children in the United States: A Fact Sheet for Schools.
Available at: “http://www2.ed.gov/about/offices/list/
osdfs/factsheet.pdf ”. Updated June 26, 2007. Accessed
May 18, 2016.
50. Greenbaum J, Crawford-Jakubiak JE; American Academy
of Pediatrics Committee on Child Abuse and Neglect.
Child sex trafficking and commercial sexual exploitation:
health care needs of victims. Pediatrics 2015;135(3):
566-74.
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51. Smith LA, Vardaman SH, Snow MA. The National Report
on Domestic Minor Sex Trafficking: America’s Prostituted
Children. Vancouver, Wash.: Shared Hope International;
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pdf ”. Accessed May 23, 2016.
52. National Alliance to End Homelessness. Issue Brief:
Commercial Sexual Exploitation of Children and Youth
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23, 2016.
53. Family Violence Prevention Fund. Turning pain in to
power: trafficking survivors’perspectives on early inter-
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54. Zimmerman C, Hossain M, Yun K, et al. The health of
trafficked women: A survey of women entering post-
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55. Lederer LJ, Wetzel CA. The health consequences of sex
trafficking and their implications for identifying victims
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56. Crane PA, Moreno M. Human trafficking: what is the
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57. Dovydaitis T. Human trafficking: the role of the health
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58. Curtis R, Terry K, Dank M, Dombrowski K, Khan B.
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York City: Size, Characteristics, and Needs. New York,
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59. American Academy of Pediatric Dentistry. Definition
of dental neglect. Available at: “http://www.aapd.org/
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60. Sanger RG, Bross DC. Clinical Management of Child
Abuse and Neglect: A Guide for the Dental Profession.
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61. Dubowitz H, Black M. Neglect of children’s health. In:
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Myers JEB, eds. The APSAC Handbook on Child
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62. California Society of Pediatric Dentists. Dental neglect:
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63. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World
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64. Bhatia SK, Maguire SA, Chadwick BL, et al. Character-
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65. Arkansas Department of Health Prevent Abuse and
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gov/programsServices/oralhealth/Pages/PANDA.aspx”.
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.:
American Academy of Pediatric Dentistry; 2022:317-20.

Abstract
This best practice provides information for parents and practitioners regarding use of fluoride as an aid in preventing and controlling dental
caries in pediatric dental patients. These recommendations address systemic fluoride (water fluoridation, dietary fluoride supplements,
possibility of fluorosis), topical fluoride delivery via professional application (acidulated phosphate fluoride gel or foam, sodium fluoride
varnish, silver diamine fluoride), and home use products (toothpastes, mouthrinses). The standard level for community water fluoridation
(0.7 parts per million fluoride) helps balance the risk of caries and the possibility of fluorosis from excessive fluoride ingestion during the early
years of tooth development. Specific recommendations for dietary supplementation of fluoride for children ages six months through 16
years are based on fluoride levels in the drinking water, other dietary sources of fluoride, and caries risk. The specific needs of each patient
determine the appropriate use of systemic and topical fluoride products, whether delivered in a professional or a home setting. Fluoride
has proven to be an effective therapy in reducing the prevalence of dental caries in infants, children, adolescents, and persons with special
needs.
Through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific Affairs, this best
practice was revised to offer updated information and recommendations to assist healthcare practitioners and parents in using fluoride
therapy for management of caries risk in pediatric patients.
KEYWORDS: ADOLESCENT, CHILD, FLUORIDATION, FLUORIDE, ORAL HEALTH, TOOTHPASTE, SILVER DIAMINE FLUORIDE

Purpose
The American Academy of Pediatric Dentistry intends
these recommendations to help practitioners and parents
make decisions concerning appropriate use of fluoride
as part of the comprehensive oral health care for infants,
children, adolescents, and persons with special health care
needs.
Methods
This document was developed by the Liaison with Other
Groups Committee and adopted in 1967. These recommen-
dations by the Council of Clinical Affairs are a revision of
the previous version, last revised in 2014. To update this
guidance, an electronic search of the scientific literature from
2012 to 2017 regarding the use of systemic and topical
fluoride was completed. Database searches were conducted
using the terms: fluoride caries prevention, fluoridation,
fluoride gel, fluoride varnish, fluoride toothpaste, fluoride
therapy, and topical fluoride. Because 720 papers were
identified through these electronic searches, an alternate
strategy of limiting the information gathering to systematic
review using the term fluoride caries prevention yielded 95
papers since 2012. Nine well-conducted systematic reviews1-9
and their references primarily were used for this update.
Expert opinions and clinical practices also were relied upon
for these recommendations.
Background
Fluoride has been a major factor in the decline in prevalence
and severity of dental caries in the U.S. and other econo-
mically developed countries. It has several caries-protective
mechanisms of action. Topically, low levels of fluoride in
plaque and saliva inhibit the demineralization of sound
enamel and enhance the remineralization of demineralized
enamel. Fluoride also inhibits dental caries by affecting the
metabolic activity of cariogenic bacteria. 10 High levels of
fluoride, such as those attained with the use of topical gels
or varnishes, produce a temporary layer of calcium fluoride-
like material on the enamel surface. The fluoride is released
when the pH drops in response to acid production and be-
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
developing dental enamel (i.e., the systemic route), but the
fluoride concentration in sound enamel does not fully explain
the marked reduction in dental caries. It is oversimplification
to designate fluoride simply as systemic or topical. Fluoride
that is swallowed, such as fluoridated water and dietary
supplements, may contribute to a topical effect on erupted
teeth (before swallowed, as well as a topical effect due to
increasing salivary and gingival crevicular fluoride levels).
ABBREVIATIONS
F: Fluoride. IQ: Intelligence quotient. NaFV: Sodium fluoride varnish.
ppm F: parts per million fluoride. SDF: Silver diamine fluoride.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 317

BEST PRACTICES: FLUORIDE THERAPY
Table. DIETARY FLUORIDE SUPPLEMENTATION SCHEDULE
Age <0.3 ppm F 0.3 to 0.6 ppm F >0.6 ppm F
Birth to 6 months 0 0 0 at high caries risk who drink fluoride-deficient (less than
6 mo to 3 years 0.25 mg 0 0
3 to 6 years 0.50 mg 0.25 mg 0 fluoride before prescribing supplements can help reduce
6 to at least 16 years 1.00 mg 0.50 mg 0
Additionally, elevated plasma fluoride levels can treat the outer
surface of fully mineralized, but unerupted, teeth topically.
Similarly, topical fluoride that is swallowed may have a
systemic effect.12
Fluoridation of community drinking water is the most
equitable and cost-effective method of delivering fluoride to
all members of most communities.13 Water fluoridation at the
level of 0.7-1.2 milligrams fluoride ion per liter (i.e., parts
per million fluoride [ppm F]) was introduced in the U.S. in
the 1940s. Since fluoride from water supplies is now one of
several sources of fluoride, the Department of Health and
Human Services has recommended not having a fluoride
range, but rather to standardize all water to the 0.7 ppm F
level. The rationale is to balance the benefits of preventing
dental caries while reducing the chance of fluorosis.1
Community water fluoridation has been associated with
the decline in caries prevalence in U.S. adolescents, from 90
percent in at least one permanent tooth in 12-17-year-olds
in the 1960s, to 60 percent in a 1999-2004 survey.14 When
used appropriately, fluoride is both safe and effective in
preventing and controlling dental caries. Although adverse
health effects (e.g., decreased cognitive ability, endocrine
disruption and cancer) have been ascribed to the use of
fluoride over the years, the preponderance of evidence from
large cohort studies and systematic reviews does not support
an association of such health issues and consumption of fluo-
ridated water.1 Regarding cognitive ability, a recent study of
mothers’ urinary fluoride levels and their child’s intelligence
quotient (IQ) levels suggested an association with exposure
levels greater than those recommended in the U.S. for water
fluoridation.15 However, a prospective study in New Zealand
did not support an association between fluoridated water
and IQ measurements, 16 and a national sample in Sweden
found no relationship between fluoride levels in water supplies
and cognitive ability, non-cognitive ability, and education.17
Consumption of fluoride during the mineralization of teeth,
however, can cause fluorosis (children 1-3 years of age being
most susceptible for fluorosis of the permanent incisors).
The National Health and Nutrition Examination Survey
1999-2004 study found 23 percent of the U.S. population
had very mild or mild fluorosis.18 Decisions concerning the
administration of fluoride are based on the unique needs
of each patient, including the risks and benefits (e.g., risk
of mild or moderate fluorosis versus the benefits of decreasing
318 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
caries increment and, in some cases preventing, devastating
dental disease).
Fluoride supplements also are effective in reducing pre-
valence of dental caries and should be considered for children
0.6 ppm F) water 19 (see Table). Determination of dietary
intake of excess fluoride. Sources of dietary fluoride may
include drinking water from home, day care, and school;
beverages such as soda20, juice21, and infant formula22; pre-
pared food23; and toothpaste. Concentrated infant formulas
requiring reconstitution with water have raised concerns
regarding an increased risk of fluorosis. 24 Infants may be
particularly susceptible because of the large consumption of
such liquid in the first year of life, while the body weight
is relatively low. 12 An evidence-based review found that
consumption of reconstituted infant formula can be associated
with an increased risk of mild fluorosis, but recommended
the continued use of fluoridated water. 25 One study has
shown that dental fluorosis levels do not vary in fluoridated
areas regardless of premixed versus reconstituted formula.26
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 fluoride [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 trials show that fluoride gels, applied at three
months to one year intervals, also are efficacious in reducing
caries in permanent teeth.27 Some topical fluoride gel and foam
products are marketed with recommended treatment times of
less than four minutes, but there are no clinical trials showing
efficacy of shorter than four-minute application times.28 There
also is limited evidence that topical fluoride foams are
efficacious in children. 2 Children at risk for caries should
Figure. Comparison of a smear (left) with a pea-sized (right) amount
of toothpaste.

receive a professional fluoride treatment at least every six
months.28
Silver diamine fluoride ([SDF]; five 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
dentinal caries. SDF arrests caries by the antibacterial effect of
silver and by remineralization of enamel and dentin.9 Some
clinical trials show a caries arrest rate greater than 80 percent,7
but such studies have a high risk of bias and a wide variation
of results, leading to conditional recommendations at this
time.29 Although the product is highly concentrated, less than
a drop is needed to treat several caries lesions. The only re-
ported side effects of SDF are that caries lesions stain black
after treatment, and it will temporarily stain skin with contact.
Home use of fluoride products for children should focus
on regimens that maximize topical contact, in lower-dose
higher-frequency approaches.30 Meta-analyses of more than
70 randomized or quasi-randomized controlled clinical
trials show that fluoride toothpaste is efficacious in reducing
prevalence of dental caries in permanent teeth, with the effect
increased in children with higher baseline level of caries with
higher concentration of fluoride in the toothpaste, greater
frequency of use, and supervision of brushing.31,32 A meta-
analysis of eight clinical trials on caries increment in preschool
children also shows that tooth brushing with fluoridated
toothpaste significantly reduces dental caries prevalence in the
primary dentition.6 Using no more than a smear or rice-size
amount of fluoridated toothpaste for children less than three
years of age may decrease risk of fluorosis. Using no more
than a pea-size amount of fluoridated toothpaste is appropriate
for children aged three to six8 (see Figure). To maximize the
beneficial effect of fluoride in the toothpaste, supervised
tooth-brushing should be done twice a day and rinsing after
brushing should be kept to a minimum or eliminated alto-
gether.4 Other topical fluoride products (e.g., prescription-
strength home-use 0.5 percent fluoride gels and pastes;
prescription-strength, home-use 0.09 percent fluoride
mouthrinse) have benefit in reducing dental caries in children
six years or older.2
Recommendations
1. There is confirmation from evidence-based reviews
that fluoride use for the prevention and control of
caries is both safe and highly effective in reducing
dental caries prevalence.
2. There is support from evidence-based reviews that
fluoride dietary supplements are effective in reducing
dental caries and should be considered for children
at caries risk who drink fluoride-deficient (less than
0.6 ppm) water.
3. There is support from evidenced-based reviews that
professionally applied topical fluoride treatments as
five percent NaFV or 1.23 percent F gel preparations
are efficacious in reducing caries in children at caries
risk.
BEST PRACTICES: FLUORIDE THERAPY
4. There is support from evidence-based reviews that
fluoridated toothpaste is effective in reducing dental
caries in children with the effect increased in chil-
dren with higher baseline level of caries, higher
concentration of fluoride in the toothpaste, greater
frequency in use, and supervision. Using no more than
a smear or rice-size amount of fluoridated toothpaste
for children less than three years of age may decrease
risk of fluorosis. Using no more than a pea-size
amount of fluoridated toothpaste is appropriate for
children aged three to six.
5. There is support from evidenced-based reviews that
prescription-strength home-use 0.5 percent fluoride
gels and pastes and prescription-strength home-use
0.09 percent fluoride mouthrinse also are effective
in reducing dental caries.
6. There is support from evidence-based reviews to
recommend the use of 38 percent silver diamine
fluoride for the arrest of cavitated caries lesions in
primary teeth as part of a comprehensive caries man-
agement program.
References
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for caries prevention: Executive summary of the updated
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8. Wright JT, Hanson N, Ristic H, et al. Fluoride tooth-
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Assoc 1999;130(11):1593-9.
320 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
21. Kiritsy MC, Levy SM, Warren JJ, Guha-Chowdhury
N, Heilman JR, Marshall T. Assessing fluoride concen-
trations of juices and juice-flavored drinks. J Am Dent
Assoc 1996;127(7):895-902.
22. Levy SM, Kohout FJ, Guha-Chowdhury N, Kiritsy
MC, Heilman JR, Wefel JS. Infants’ fluoride intake from
drinking water alone, and from water added to formula,
beverages, and food. J Dent Res 1995;74(7):1399-407.
23. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Fluoride
concentrations of infant foods. J Am Dent Assoc 1997;
128(7):857-63.
24. Hujoel PP, Zina LG. Moimas SAS, Cunha-Cruz J. Infant
formula and enamel fluorosis. A systematic review. J Am
Dent Assoc 2009;140(7):841-54.
25. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based
clinical recommendations regarding fluoride intake from
reconstituted infant formula and enamel fluorosis. J Am
Dent Assoc 2011;142(1):79-87.
26. Do LG, Levy SM, Spencer AJ. Association between
infant formula feeding and dental fluorosis and caries in
Australian children. J Public Health Dent 2012;72(2):
112-21.
27. Marinho VC, Higgin JP, Logan, S, Sheiham A. System-
atic review of controlled trials on the effectiveness of
fluoride gels for the prevention of dental caries in chil-
dren. J Dent Ed 2003;67(4):448-58.
28. Hunter JW, Chan JT, Featherstone DB, et al.
Professionally-applied topical fluoride: Evidence-based
clinical recommendations. J Am Dent Assoc 2006;137
(8):1151-9.
29. 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.
30. Adair SM. Evidence-based use of fluoride in contem-
porary pediatric dental practice. Pediatr Dent 2006;28
(2):133-42.
31. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride
toothpaste for preventing dental caries in children and
adolescents. Cochrane Database of Sys Rev 2003;(1):
CD002278.
32. Walsh T, Worthington HV, Glenny AM, Appelbe P,
Marinho VC, Shi X. Fluoride toothpastes of different
concentrations for preventing dental caries in children
and adolescents. Cochrane Database of Sys Rev 2010;
(1):CD007868.
 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 of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:321-39.

Abstract
This best practice provides health care personnel, parents, and others with information for predicting and guiding behavior in children during
dental procedures. Successful treatment of pediatric dental patients depends on effective communication and developing customized
behavior guidance plans dependent on the patient’s treatment needs and the skills of the dentist. Behavior guidance is a continual process
from basic to advanced techniques, using non-pharmacological and pharmacological options. The following items should be addressed
before, during, and after patient treatment: informed consent, pain assessment, behavior documentation, and preventive and deferred treat-
ment considering all behavior guidance options. Basic behavior guidance includes communication guidance, positive pre-visit imagery, direct
observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, positive reinforcement and descriptive praise, distraction,
and desensitization. For anxious patients and those with special health care needs, additional behavior guidance options include sensory-
adapted dental environments, animal assisted therapy, picture exchange communication systems, and nitrous oxide-oxygen inhalation.
Advanced behavior guidance includes protective stabilization, sedation, and general anesthesia. Each option should be assessed for objectives,
indications, contraindications, and precautions. Knowledge of these options will aid healthcare professionals in providing appropriate patient-
specific and family-centered behavior guidance for infants, children, adolescents, and persons with special health care needs.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations to inform health care providers, parents and others about the
behavior guidance techniques used and behavioral influences impacting contemporary pediatric dental care.
KEYWORDS: ANESTHESIA, GENERAL, BEHAVIOR THERAPY, CHILD, INFORMED CONSENT, NITROUS OXIDE, PAIN MEASUREMENT

Purpose last revised in 2015.8 The original guidance was developed

The American Academy of Pediatric Dentistry (AAPD)
recognizes that dental care is medically necessary for the pur-
pose of preventing and eliminating orofacial disease, infection,
and pain, restoring the form and function of the dentition,
and correcting facial disfiguration or dysfunction.1 Behavior
guidance techniques, both nonpharmalogical and pharma-
logical, are used to alleviate anxiety, nurture a positive dental
attitude, and perform quality oral health care safely and
efficiently for infants, children, adolescents, and persons with
special health care needs (SHCN). Selection of techniques must
be tailored to the needs of the individual patient and the skills
of the practitioner. The AAPD offers these recommendations
to inform health care providers, parents, and other interested
parties about influences on the behavior of pediatric dental
patients and the many behavior guidance techniques used in
contemporary pediatric dentistry. Information regarding pain
management, protective stabilization, and pharmacological
behavior management for pediatric dental patients is provided
in greater detail in additional AAPD best practices
documents.2-6
Methods
Recommendations on behavior guidance were developed
by the Clinical Affairs Committe, Behavior Management
Subcommittee and adopted in 1990.7 This document by the
Council of Clinical Affairs is a revision of the previous version,
subsequent to the AAPD’s 1988 conference on behavior
management and modified following the AAPD’s symposia
on behavior guidance in 2003 10 and 2013.11 This update
reflects a review of the most recent proceedings, other dental
and medical literature related to behavior guidance of the pedi-
atric patient, and sources of recognized professional expertise
and stature including both the academic and practicing
pediatric dental communities and the standards of the American
Dental Association Commission on Dental Accreditation.12 In
®
addition, a search of the PubMed /MEDLINE electronic
database was performed, (see Appendix 1 after References).
Articles were screened by viewing titles and abstracts. Data was
abstracted and used to summarize research on behavior
guidance for infants and children through adolescents, includ-
ing those with special healthcare needs. When data did not
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. AAT: Animal-
assisted therapy. ITR: Interim therapeutic restoration. PECS: Picture
exchange communication system. SADE: Sensory-adapted dental
environment. SDF: Silver diamine fluoride. SHCN: Special health-
care needs.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 321

BEST PRACTICES: BEHAVIOR GUIDANCE
Background
Dental practitioners are expected to recognize and effectively
treat childhood dental diseases that are within the knowledge
and skills acquired during their professional education. Safe
and effective treatment of these diseases requires an under-
standing of and, at times, modifying the child’s and family’s
response to care. Behavior guidance a continuum of interaction
involving the dentist and dental team, the patient, and parent
directed toward communication and education, while also
ensuring the safety of both oral health professionals and the
child, during the delivery of medically necessary care. Goals
of behavior guidance are to: 1) establish communication, 2)
alleviate the child’s dental fear and anxiety, 3) promote pa-
tient’s and parents’ awareness of the need for good oral health
and the process by which it is achieved, 4) promote the child’s
positive attitude toward oral health care, 5) build a trusting
relationship between dentist/staff and child/parent, and 6)
provide quality oral health care in a comfortable, minimally-
restrictive, safe, and effective manner. Behavior guidance tech-
niques range from establishing or maintaining communication
to stopping unwanted or unsafe behaviors.13 Knowledge of
the scientific basis of behavior guidance and skills in com-
munication, empathy, tolerance, cultural sensitivity, and
flexibility are requisite to proper implementation. Behavior
guidance should never be punishment for misbehavior, power
assertion, or use of any strategy that hurts, shames, or belittles
a patient.
Predictors of child behaviors
Patient attributes
A dentist who treats children should be able to accurately
assess the child’s developmental level, dental attitudes, and
temperament to anticipate the child’s reaction to care. The
response to the demands of oral health care is complex and
determined by many factors.
Factors that may contribute to noncompliance during the
dental appointment include fears, general or situational
anxiety, a previous unpleasant and/or painful dental/medical
experience, pain, inadequate preparation for the encounter,
and parenting practices.13-19 In addition, cognitive age, devel-
opmental delay, inadequate coping skills, general behavioral
considerations, negative emotionality, maladaptive behaviors,
physical/mental disability, and acute illness or chronic disease
are potential reasons for noncompliance during the dental
appointment.13-19
Dental behavior management problems often are more
readily recognized than dental fear/anxiety due to associations
with general behavioral considerations (e.g., activity, impul-
sivity) versus temperamental traits (e.g., shyness, negative
emotionality) respectively. 20 Only a minority of children
with uncooperative behavior have dental fears, and not all
fearful children present with dental behavior guidance prob-
lems.14,21,22 Fears may occur when there is a perceived lack of
control or potential for pain, especially when a child is aware
of a dental problem or has had a painful healthcare experience.
322 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
If the level of fear is incongruent with the circumstances and
the patient is not able to control impulses, disruptive behavior
is likely.20
Cultural and linguistic factors also may play a role in patient
cooperation and selection of behavior guidance techniques.23-26
Since every culture has its own beliefs, values, and practices,
it is important to understand how to interact with patients
from different cultures and to develop tools to help navigate
their encounters. Translation services should be made available
for those families who have limited English proficiency. 26,27
A federal mandate requires translation services for non-English
speaking families be available at no cost to the family in
healthcare facilities that receive federal funding for services.28
As is true for all patients/families, the dentist/staff must listen
actively and address the patient’s/parents’ concerns in a sensitive
and respectful manner.23
Parental influences
Parents influence their child’s behavior at the dental office in
several ways. Positive attitudes toward oral health care may
lead to the early establishment of a dental home. Early pre-
ventive care leads to less dental disease, decreased treatment
needs, and fewer opportunities for negative experiences.29,30
Parents who have had negative dental experiences as a patient
may transmit their own dental anxiety or fear to the child
thereby adversely affecting her attitude and response to
care. 14,17,31,32 Long term economic hardship leads to stress,
which can lead to parental adjustment problems such as de-
pression, anxiety, irritability, substance abuse, and violence.23
Parental depression may result in parenting changes, including
decreased supervision, caregiving, and discipline for the child,
thereby placing the child at risk for a wide variety of adjust-
ment issues including emotional and behavior problems.23 In
America, evolving parenting styles17,18 and parental behaviors
influenced by economic hardship have left practitioners
challenged by an increasing number of children ill-equipped
with the coping skills and self-discipline necessary to contend
with new experiences.23,24,26 Frequently, parental expectations
for the child’s response to care (e.g., no tears) are unrealistic,
while expectations for the dentist who guides their behavior
are great.19
Orientation to dental environment
The nonclinical office staff plays an important role in
behavior guidance. The scheduling coordinator or receptionist
often will be the first point of contact with a prospective
patient and family, either through the internet or a telephone
conversation. The tone of the communication should be wel-
coming. The scheduling coordinator or receptionist should
actively engage the patient and family to determine their
primary concerns, chief complaint, and any special health care
or cultural/linguistic needs. The communication can provide
insights into patient or family anxiety or stress. Staff should
help set expectations for the initial visit by providing relevant
information and may suggest a pre-appointment visit to the

office to meet the doctor and staff and tour the facility.20 The
nonclinical staff should confirm the office’s location, offer
directions, and ask if there are any further questions. Such
encounters serve as educational tools that help to allay fears
and better prepare the family and patient for the first visit.
The parent’s/patient’s initial contact with the dental practice
allows both parties to address the child’s primary oral health
needs and to confirm the appropriateness of scheduling an
appointment.33 From a behavioral standpoint, many factors
are important when appointment times are determined. 20
Appointment-related concerns include patient age, presence
of a special health care need, the need for sedation, distance
the parent/patient travels, length of appointment, additional
staffing requirements, parent’s work schedule, and time of day.
Emergent or urgent treatment should not be delayed on these
grounds alone.34 Appointment scheduling should be tailored
to the needs of the individual patient’s circumstances and the
skills of the practitioner. The practitioner should formulate
a policy regarding scheduling, and scheduling should not
be left to chance. 20 Appointment duration should not be
prolonged beyond a patient’s tolerance level solely for the
practitioner’s convenience. 20 Consideration of appointment
scheduling will benefit the parent/patient and practitioner by
building a trusting relationship that promotes the patient’s
positive attitude toward oral health care.
Reception staff are usually the first team members the
patient meets upon arrival at the office. The caring and assuring
manner in which the child is welcomed into the practice
at the first and subsequent visits is important. 19,35 A child-
friendly reception area (e.g., age-appropriate toys and games)
can provide a distraction for and comfort young patients.
These first impressions may influence future behaviors.
Patient assessment
An evaluation of the child’s cooperative potential is essential
for treatment planning. No single assessment method or tool
is completely accurate in predicting a patient’s behavior, but
awareness of the multiple influences on a child’s response to
care can aid in treatment planning.36 Initially, information can
be gathered from the parent through questions regarding the
child’s cognitive level, temperament/personality characteris-
tics,15,22,37,38,39 anxiety and fear,14,22,40 reaction to strangers,41
and behavior at previous medical/dental visits, as well as how
the parent anticipates the child will respond to future dental
treatment. Later, the dentist can evaluate cooperative potential
by observation of and interaction with the patient. Whether
the child is approachable, somewhat shy, or definitely shy
and/or withdrawn may influence the success of various com-
municative techniques. Assessing the child’s development,
past experiences, and current emotional state allows the
dentist to develop a behavior guidance plan to accomplish the
necessary oral health care.20 During delivery of care, the dentist
must remain attentive to physical and/or emotional indicators
of stress.23-26,42 Changes in behaviors may require alterations
to the behavioral treatment plan.
BEST PRACTICES: BEHAVIOR GUIDANCE
Dentist/dental team behaviors
The behaviors of the dentist and dental staff members are the
primary tools used to guide the behavior of the pediatric
patient. The dentist’s attitude, body language, and communi-
cation skills are critical to creating a positive dental visit for
the child and to gain trust from the child and parent.29 Dentist
and staff behaviors that can help reduce anxiety and encourage
patient cooperation include giving clear and specific instruc-
tions, having empathetic communication style, and offering
verbal reassurance.43 Dentists and staff must continue to be
attentive to their communication styles throughout interactions
with patients and families.44
Communication (i.e., imparting or interchange of thoughts,
opinions, or information) may occur by a number of means
but, in the dental setting, it is accomplished primarily through
dialogue, tone of voice, facial expression, and body language.45
Communication between the doctor/staff and the child and
parent is vital to successful outcomes in the dental office.
The four essential ingredients of communication are:
1. the sender,
2. the message, including the facial expression and body
language of the sender,
3. the context or setting in which the message is sent, and
4. the receiver.46
For successful bi-directional communication to take place,
all four elements must be present and consistent. Without
consistency, there may be a poor fit between the intended
message and what is understood.45
Communicating with children poses special challenges
for the dentist and the dental team. A child’s cognitive
development will dictate the level and amount of information
interchange that can take place.26 With a basic understanding
of the cognitive development of children, the dentist can use
appropriate vocabulary and body language to send messages
consistent with the receiver’s intellectual development.26,45
Communication may be impaired when the sender’s expres-
sion and body language are not consistent with the intended
message. When body language conveys uncertainty, anxiety,
or urgency, the dentist cannot effectively communicate con-
fidence or a calm demeanor.45
In addition, the operatory may contain distractions (e.g.,
another child crying) that, for the patient, produce anxiety
and interfere with communication. Dentists and other mem-
bers of the dental team may find it advantageous to discuss
certain information (e.g., postoperative instructions,
preventive counseling) away from the operatory and its many
distractions.19
The communicative behavior of dentists is a major factor
in patient satisfaction.46,47 Dentist actions that are reported to
correlate with low parent satisfaction include rushing through
appointments, not taking time to explain procedures, barring
parents from the examination room, and generally being
impatient.37,43 However, when a provider offers compassion,
empathy, and genuine concern, there may be better acceptance
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 323
BEST PRACTICES: BEHAVIOR GUIDANCE
of care.43 While some patients may express a preference for a
provider of a specific gender, female and male practitioners
have been found to treat patients and parents in a similar
manner.39
The clinical staff is an extension of the dentist in behavior
guidance. A collaborative approach helps assure that both the
patient and parent have a positive dental experience. All den-
tal team members are encouraged to expand their skills and
knowledge through dental literature, video presentations, and/
or continuing education courses.49
Informed consent
All behavior guidance decisions must be based on a review of
the patient’s medical, dental, and social history followed by an
evaluation of current behavior. Decisions regarding the use
of behavior guidance techniques other than communicative
management cannot be made solely by the dentist. They must
involve a parent and, if appropriate, the child. The practitioner,
as the expert on dental care (i.e., the timing and techniques
by which treatment can be delivered), should effectively com-
municate behavior and treatment options, including potential
benefits and risks, and help the parent decide what is in the
child’s best interests. 29 Successful completion of diagnostic
and therapeutic services is viewed as a partnership of dentist,
parent, and child.29,50,51 The conversation should allow questions
from the parent and patient in order to clarify issues and to
verify the parents’ and child’s comprehension. This should be
done in the family’s preferred language, with assistance of a
trained interpreter if needed.13,28
Communicative management, by virtue of being a basic
element of communication, requires no specific consent. All
other behavior guidance techniques require informed consent
consistent with AAPD’s Informed Consent 52 and applicable
state laws. A signature on the consent form does not neces-
sarily constitute informed consent. Informed consent implies
information was provided to the parent, risks/benefits and
alternatives were discussed, questions were answered, and
permission was obtained prior to administration of treat-
ment. 13 If the parent refuses treatment after discussions of
the risks/benefits and alternatives of the proposed treatment
and behavior guidance techniques, an informed refusal
form should be signed by the parent and retained in the
patient’s record.53 If the dentist believes the informed refusal
violates proper standard of care, he should recommend the
patient seek another opinion and/or dismiss the patient
from the practice. 52 If the dentist suspects dental neglect 54,
he is obligated to report to appropriate authorities.52,55
In the event of an unanticipated behavioral reaction to
dental treatment, it is incumbent upon the practitioner to pro-
tect the patient and staff from harm. Following immediate
intervention to assure safety, if a new behavior guidance plan is
developed to complete care, the dentist must obtain informed
consent for the alternative methods.52,56,57
324 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Pain assessment and management during treatment
Pain has a direct influence on behavior and should be assessed
and managed throughout treatment.58 Anxiety may be a pre-
dictor of increased pain perception. 59 Findings of pain or a
painful past health care visit are important considerations in
the patient’s medical/dental history that will help the dentist
anticipate possible behavior problems. 2,53,58 Prevention or
reduction of pain during treatment can nurture the relation-
ship between the dentist and the patient, build trust, allay fear
and anxiety, and enhance positive dental attitudes for future
visits.60-64 Pain can be assessed using self-report, behavioral, and
biological measures. In addition, there are several pain assess-
ment instruments that can be used in patients.2 The subjective
nature of pain perception, varying patient responses to painful
stimuli, and lack of use of accurate pain assessment scales may
hinder the dentist’s attempts to diagnose and intervene during
procedures.31,61,62,65-67 Observing changes in patient behavior
(e.g., facial expressions, crying, complaining, body movement
during treatment) as well as biologic measures (e.g., heart
rate, sweating) is important in pain evaluation. 2,61,64 The
patient is the best reporter of her pain. 31,62,65,66 Listening to
the child at the first sign of distress will facilitate assessment
and any needed procedural modifications.62 At times, dental
providers may underestimate a patient’s level of pain or may
develop pain blindness as a defense mechanism and continue
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
sensitization for future appointments as well as psychological
trauma.72
Documentation of patient hehaviors
Recording the child’s behavior serves as an aid for future
appointments.66 One of the more reliable and frequently used
behavior rating systems in both clinical dentistry and research
is the Frankl Scale.20,66,73 This scale (see Appendix 2) separates
observed behaviors into four categories ranging from definitely
negative to definitely positive.20,66,73 In addition to the rating
scale, an accompanying descriptor (e.g., “+, non-verbal”) will
help practitioners better plan for subsequent visits.
Treatment deferral
Dental disease usually is not life-threatening, and the type and
timing of dental treatment can be deferred in certain circum-
stances. When a child’s cognitive abilities or behavior prevents
routine delivery of oral health care using communicative
guidance techniques, the dentist must consider the urgency of
dental need when determining a plan of treatment.56,57 In some
cases, treatment deferral may be considered as an alternative
to treating the patient under sedation or general anesthesia.
However, rapidly advancing disease, trauma, pain, or infection
usually dictates prompt treatment. Deferring some or all treat-
ment or employing therapeutic interventions (e.g., silver
diamine fluoride [SDF] 74 interim therapeutic restoration
[ITR],75,76 fluoride varnish, antibiotics for infection control)
until the child is able to cooperate may be appropriate when

based upon an individualized assessment of the risks and
benefits of that option. The dentist must explain the risks and
benefits of deferred or alternative treatments clearly, and
informed consent must be obtained from the parent.52,53,56 In
select cases where ITR or SDF is employed, regular reevalu-
ations are recommended and retreatment may be needed.77,78
Treatment deferral also should be considered in cases when
treatment is in progress and the patient’s behavior becomes
hysterical or uncontrollable. In such cases, the dentist should
halt the procedure as soon as possible, discuss the situation
with the patient/parent, and either select another approach
for treatment or defer treatment based upon the dental needs
of the patient. If the decision is made to defer treatment, the
practitioner immediately should complete the necessary steps
to bring the procedure to a safe conclusion before ending the
appointment.57,75,76
Caries risk should be reevaluated when treatment options
are compromised due to child behavior.79 An individualized
preventive program, including appropriate parent education
and a dental recall schedule, should be recommended after
evaluation of the patient’s caries risk, oral health needs, and
abilities. Topical fluorides (e.g., brush-on gels, fluoride
varnish, professional application during prophylaxis) may
be indicated. 80 ITR may be useful as both preventive and
therapeutic approaches.75,76
Behavior guidance techniques
Since children exhibit a broad range of physical, intellectual,
emotional, and social development and a diversity of attitudes
and temperament, it is important that dentists have a wide
range of behavior guidance techniques to meet the needs of
the individual child and be tolerant and flexible in their
implementation.18,25 Behavior guidance is not an application
of individual techniques created to deal with children, but
rather a comprehensive, continuous method meant to develop
and nurture the relationship between the patient and doctor,
which ultimately builds trust and allays fear and anxiety. Some
of the behavior guidance techniques in this document are in-
tended to maintain communication, while others are intended
to extinguish inappropriate behavior and establish communi-
cation. As such, these techniques cannot be evaluated on an
individual basis as to validity but must be assessed within the
context of the child’s total dental experience. Techniques must
be integrated into an overall behavior guidance approach
individualized for each child. Consequently, behavior guidance
is as much an art as it is a science.
Recommendations
Basic behavior guidance
Communication and communicative guidance
Communicative management and appropriate use of commands
are applied universally in pediatric dentistry with both the
cooperative and uncooperative child. At the beginning of
a dental appointment, asking questions and active/reflective
listening can help establish rapport and trust.81,82 The dentist
BEST PRACTICES: BEHAVIOR GUIDANCE
may establish teacher/student roles in order to develop an
educated patient and deliver quality dental treatment safely.20,29
Once a procedure begins, bi-directional communication
should be maintained, and the dentist should consider the
child as an active participant in his well-being and care.83
With this two-way interchange of information, the dentist also
can provide one-way guidance of behavior through directives.
Use of self-disclosing assertiveness techniques (e.g., “I need
you to open your mouth so I can check your teeth”, “I need
you to sit still so we can take an X-ray”) tells the child exactly
what is required to be cooperative.82 The dentist can ask the
child ‘yes’ or ‘no’ questions where the child can answer with
a ‘thumbs up’ or ‘thumbs down’ response. Also, observation
of the child’s body language is necessary to confirm the
message is received and to assess comfort and pain level.60,61,82
Communicative guidance comprises a host of specific tech-
niques that, when integrated, enhance the evolution of a
cooperative patient. Rather than being a collection of singular
techniques, communicative guidance is an ongoing subjective
process that becomes an extension of the personality of the
dentist. Associated with this process are the specific techniques
of pre-visit imagery, direct observation, tell-show-do,
ask-tell-ask, voice control, nonverbal communication, positive
reinforcement, various distraction techniques (e.g., audio,
visual, imagination, thoughtful designs of clinic), memory
restructuring desensitization to dental setting and procedures,
parental presence/absence, enhanced control, additional
considerations for patients with anxiety or SHCN and nitrous
oxide/oxygen inhalation. 81 The dentist should consider the
development of the patient, as well as the presence of other
communication deficits (e.g., hearing disorder), when choosing
specific communicative guidance techniques.
Positive pre-visit imagery
• Description: Patients preview positive photographs or
images of dentistry and dental treatment before the dental
appointment.84
• Objectives: The objectives of positive pre-visit imagery are
to:
— provide children and parents with visual information
on what to expect during the dental visit; and
— provide children with context to be able to ask providers
relevant questions before dental procedures commence.
• Indications: Use with any patient.
• Contraindication: None.
Direct observation
• Description: Patients are shown a video or are permitted
to directly observe a young cooperative patient undergoing
dental treatment.85,86
• Objectives: The objectives of direct observation are to:
— familiarize the patient with the dental setting and
specific steps involved in a dental procedure; and
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 325
BEST PRACTICES: BEHAVIOR GUIDANCE
— provide an opportunity for the patient and parent to
ask questions about the dental procedure in a safe
environment.
• Indications: Use with any patient.
• Contraindications: None.
Tell-show-do
• Description: The technique involves verbal explanations of
procedures in phrases appropriate to the developmental
level of the patient (tell); demonstrations for the patient of
the visual, auditory, olfactory, and tactile aspects of the
procedure in a carefully defined, nonthreatening setting
(show); and then, without deviating from the explanation
and demonstration, completion of the procedure (do). The
tell-show-do technique operates with communication skills
(verbal and nonverbal) and positive reinforcement.29,34,35,81
• Objectives: The objectives of tell-show-do are to:
— teach the patient important aspects of the dental visit
and familiarize the patient with the dental setting and
armamentarium; and
— shape the patient’s response to procedures through
desensitization and well-described expectations.
• Indications: Use with any patient.
• Contraindications: None.
Ask-tell-ask
• Description: This technique involves inquiring about the
patient’s visit and feelings toward or about any planned
procedures (ask); explaining the procedures through dem-
onstrations and non-threatening language appropriate to
the cognitive level of the patient (tell); and again inquiring
if the patient understands and how she feels about the
impending treatment (ask). If the patient continues to have
concerns, the dentist can address them, assess the situation,
and modify the procedures or behavior guidance techniques
if necessary.26
• Objectives: The objectives of ask-tell-ask are to:
— assess anxiety that may lead to noncompliant behavior
during treatment;
— teach the patient about the procedures and their imple-
mentation; and
— confirm the patient is comfortable with the treatment
before proceeding.
• Indications: Use with any patient able to dialogue.
• Contraindications: None.
Voice control
• Description: Voice control is a deliberate alteration of voice
volume, tone, or pace to influence and direct the patient’s
behavior. While a change in cadence may be readily ac-
cepted, use of an assertive voice may be considered aversive
to some parents unfamiliar with this technique. An explana-
tion before its use may prevent misunderstanding.20,29,34,35
• Objectives: The objectives of voice control are to:
— gain the patient’s attention and compliance;
326 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
— avert negative or avoidance behavior; and
— establish appropriate adult-child roles.
• Indications: Use with any patient.
• Contraindications: Patients who are hearing impaired.
Nonverbal communication
• Description: Nonverbal communication is the reinforcement
and guidance of behavior through appropriate contact,
posture, facial expression, and body language.29,34,35,51,81
• Objectives: The objectives of nonverbal communication are to:
— enhance the effectiveness of other communicative
guidance technique; and
— gain or maintain the patient’s attention and compliance.
• Indications: Use with any patient.
• Contraindications: None.
Positive reinforcement and descriptive praise
• Description: In the process of establishing desirable patient
behavior, it is essential to give appropriate feedback.
Positive reinforcement rewards desired behaviors thereby
strengthening the likelihood of recurrence of those behav-
iors. Social reinforcers include positive voice modulation,
facial expression, verbal praise, and appropriate physical
demonstrations of affection by all members of the dental
team. Descriptive praise emphasizes specific cooperative
behaviors (e.g., “Thank you for sitting still”, “You are doing
a great job keeping your hands in your lap”) rather than a
generalized praise (e.g., “Good job”).82 Nonsocial reinforcers
include tokens and toys.
• Objective: The objective of positive reinforcement and
descriptive praise is to reinforce desired behavior.20,34,45,81,87
• Indications: Use with any patient.
• Contraindications: None.
Distraction
• Description: Distraction is the technique of diverting the
patient’s attention from what may be perceived as an un-
pleasant procedure. Distraction may be achieved by
imagination (e.g., stories), clinic design, and audio (e.g.,
music) and/or visual (e.g., television, virtual reality eye-
glasses) effects.81,88 Giving the patient a short break during
a stressful procedure can be an effective use of distraction
before considering more advanced behavior guidance
techniques.20,45,87
• Objectives: The objectives of distraction are to:
— decrease the perception of unpleasantness; and
— avert negative or avoidance behavior.
• Indications: Use with any patient.
• Contraindications: None.
Memory restructuring
• Description: Memory restructuring is a behavioral approach
in which memories associated with a negative or difficult
event (e.g., first dental visit, local anesthesia, restorative pro-
cedure, extraction) are restructured into positive memories

using information suggested after the event has taken place.89
This approach was utilized with children who received local
anesthesia at an initial restorative dental visit and showed
a change in local anesthesia-related fears and behaviors at
subsequent treatment visits.89,90 Restructuring involves four
components: (1) visual reminders; (2) positive reinforcement
through verbalization; (3) concrete examples to encode
sensory details; and (4) sense of accomplishment. A visual
reminder could be a photograph of the child smiling at the
initial visit (i.e., prior to the difficult experience). Positive
reinforcement through verbalization could be asking if the
child had told her parent what a good job she had done at
the last appointment. The child is asked to role-play and
to tell the dentist what she had told the parent. Concrete
examples to encoding sensory details include praising the
child for specific positive behavior such as keeping her hands
on her lap or opening her mouth wide when asked. The child
then is asked to demonstrate these behaviors, which leads to
a sense of accomplishment.
• Objectives: The objectives of memory restructuring are to:
— restructure difficult or negative past dental experiences;
and
— improve patient behaviors at subsequent dental visits.
• Indications: Use with patients who had a negative or
difficult dental visit.
• Contraindications: None.
Desensitization to dental setting and procedures
• Description: Systematic desensitization is a psychological
technique that can be applied to modify behaviors of
anxious patients in the dental setting.91 It is a process that
diminishes emotional responsiveness to a negative, aversive,
or positive stimulus after progressive exposure to it. Patients
are exposed gradually through a series of sessions to compo-
nents of the dental appointment that cause them anxiety.
Patients may review information regarding the dental office
and environment at home with a preparation book or video
or by viewing the practice website. Parents may model actions
(e.g., opening mouth and touching cheek) and practice
with the child at home using a dental mirror. Successful
approximations would continue with an office tour during
non-clinical hours and another visit in the dental operatory
to explore the environment. After successful completion of
each step, an appointment with the dentist and staff may
be attempted.91
• Objectives: The objective of systematic desensitization is for
the patient to:
— proceed with dental care after habituation and successful
progression of exposure to the environment;
— identify his fears;
— develop relaxation techniques for those fears; and
— be gradually exposed, with developed techniques, to
situations that evoke his fears and diminish the emotional
responses.34
BEST PRACTICES: BEHAVIOR GUIDANCE
• Indications: Use with patients who have experienced fear-
invoking stimuli, anxiety, and/or neurodevelopmental
disorders (e.g., autism spectrum disorder).
• Contraindications: None.
Enhancing control
• Description: Enhancing control is a technique used to allow
the patient, especially an anxious/fearful one, to assume an
active role in the dental experience. The dentist provides the
patient a signal (e.g., raising a hand) to use if he becomes
uncomfortable or needs to briefly interrupt care. The patient
should practice this gesture before treatment is initiated to
emphasize it is a limited movement away from the operatory
field. When the patient employs the signal during dental
procedures, the dentist should quickly respond with a pause
in treatment and acknowledge the patient’s concern. En-
hancing control has been shown to be effective in reducing
intraoperative pain.92
• Objectives: The objective is to allow a patient to have some
measure of control during treatment in order to contain
emotions and deter disruptive behaviors.92,93
• Indications: Use with patients who can communicate.
• Contraindications: None, but if used prematurely, fear may
increase due to an implied concern about the impending
procedure.
Communication techniques for parents (and age-appropriate
patients)
Because parents are the legal guardians of minors, successful
bi-directional communication between the dentist/staff and the
parent is essential to assure effective guidance of the child’s
behavior.52 Socioeconomic status, stress level, marital discord,
dental attitudes aligned with a different cultural heritage, and
linguistic skills may present challenges to open and clear
communication. 23,26,94 Communication techniques such as
ask-tell-ask, teach back, and motivational interviewing can
reflect the dentist/staff’s caring for and engaging in a patient/
parent centered-approach.26 These techniques are presented in
Appendix 3.
Parental presence/absence
• Description: The presence or absence of the parent some-
times can be used to gain cooperation for treatment. A wide
diversity exists in practitioner philosophy and parents’ atti-
tude regarding parental presence/absence during pediatric
dental treatment. As establishment of a dental home by 12
months of age continues to grow in acceptance, parents will
expect to be with their infants and young children during
examinations as well as during treatment. Parental involve-
ment, especially in their children’s health care, has changed
dramatically in recent years.29,95 Parents’ desire to be present
during their child’s treatment does not mean they intellec-
tually distrust the dentist; it might mean they are uncom-
fortable if they visually cannot verify their child’s safety. It
is important to understand the changing emotional needs
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 327
BEST PRACTICES: BEHAVIOR GUIDANCE
of parents because of the growth of a latent but natural
sense to be protective of their children. 96 Practitioners
should become accustomed to this added involvement of
parents and welcome the questions and concerns for their
children. Practitioners must consider parents’ desires and
wishes and be open to a paradigm shift in their own think-
ing.9,19,29,81,96,97
• Objectives: The objectives of parental presence/absence for
parents are to:
— participate in examinations and treatment;
— offer physical and psychological support; and
— observe the reality of their child’s treatment.
The objectives of parental presence/absence for practitioners
to:
— gain the patient’s attention and improve compliance;
— avert negative or avoidance behaviors;
— establish appropriate dentist-child roles;
— enhance effective communication among the dentist,
child, and parent;
— minimize anxiety and achieve a positive dental experience;
and
— facilitate rapid informed consent for changes in treatment
or behavior guidance.
• Indications: Use with any patient.
• Contraindications: Parents who are unwilling or unable to
extend effective support.
Additional considerations for dental patients with anxiety or
special health care needs
Sensory-adapted dental environments (SADE)
• Description: The SADE intervention includes adaptions of
the clinical setting (e.g., dimmed lighting, moving projec-
tions such as fish or bubbles on the ceiling, soothing
background music, application of wrap/blanket around the
child to provide deep pressure input) to produce a calming
effect.91,98
• Objectives: The objective of SADE is to enhance relaxation
and avert negative or avoidance behaviors.99
• Indications: Use with patients having autism spectrum
disorder, sensory processing difficulties, other disabilities, or
dental anxiety.100
• Contraindications: None.
Animal-assisted therapy (AAT)
• Description: AAT has been beneficial in a variety of settings
including the dental environment.101 It is a goal-oriented
intervention which utilizes a trained animal in a healthcare
setting to improve interactions or decrease a patient’s anxiety,
pain, or distress. Unlike animal-assisted activities (e.g., a pet
entertains patients in the waiting area), AAT appointments
are scheduled for specific time and duration to include an
animal that has undergone temperament testing, rigorous
training, and certification. The animal, which is available
for companionship during the dental visit, can help break
communication barriers and enable the patient to establish a
328 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
safe and comforting relationship, thereby reducing treatment-
related stress. For each visit, the goals and results of the
intervention should be documented.
• Objectives: The objectives of AAT include to:
— enhance interactions between the patient and dental team;
— calm or comfort an anxious or fearful patient;
— provide a distraction from a potentially stressful situation;
and
— decrease perceived pain.102
The health and safety of the animal and its handler need
to be maintained.102
• Indications: Use AAT as an adjunctive technique to decrease
a patient’s anxiety, pain, or emotional distress.
• Contraindications: The contraindications for the parent:
— allergy or other medical condition (e.g., asthma,
compromised immune system) aggravated by exposure
to the animal; and
— lack of interest in or fear of the therapy animal.
The contraindications for the parent:
— a situation that presents a significant risk to one’s health
or safety.103
Picture exchange communication system (PECS)
• Description: PECS is a communication technique developed
for individuals with limited to no verbal communication
abilities, specifically those with autism. The individual
shares a picture card with a recognizable symbol to express a
request or thought. PECS has a one-to-one correspondence
with objects, people, and concepts, thereby reducing the
degree of ambiguity in communication.104 The patient is
able to initiate communication, and no special training is
required by the recipient.
• Objectives: The objective is to allow individuals with limited
to no verbal communication abilities to express requests or
thoughts using symbolic imagery. A prepared picture board
may be present for the dental appointment so the dentist
can communicate the steps required for completion (e.g.,
pictures of a dental mirror, handpiece). The patient may
have symbols (e.g., a stop sign) to show they need a brief
interruption in the procedure.105
• Indications: Use as an adjunctive approach to assist individ-
uals with limited to no verbal communication abilities
improve exchange of ideas.91,106
• Contraindications: None.107
Nitrous oxide/oxygen inhalation
• Description: Nitrous oxide/oxygen inhalation is a safe and
effective technique to reduce anxiety and enhance effective
communication. Its onset of action is rapid, the effects
easily are titrated and reversible, and recovery is rapid and
complete. Additionally, nitrous oxide/oxygen inhalation
mediates a variable degree of analgesia, amnesia, and gag
reflex reduction. The need to diagnose and treat, as well
as the safety of the patient and practitioner, should be
considered before the use of nitrous oxide/oxygen analgesia/

anxiolysis. If nitrous oxide/oxygen inhalation is used in con-
centrations greater than 50 percent or in combination with
other sedating medications (e.g., benzodiazepines, opioids),
the likelihood for moderate or deep sedation increases.108 In
these situations, the clinician must be prepared to institute
the guidelines for moderate or deep sedation. 5 Detailed
information concerning the indications, contraindications,
and additional clinical considerations appear in AAPD’s
Use of Nitrous Oxide for Pediatric Dental Patients 4 and
Guidelines for Monitoring and Management of Pediatric
Patients Before, During and After Sedation for Diagnostic
and Therapeutic Procedures 5 by the AAPD and the American
Academy of Pediatrics.
• Objectives: The objectives of nitrous oxide/oxygen inhala-
tion include to:
— reduce or eliminate anxiety;
— reduce untoward movement and reaction to dental
treatment;
— enhance communication and patient cooperation;
— raise the pain reaction threshold;
— increase tolerance for longer appointments;
— aid in treatment of the mentally/physically disabled or
medically compromised patients;
— reduce gagging; and
— potentiate the effect of sedatives.
• Indications: Indications for use of nitrous oxide/oxygen
inhalation analgesia/anxiolysis include:
— a fearful, anxious, or obstreperous patient;
— certain patients with SHCN;
— a patient whose gag reflex interferes with dental care;
— a patient for whom profound local anesthesia cannot
be obtained; and
— a cooperative child undergoing a lengthy dental pro-
cedure.
• Contraindications: Contraindications for use of nitrous
oxide/oxygen inhalation may include:
— some chronic obstructive pulmonary diseases;108,109
— current upper respiratory tract infections;109
— recent middle ear disturbance/surgery;109
— severe emotional disturbances or drug-related de-
pendencies;108,109
— first trimester of pregnancy;108,110
— treatment with bleomycin sulfate; 111
— methylenetetrahydrofolate reductase deficiency;112 and
— cobalamin (vitamin B-12) deficiency113.
Advanced behavior guidance
Most children can be managed effectively using the techniques
outlined in basic behavior guidance. Such techniques should
form the foundation for all behavior guidance provided by
the dentist. Children, however, occasionally present with
behavioral considerations that require more advanced tech-
niques. These children often cannot cooperate due to lack
of psychological or emotional maturity and/or mental, phys-
ical, or medical disability. The advanced behavior guidance
BEST PRACTICES: BEHAVIOR GUIDANCE
techniques commonly used and taught in advanced pediatric
dental training programs include protective stabilization,
sedation, and general anesthesia.49 The use of general anesthesia
or sedation for dental rehabilitation may improve quality of life
in children. It is unclear if these behavior guidance techniques
address factors that contribute to the initial dental fear and
anxiety.114,115 Protective stabilization, active or passive, may not
always be accepted by parents who may be more accepting of
pharmacologic behavior guidance.116
Consideration of advanced behavior guidance techniques
requires the practitioner to thoroughly assess the patient’s
medical, dental, and social histories and temperament. Risks,
benefits, and alternatives should be discussed prior to obtaining
an informed consent for the recommended technique.117 Skill-
ful diagnosis of behavior and safe and effective implementation
of these techniques necessitate knowledge and experience that
are generally beyond the core knowledge students receive
during predoctoral dental education. While most predoctoral
programs provide didactic exposure to treatment of very
young children (i.e., aged birth through two years), patients
with special health care needs, and patients requiring advanced
behavior guidance techniques, hands-on experience is lacking.49
Dentists considering the use of advanced behavior guidance
techniques should seek additional training through a residency
program, a graduate program, and/or an extensive continuing
education course that involves both didactic and experiential
mentored training.
Protective stabilization
• Description: The use of any type of protective stabilization
in the treatment of infants, children, adolescents, or patients
with special health care needs is a topic that concerns health
care providers and care givers.56,118-127 Protective stabilization
is the restriction of a patient’s freedom of movement, with
or without the patient’s permission, to decrease risk of
injury while allowing safe completion of treatment. “A
restraint is any manual method, physical or mechanical
device, material, or equipment that immobilizes or reduces
the ability of a patient to move his or her arms, legs, body,
or head freely; or a drug or medication when it is used as a
restriction to manage the patient’s behavior or restrict the
patient’s freedom of movement and is not a standard treat-
ment or dosage for the patient’s condition”.128 Protective
stabilization can be performed by the dentist, staff, or
parent with or without the aid of a stabilization device.56 If
the restriction involves another person(s), it is considered
active restraint. If a patient stabilization device is utilized, it
is considered passive restraint. Active and passive restraint
can be used in combination.
Stabilization devices such as a papoose board (passive
restraint) placed around the chest may restrict respirations.
They must be used with caution, especially for patients with
respiratory compromise (e.g., asthma) and/or for patients
who will receive medications (e.g., local anesthetics, sedatives)
that can depress respirations. Because of the associated risks
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 329
BEST PRACTICES: BEHAVIOR GUIDANCE
and possible consequences of use, the dentist is encouraged
to evaluate thoroughly their use on each patient and possible
alternatives. 56,128 Careful, continuous monitoring of the
patient is mandatory during protective stabilization.56,128
Partial or complete stabilization of the patient sometimes
is necessary to protect the patient, practitioner, staff, or the
parent from injury while providing dental care. The dentist
always should use the least restrictive, but safe and effective,
protective stabilization.56,128 The use of a mouth prop in a
compliant child is not considered protective stabilization.
The need to diagnose, treat, and protect the safety of the
patient, practitioner, staff, and parent should be considered
prior to the use of protective stabilization. The decision to
use protective stabilization must take into consideration:
— alternative behavior guidance modalities;
— dental needs of the patient;
— the effect on the quality of dental care;
— the patient’s emotional development; and
— the patient’s medical and physical considerations.
Protective stabilization, with or without a restrictive
device, led by the dentist and performed by the dental team
requires informed consent from a parent. Informed consent
must be obtained and documented in the patient’s record
prior to use of protective stabilization. Furthermore, when
appropriate, an explanation to the patient regarding the
need for restraint, with an opportunity for the patient to
respond, should occur.52,56,129
• Objectives: The objectives of patient stabilization are to:
— reduce or eliminate untoward movement;
— protect patient, staff, dentist, or parent from injury; and
— facilitate delivery of quality dental treatment.
• Indications: Patient stabilization is indicated for:
— a patient who requires immediate diagnosis and/or
urgent limited treatment and cannot cooperate due to
developmental levels (emotional or cognitive), lack of
maturity, or mental or physical conditions;
— a patient who requires urgent care and uncontrolled
movements risk the safety of the patient, staff, dentist, or
parent without the use of protective stabilization;
— a previously cooperative patient who quickly becomes
uncooperative and cooperation cannot be regained by
basic behavior guidance techniques in order to protect
the patient’s safety and help complete a procedure and/
or stabilize the patient;
— an uncooperative patient who requires limited (e.g.,
quadrant) treatment and sedation or general anesthesia
may not be an option because the patient does not meet
sedation criteria or because of a long operating room wait
time, financial considerations, and/or parental preferences
after other options have been discussed;
— a sedated patient requires limited stabilization to help
reduce untoward movement during treatment; and
— a patient with SHCN exhibits uncontrolled movements
that would be harmful or significantly interfere with the
quality of care.3
330 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• Contraindications: Patient stabilization is contraindicated
for:
— a cooperative nonsedated patient;
— an uncooperative patient when there is not a clear need
to provide treatment at that particular visit;
— a patient who cannot be immobilized safely due to asso-
ciated medical, psychological, or physical conditions;
— a patient with a history of physical or psychological
trauma, including physical or sexual abuse or other
trauma that would place the individual at greater
psychological risk during restraint;
— a patient with non-emergent treatment needs in order
to accomplish full mouth or multiple quadrant dental
rehabilitation;
— a practitioner’s convenience; and
— a dental team without the requisite knowledge and skills
in patient selection and restraining techniques to prevent
or minimize psychological stress and/or decrease risk of
physical injury to the patient, the parent, and the staff.
• Precautions: The following precautions are recommended:
— the patient’s medical history must be reviewed careful-
ly to ascertain if there are any medical conditions (e.g.,
asthma) which may compromise respiratory function;
— tightness and duration of the stabilization must be
monitored and reassessed at regular intervals;
— stabilization around extremities or the chest must not
actively restrict circulation or respiration;
— observation of body language and pain assessment must
be continuous to allow for procedural modifications at
the first sign of distress; and
— stabilization should be terminated as soon as possible in
a patient who is experiencing severe stress or hysterics
to prevent possible physical or psychological trauma.
• Documentation: The patient’s record must include:
— indication for stabilization;
— type of stabilization;
— informed consent for protective stabilization;
— reason for parental exclusion during protective stabiliza-
tion (when applicable);
— the duration of application of stabilization;
— behavior evaluation/rating during stabilization;
— any untoward outcomes, such as skin markings; and
— management implication for future appointments.
Sedation
• Description: Sedation can be used safely and effectively with
patients who are unable to cooperate due to lack of psycho-
logical or emotional maturity and/or mental, physical, or
medical conditions. Background information and docu-
mentation for the use of sedation is detailed in the Guideline
for Monitoring and Management of Pediatric Patients
During and After Sedation for Diagnostic and Therapeutic
Procedures.5
The need to diagnose and treat, as well as the safety of
the patient, practitioner, and staff, should be considered

for the use of sedation. The decision to use sedation must
take into consideration:
— alternative behavioral guidance modalities;
— dental needs of the patient;
— the effect on the quality of dental care;
— the patient’s emotional development; and
— the patient’s medical and physical considerations.
• Objectives: The goals of sedation are to:
— guard the patient’s safety and welfare;
— minimize physical discomfort and pain;
— manage anxiety, minimize psychological trauma, and
maximize the potential for amnesia;
— manage behavior and/or movement so as to allow the
safe completion of the procedure; and
— return the patient to a state in which safe discharge
from medical supervision, as determined by recognized
criteria, is possible.
• Indications: Sedation is indicated for:
— fearful/anxious patients for whom basic behavior
guidance techniques have not been successful;
— patients who cannot cooperate due to a lack of psycho-
logical or emotional maturity and/or mental, physical,
or medical conditions; and
— patients for whom the use of sedation may protect the
developing psyche and/or reduce medical risk.
• Contraindications: The use of sedation is contraindicated
for:
— the cooperative patient with minimal dental needs; and
— predisposing medical and/or physical conditions which
would make sedation inadvisable.
• Documentation: The patient’s record shall include:5
— informed consent that is obtained from the parent and
documented prior to the use of sedation;
— pre- and postoperative instructions and information
provided to the parent;
— health evaluation;
— a time-based record that includes the name, route, site,
time, dosage, and effect on patient of administered drugs;
— the patient’s level of consciousness, responsiveness,
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
— time and condition of the patient at discharge.
General anesthesia
• Description: General anesthesia is a controlled state of
unconsciousness accompanied by a loss of protective reflexes,
including the ability to maintain an airway independently
and respond purposefully to physical stimulation or verbal
command. Depending on the patient, general anesthesia can
be administered in a hospital or an ambulatory setting,
including the dental office. Practitioners who provide in-
office general anesthesia (dentist and the anesthesia provider)
BEST PRACTICES: BEHAVIOR GUIDANCE
should be familiar with and follow the recommendations
found in AAPD’s Use of Anesthesia Providers in the Adminis-
tration of Office-Based deep Sedation/General Anesthesia to the
Pediatric Dental Patient.6
Because laws and codes vary from state to state, each prac-
titioner must be familiar with his state guidelines regarding
office-based general anesthesia. The need to diagnose and
treat, as well as the safety of the patient, practitioner, and
staff should be considered for the use of general anesthesia.
Anesthetic and sedative drugs are used to help ensure the
safety, health, and comfort of children undergoing proce-
dures. Increasing evidence from research studies suggests the
benefits of these agents should be considered in the context
of their potential to cause harmful effects. 130 Additional
research is needed to identify any possible risks to young
children. “In the absence of conclusive evidence, it would
be unethical to withhold sedation and anesthesia when
necessary”.131
The decision to use general anesthesia must take into
consideration:
— alternative modalities;
— the age of the patient;
— risk benefit analysis;
— treatment deferral;
— dental needs of the patient;
— the effect on the quality of dental care;
— the patient’s emotional development;
— the patient’s medical status; and
— barriers to care (e.g., finances).
• Objectives: The goals of general anesthesia are to:
— provide safe, efficient, and effective dental care;
— eliminate anxiety;
— eliminate untoward movement and reaction to dental
treatment;
— aid in treatment of the mentally- physically-, or
medically-compromised patient; and
— minimize the patient’s pain response.
• Indications: General anesthesia is indicated for patients:
— who cannot cooperate due to a lack of psychological or
emotional maturity and/or mental, physical, or medical
disability;
— for whom local anesthesia is ineffective because of acute
infection, anatomic variations, or allergy;
— who are extremely uncooperative, fearful, or anxious;
— who are precommunicative or noncommunicative
child or adolescent;
— requiring significant surgical procedures that can be
combined with dental procedures to reduce the number
of anesthetic exposures;
— for whom the use of general anesthesia may protect
the developing psyche and/or reduce medical risk; and
— requiring immediate, comprehensive oral/dental care
(e.g., due to dental trauma, severe infection/cellulitis,
acute pain).
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 331
BEST PRACTICES: BEHAVIOR GUIDANCE
• Contraindications: The use of general anesthesia is contra-
indicated for:
— a healthy, cooperative patient with minimal dental
needs;
— a very young patient with minimal dental needs that
can be addressed with therapeutic interventions (e.g.,
ITR, fluoride varnish, SDF) and/or treatment deferral;
— patient/practitioner convenience; and
— predisposing medical conditions which would make
general anesthesia inadvisable.
Appendices
Appendix 1. SEARCH STRATEGIES
PubMed®/MEDLINE—date limit August 2019
Search #1. (ped & dental) 2557 results
((((((“behavior management”[tiab] OR “behavior guidance”
[tiab] OR “child behavior”[tiab] OR “dental anxiety”[tiab] OR
“personality test”[tiab] OR “patient cooperation”[tiab] OR
“dentist-patient relations”[tiab] OR “behavior assessment”
[tiab] OR “temperament assessment”[tiab] OR “personality
assessment”[tiab] OR “treatment deferral”[tiab] OR
“treatment delay”[tiab] OR compliance[tiab] OR
adherence[tiab] OR “protective stabilization”[tiab] OR
immobilization[tiab] OR restraints [tiab] OR Sedation
[tiab] OR general anesthesia[tiab] OR “Restraint, Physical”
[mesh] OR “Protective Devices”[mesh] OR “Immobilization”
[mesh] OR “Behavior Control”[mesh] OR “child behavior”
[mesh] OR “dental anxiety”[mesh] OR “personality tests”
[mesh] OR “patient compliance”[mesh] OR “dentist-patient
relations”[mesh] OR “personality assessment”[mesh] OR
“patient compliance”[mesh] OR “anesthesia, general”[mesh]
OR “Conscious Sedation”[Mesh]))) AND (((dental[tiab]
OR “dental health services”[MeSH Terms] OR dentistry
[TIAB] OR “dentistry”[MeSH Terms] OR “dental care”
[tiab] OR “dental care”[MeSH Terms] OR dentist[tiab] OR
“dentists”[MeSH Terms] OR “Dental Care for Children”
[mesh] OR “Pediatric Dentistry”[mesh])))) 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]))
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
332 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• Documentation: Prior to the delivery of general anesthesia,
appropriate documentation shall address the rationale
for use of general anesthesia, informed consent, instructions
provided to the parent, dietary precautions, and preoperative
health evaluation. Because laws and codes vary from state
to state, each practitioner must be familiar with her state
guidelines. For information regarding requirements for a
time-based anesthesia record, refer to 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.
“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]))))
Search #3. (adults & dentists) 62 results
(((“personality test” OR “personality tests”[MeSH Terms] OR
“personality assessment”[MeSH Terms] OR personality[tiab]
OR “gender shifts”[tiab] OR “gender equality” OR ((“Wom-
en, Working”[mesh] OR “Dentists, Women”[mesh]) AND
“Practice Patterns, Dentists’”[MeSH Terms]))) AND
(dentist[TIAB] OR dentist[TIAB] OR “Dentists”[Mesh]))
AND ((“2009/01/01”[PDAT]: “3000/12/31”[PDAT]) AND
english[filter] NOT (“animals”[MeSH Terms] NOT
“humans”[MeSH Terms]))
Search #4. (adults & parents) 226 results
(((((dental[tiab] OR “dental health services”[MeSH Terms]
OR dentistry[TIAB] OR “dentistry”[MeSH Terms] OR
“dental care”[tiab] OR “dental care”[MeSH Terms] OR
dentist[tiab] OR “dentists”[MeSH Terms] OR “Dental Care
for Children”[mesh] OR “Pediatric Dentistry”[mesh])))
AND ((Parents[tiab] OR Fathers[tiab] OR mothers[tiab]
OR parental[tiab] OR Parent[tiab] OR Father[tiab] OR
mother[tiab] or “mothers”[MeSH Terms] OR “fathers”
[MeSH Terms] OR “parents”[MeSH Terms]))) AND
(“behavior management”[tiab] OR “behavior guidance”
[tiab] OR “dentist parent relations”[tiab] OR “Informed
consent”[tiab] OR “family compliance”[tiab] OR “parent
compliance”[tiab] OR “family adherence”[tiab] OR “parent
adherence”[tiab] OR “parenting style”[tiab] OR “dentist-
patient relations”[tiab] OR “dentist-patient relations”
[MeSH Terms] OR “Behavior Control”[mesh] OR “pa-
tient compliance”[MeSH Terms] OR “Informed Consent”
[Mesh])) AND (((“2009/01/01”[PDAT]: “3000/12/31”
[PDAT]) AND english[filter] NOT (“animals”[MeSH
Terms] NOT “humans”[MeSH Terms])))
 BEST PRACTICES: BEHAVIOR GUIDANCE

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? ” “ 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 333

BEST PRACTICES: BEHAVIOR GUIDANCE

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”.

334 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


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98. Cermak SA. Stein Duker LI, Williams ME, et al.
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children with autism. Am J Occup Ther 2015;69(3):
6903220020p1-10. Available at: “http://dx.doi.org/10.
5014/ajot.2015.013714”. Accessed July 18, 2020.
99. Bodison SC, Parham DL. Specific sensory techniques
and sensory environment modifications for children and
youth with sensory integration difficulties: A systematic
review. Am J Occup Ther 2018;72(1):7201190040p1-
7201190040p11. Available at: “http://doi.org/10.5014/
ajot.2018.029413”. Accessed July 18, 2020.
100. Cermak SA, Stein Duker LI, Williams ME, et al. Sensory
adapted dental environment to enhance oral care for
children with autism spectrum disorders: A randomized
controlled pilot study. J Autism Dev Disord 2015;45(9):
2876-88.
101. Cajares CM, Rutledge CM, Haney TS. Animal assisted
therapy in a special needs dental practice: An interpro-
fessional model for anxiety reduction. J of Intell Disabl
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102. Cruz-Fierro N, Vanegas-Farfano M, González-Ramírez
MT. Dog-assisted therapy and dental anxiety: A pilot
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www.mdpi.com/2076-2615/9/8/512”. Accessed September
24, 2020.
103. Gussard AM, Weese JS, Hensten A, Jokstad A. Dog-
assisted therapy in the dental clinic. Part B. Hazards and
assessment of potential risks to the health and safety of
the dental therapy dog. Clin Exp Dent Res 2019;5(6):
701-11.
104. Ganz JB, Davis JL, Lund EM, Goodwyn FD, Simpson
RL. Meta-analysis of PECS with individuals with ASD:
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participant characteristics, and implementation phase.
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105. Flippin M, Reszka S, Watson LR. The effectiveness of
picture exchange communication system (PECS) on
communication and speech for children with autism
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Pathol 2010;19(2):178-95.
106. Zink AG, Molina EC, Diniz MB, Santos MTBR, Guaré
RO. Communication applications for use during the
first dental visit for children and adolescents with autism
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107. Kuhaneck HM, Chisholm EC. Improving dental visits
for individuals with autism spectrum disorders through
an understanding of sensory processing. Spec Care Dentist
2012;32(6):229-33.
108. Clark MS, Brunick AL. N 2O and its interaction with
the body. In: Handbook of Nitrous Oxide and Oxygen
Sedation. 5th ed. Maryland Heights, Md.: Mosby
Elsevier; 2019:103-13.
109. Becker DE, Rosenberg M. Nitrous oxide and the inhala-
tion anesthetics. Anesth Prog 2008;55(4):124-31.
110. American Academy of Pediatric Dentistry. Oral health
care for the pregnant adolescent. The Reference Manual of
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Pediatric Dentistry; 2020:267-74.
111. Fleming P, Walker PO, Priest JR. Bleomycin therapy: A
contraindication to the use of nitrous oxide-oxygen
psycho-sedation in the dental office. Pediatr Dent 1988;
10(4):345-6.
112. Wyatt SS, Gill RS. An absolute contraindication to nitrous
oxide. Anaesthesia 1999;54(3):307.
113. Sanders RDB, Weimann J, Maze M. Biologic effects
of nitrous oxide: A mechanistic and toxicologic review.
Anesthesiology 2008;109(4):707-22.
114. Guney S, Araz C, Tirali R, Cehreli S. Dental anxiety and
oral health-related quality of life in children following
dental rehabilitation under general anesthesia or intra-
venous sedation: A prospective cross sectional study.
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115. Aldossari GS, Aldosari AA, Alasmari AA, Aldakheel RM,
Al-Natsha RR, Aldossary MS. The long-term effect of
previous dental treatment under general anesthesia on
children’s dental fear and anxiety. Int J Paediatr Dent
2019;29(2):177-84.
116. Patel M, McTigue DJ, Thikkurissy S, Fields HW. Parental
attitudes toward advanced behavior guidance techniques
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117. Hulin J, Baker S, Marshman Z, Albadri S, Rodd H. The
decisional needs of young patients faced with the decision
to undergo dental treatment with sedation or GA. SAAD
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118. Connick C, Palat M, Puagliese S. The appropriate use of
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119. Crossley ML, Joshi G. An investigation of pediatric
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120. Peretz B, Gluck GM. The use of restraint in the treatment
of pediatric dental patients: Old and new insights. Int J
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121. Brill WA. Parents’ assessment and children’s reactions to
a passive restraint device used for behavior control in a
private pediatric dental practice. ASDC J Dent Child
2002;69(3):236, 310-3.
122. Kupietzky A. Strap him down or knock him out: Is
conscious sedation with restraint an alternative to general
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123. Manley MCG. A UK perspective. Br Dent J 2004;196
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124. Morris CDN. A commentary on the legal issues. Br Dent
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125. Martinez Mier EA, Walsh CR, Farah CC, Vinson LA,
Soto-Rojas AE, Jones JE. Acceptance of behavior guidance
techniques used in pediatric dentistry by parents from
diverse backgounds. Clin Pediatr 2019;58(9):977-984.
126. Theriot AL, Gomez L, Chang CT, et al. Ethnic and
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behaviour management techniques. Int J Paediatr
Dent 2019;29(3):301-9.
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127. Davis DM, Fadavi S, Kaste LM, Vergotine R, Rada R.
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Dent Child 2016;83(2):60-6.
128. Centers for Medicare and Medicaid Services. State Op-
erations Manual Appendix A - Survey protocol. Regula-
tions, and Interpretive Guidelines for Hospitals. §482.13
Condition of Participation: Patient Rights A-0154
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Guidance/Manuals/downloads/som107ap_a_hospitals.pdf”.
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129. American Academy of Pediatrics Committee on Pediatric
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130. American Academy of Pediatrics. The pediatrician’s role
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undergoing anesthesia. Pediatrics 2014;134(3):634-41.
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anesthesia-safety-in-children”. Accessed July 18, 2020.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 339
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
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:340-6.

Abstract
This best practice is presented to assist dentists and other health professionals regarding the need for and appropriate use of protective
stabilization/medical immobilization when treating pediatric patients and individuals with special health care needs. Immobilization of a
person for delivery of safe, quality dental/medical care can be passive (using equipment or mechanical devices) or active (being held by
other persons). Details to consider before using protective stabilization include the patient’s particular needs, dental and medical histories,
and cognitive and emotional development as well as the desires of the parent. Recommendations for using protective stabilization focus on
the following areas: education of the health care providers, discussion of consent/assent with parent and patient, parental presence in the
operatory or treatment area, specific immobilization techniques and equipment, method of monitoring the patient, and individualized
considerations for patients with special health care needs. Indications, contraindications, risks, and required documentation are addressed.
In the spirit of patient safety, the decision to utilize protective stabilization and chosen techniques should be customized for each patient,
depending on his medications and physical and psychological health. Protective stabilization is considered within an overall behavior guidance
plan that promotes a positive dental attitude and quality of care.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding assessment of caries risk and risk-based management
protocols.

KEYWORDS: BEHAVIOR THERAPY, CHILD, DELIVERY OF HEALTH CARE, INFORMED CONSENT; RESTRAINT, PHYSICAL

Purpose version and is based on a review of the current dental and

The American Academy of Pediatric Dentistry (AAPD)
believes that all infants, children, adolescents, and individuals
with special health care needs (SHCN) are entitled to receive
oral health care that meets the treatment and ethical principles
of our specialty. The AAPD has included use of protective
stabilization (formerly referred to as physical restraint and
medical immobilization) in its guidelines on behavior guidance
since 1990.1,2 This separate document, specific to protective
stabilization, provides additional information to assist the
dental professional and other stakeholders in understanding
the indications for and developing appropriate prac tices in
the use of protective stabilization as an advanced behavior
guidance technique in contemporary pediatric dentistry. This
advanced technique must be integrated into an overall behav-
ior guidance approach that is individualized for each patient
in the context of promoting a positive dental attitude for the
patient, while ensuring the highest standards of safety and
quality of care.
medical literature related to the use of protective stabilization
devices and restraint in the treatment of infants, children,
adolescents, and patients with SHCN in the dental office. This
revision included electronic database searches using the terms:
protective stabilization and dentistry, protective stabilization
and medical procedures, medical immobilization, restraint and
dentistry, restraint and medical procedures, papoose board and
dentistry, papoose board and medical procedures, and patient
restraint for treatment. Fifty-five articles matched these criteria
and were evaluated by title and/or abstract. When data did
not appear sufficient or were inconclusive, recommendations
were based upon expert and/or consensus opinion by experi-
enced researchers and clinicians.
Definitions
Physical restraint is broadly defined by the Centers for
Medicare and Medicaid Services as “(A) Any manual method,
physical or mechanical device, material, or equipment that

Methods
Recommendations on protective stabilization were developed ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. SHCN: Special health
by the Council on Clinical Affairs, adopted in 2013 3 and care needs.
revised in 20174. This document is a revision of the previous

340 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


immobilizes or reduces the ability of a patient to move his or
her arms, legs, body, or head freely; or (B) A drug or medication
when it is used as a restriction to manage the patient’s behavior
or restrict the patient’s freedom of movement and is not a
standard treatment or dosage for the patient’s condition.”5 This
definition has limitations when applied to dentistry as it does
not accurately or comprehensively reflect the indications or
utilization of restraint in dentistry.
Protective stabilization is the term utilized in dentistry for
the physical limitation of a patient’s movement by a person or
restrictive equipment, materials or devices for a finite period of
time6 in order to safely provide examination, diagnosis, and/or
treatment. The definition of protective stabilization is similar
to that used for restraint in other healthcare disciplines. 5,8
Other terms such as medical immobilization and medical
immobilization/protective stabilization have been used as de-
scriptors for procedures categorized as protective stabilization.6,9
Active immobilization involves restraint by another person,
such as the parent, dentist, or dental auxiliary. 9 Passive
immobilization utilizes a restraining device.9
Background
Pediatric dentists receive formal education and training to gain
the knowledge and skills required to manage the various phys-
ical challenges, cognitive capacities, and age-defining traits of
their patients. A dentist who treats children should be able
to assess each child’s developmental level, dental attitude, and
temperament and also be able to recognize potential barriers
to delivery of care (e.g., previous unpleasant and/or painful
medical or dental experiences) to help predict the child’s
reaction to treatment.2 A continuum of non-pharmacological
and pharmacological behavior guidance techniques, including
protective stabilization, may be employed in providing oral
health care for infants, children, adolescents, and individuals
with SHCN.2 Behavior guidance approaches for each patient
who is unable to cooperate should be customized to the
individual needs of the child and the desires of the parent *
and may include sedation, general anesthesia, protective
stabilization, or referral to another dentist. 2 AAPD’s Behavior
Guidance for the Pediaric Dental Patient 2 should be
consulted for additional information regarding the spectrum
of behavior guidance techniques.
When determining whether to recommend use of stabiliza-
tion or immobilization techniques, the dentist should consider
the patient’s oral health needs, emotional and cognitive devel-
opment levels, medical and physical conditions, and parental
preferences.10,11 Alternative approaches (e.g., treatment options
or deferral, sedation, general anesthesia) and their potential
impact on quality of care and the patient’s well-being should
* 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
of Pediatric Dentistry; 2019:7-9.
BEST PRACTICES: PROTECTIVE STABILIZATION
be included in the deliberation.10,11 Socioeconomic status, geo-
graphic location, and ethnic/cultural differences of patients and
their parents may influence parental preference for behavior
management techniques.12,13
Indications for protective stabilization along with practitioner
and parent acceptance have been evaluated in the literature. A
recent survey demonstrated over 50 percent use and acceptance
of protective stabilization devices among practicing board-
certified pediatric dentists. 14 Practitioner gender, practice
setting, region, and perception of parental acceptance were
important factors relating to protective stabilization use and
acceptance.14,15
Recommendations
Education. Didactic and clinical experiences vary for pre-
doctoral students between and within dental schools.16 While
some schools provide didactic and hands-on training in
advanced behavior guidance, others offer limited exposure. A
survey of pre-doctoral program directors found a majority
of dental schools spend fewer than five classroom hours on
behavior guidance techniques.9 Furthermore, 42 percent of
institutions reported fewer than 25 percent of students had
one hands-on experience with passive immobilization for
non-sedated patients, while 27 percent of programs provided
no clinical experiences.9 A predoctoral dental survey demon-
strated 73 percent of students were instructed on use of an
immobilization device (Papoose Board , Olympic Medical®
Corp, Seattle, Wash., USA); however, only 11 percent observed
use in clinical settings, with two percent actually using it
on a patient.17 Therefore, graduates from dental school may
lack knowledge and competency in the use of protective
stabilization. Limited training in protective stabilization is
not unique to dentistry as other health care disciplines have
suggested a need for advanced training and guidelines.8,18-20
Protective stabilization is considered an advanced behavior
guidance technique in dentistry.2 Attempts to restrain or sta-
bilize patients without adequate training can leave not only the
patient, but also the practitioner and staff, at risk for physical
harm.21,22 Both didactic and hands-on mentored education
beyond dental school is essential to ensure appropriate, safe,
and effective implementation of protective stabilization of a
patient unable to cooperate. Advanced training can be attained
through an accredited postdoctoral program (e.g., advanced
education in general dentistry, general practice residency, pedi-
atric dentistry residency) or an extensive and focused contin-
uing education course that includes both didactic and mentored
hands-on experiences. Formal training will allow the dentist
and staff members to acquire the necessary knowledge and
skills in patient selection and in the successful use of restraining
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 341
BEST PRACTICES: PROTECTIVE STABILIZATION
techniques to prevent or minimize psychological stress and/or
decrease risk of physical injury to the patient, the parent, and
the staff. Providing the opportunity for the staff members to
debrief following the use of protective stabilization should be
considered.23 Currently, at least one state (Colorado) requires
training beyond basic dental education in order for the
practitioner to utilize protective stabilization devices.24
Consent. Protective stabilization, with or without a restrictive
device, led by the dentist and performed by the dental team
requires informed consent from a parent.25,26 A parent’s sig-
nature on a consent form should not preclude a thorough
discussion of the procedure. The practitioner must explain the
benefits and risks of protective stabilization, as well as alter-
native treatment options (e.g., interim therapeutic restoration
[ITR], silver diamine fluoride [SDF], treatment deferral) and
alternative behavior guidance techniques (e.g., sedation, gen-
eral anesthesia), and assist the parent in determining the most
appropriate approach to treat his/her child.27 Informed consent
discussion, when possible, should occur on a day separate from
the treatment.28,29 Supplements such as informational booklets
or videos may be helpful to the parent and/or patient in
understanding the proposed procedure. Informed consent
must be obtained and documented in the patient’s record
prior to performing protective stabilization.6,22,30,31 If a patient’s
behavior during treatment necessitates a change in stabilization
procedure or technique, further consent must be obtained and
documented.30
When appropriate, an explanation to the patient regarding
the need for restraint, with an opportunity for the patient to
respond, should occur.26 Although a minor does not have the
statutory right to give or refuse consent for treatment, the
child’s wishes and feelings (assent) should be considered when
addressing the issue of consent. 30,32 Also, when providing
dental care for adolescents or adults with mild intellectual dis-
abilities, patient assent for protective stabilization should be
considered.33 A conditional comprehensive explanation of the
technique to be used and the reasons for application should
be provided.33
Laws governing informed consent vary by state. It is in-
cumbent on the practitioner to be familiar with applicable
statutes. Currently, approximately 50 percent of states have
adopted the patient-oriented standard.34 Thus, a practitioner
may be held liable if a parent has not received all of the
information that is essential to his/her decision to accept or
reject proposed treatment.33
Written consent before treatment of a patient is mandated
by some states.35 Even if not required by state law, detailed
written consent for protective stabilization should be obtained
separately from consent for other procedures as it increases
the parent’s/patient’s awareness of the procedure.25,30
Parental presence. Parental presence in the operatory may
help both the parent and child during a difficult experience.36
Ninety-two percent of mothers in one study believed they
should have been with their child when he/she was placed on
342 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
a rigid stabilization board to increase the child’s security and/
or comfort.36 In addition, 90 percent recognized that immo-
bilization protected the children from harm.36 The dentist
should consider allowing parental presence in the operatory
or direct visual observation of the patient during use of
protective stabilization unless the health and safety of the
patient, parent, or the dental staff would be at risk.28 Further,
if parents are denied access, they must be informed of the
reason with documentation of the explanation in the patient’s
chart.24 If parents choose not to be present, they should be
encouraged to provide positive nurturing support for the
child both before and after the procedure. Ultimately, a parent
has the right to terminate use of restraint at any time if he
or she believes the child may be experiencing physical or
psychological trauma due to immobilization. If termination is
requested, the practitioner immediately should complete the
necessary steps to bring the procedure to a safe conclusion
before ending the appointment.
Techniques. Alternative approaches to restricting patient
movement during medically-necessary dental care should be
explored before immobilizing a patient. Protective stabiliza-
tion should be used only when less restrictive interventions are
not effective. It should not be used as a means of discipline,
convenience, or retaliation. Furthermore, the use of protective
stabilization should not induce pain for the patient.
Treatment should first be attempted with communicative
behavior guidance without protective stabilization unless there
is a history of maladaptive or combative behavior that could
be injurious to the patient and/or staff.37 Active stabilization
involves limitation of movement by another person, such as
the parent, dentist, or dental auxiliary, whereas passive
(mechanical) stabilization requires use of restraints.9 When
immobilization is indicated, the least restrictive alternative or
technique should be used.23,38
An accurate, comprehensive, and up-to-date medical history
is necessary for effective treatment. This would include careful
review of the patient’s medical history to ascertain if there are
any conditions (e.g., asthma) which may compromise respiratory
function or neuromuscular or bone/skeletal disorders which may
require additional positioning aids due to rigid extremities.28
Following explanation of the procedures and consent by
the parent, protective stabilization of the patient should begin
in conjunction with distraction techniques39 by placing the
child, in a manner as comfortable as possible, in a supine
position. If restriction of extremity movement is needed, the
dentist may ask a dental auxiliary or parent to employ hand
guarding or hold the patient’s hands. Gradually increasing or
decreasing levels of restriction in response to the patient’s
behavior is one method of providing protective stabilization.23
Full-body protective stabilization, when indicated, should be
accomplished in a sequential manner.40 If the stabilization
device includes a head hold, that is activated last. At no time
should the device be active to the point of restricting blood
flow or respiration.41

Equipment. Numerous devices are available to limit move-
ments by a patient unable to cooperate during dental treatment.
The ideal characteristics of a passive restraining device to use
as an adjunct to dental procedures include the following:
• easily used;
• appropriately sized for the patient;
• soft and contoured to minimize potential injury to the
patient;
• specifically designed for patient stabilization (i.e., not
improvised equipment)40; and
• able to be disinfected.
Stabilization of a patient’s extremities can be accomplished
®
using devices (e.g., Posey straps [Tidi Products, Neehah, Wis,
USA], hook and loop straps, seat belts) or an extra assistant.
If hand guarding or hand holding does not deter disruptive
movement of a patient’s hands, wrist restraints may be
utilized.37,42 If a patient is unable (due to medical diagnosis)
or unwilling (due to maladaptive behaviors) to control bodily
movement, a full body wrap may need to be used. Full-
body stabilization devices include, but are not limited to,
® ®
Papoose Board and Pedi-Wrap (The Medi-Kid Co., Hemet,
Calif., USA). 37,42 Devices with a flat board design may not
adapt to the dental chair. Pillows or beanbags under the
board may be used to promote stability.28 Stabilization for the
head may be accomplished using forearm-body support, a
head positioner, or an extra assistant.42 Positioning devices
or stabilizers such as wheelchair head supports or dental chair
cushions are adjunct devices that are not necessarily consid-
ered protective stabilization devices.28 Although a mouth prop
may be used as an immobilization device, the use of a mouth
prop in a compliant child is not considered protective
stabilization.
Monitoring. Ongoing awareness/assessment of the patient’s
physical and psychological well-being during the dental proce-
dure must be performed.28 Tightness of the stabilization device
must be monitored continuously throughout the procedure.41
For a patient who is experiencing severe emotional stress,
protective stabilization must be terminated as soon as possible
to prevent possible physical or psychological trauma.28 At the
completion of dental procedures, removal of restraints may be
accomplished sequentially with short pauses between stages
to assess the patient’s level of cooperation.37 Struggling during
removal of restraints may increase the potential for injury to
the child as well as others. When immobilization has been
introduced intra-operatively (i.e., unplanned intervention),
debriefing is beneficial for parent/patient understanding 22
and to discuss management implications for future
appointments.
Patients with SHCN. The provider should consider utilizing
alternative behavioral approaches to reduce movement and
resistance as well as increase cooperation when providing
medically-necessary dental care for patients with SHCN prior
BEST PRACTICES: PROTECTIVE STABILIZATION
to implementing protective stabilization.28,43 Various behavioral
modification approaches such as distraction, shaping, model-
ing, sensory integration, desensitization, and reinforcement are
regarded as alternatives.43-45 Non-pharmacological behavior
guidance approach have been effective in patients with autism
spectrum disorders.46-49 Children and adolescents with SHCN
will, at times, require protective stabilization to facilitate
completion of necessary dental treatment. 28 Aggressive,
uncontrolled, and impulsive behaviors along with involuntary
movements may cause harm to both the patient and dental
personnel.50 Use of protective stabilization reduces potential
risks and provides safer management of patients with
SHCN.50,51 Studies have demonstrated that sensory adapted
environments and techniques such as deep pressure from an
immobilization device (e.g., Papoose Board ) provided ®
comfort, reduced effects of stressful stimuli, and were observed
to be non-harmful to special needs patients receiving medical
and dental care.50,51 One study reported parents of children
with SHCN had greater acceptance of protective stabilization
in comparison to parents of children with no disabilities.52
When considering protective stabilization during dental
treatment for patients with SHCN, the dentist in collabora-
tion with the parent must consider the importance of treatment
and the safety consideration of the restraint.33 The dentist
should be cautious when utilizing protective stabilization for
children and adolescents receiving multiple medications. The
propensity of adverse central nervous system or cardiac
events occurring may increase when protective stabilization is
instituted on patients receiving psychotropic or other
medications.41
Indications. Protective stabilization is indicated for:
• a patient who requires immediate diagnosis and/or
urgent limited treatment and cannot cooperate due to
developmental levels (emotional or cognitive), lack of
maturity, or medical/physical conditions;
• a patient who requires urgent care and uncontrolled
movements risk the safety of the patient, staff, dentist,
or parent without the use of protective stabilization.
• a previously cooperative patient who quickly becomes
uncooperative and cooperation cannot be regained by
basic behavior guidance techniques in order to protect
the patient’s safety and help complete a procedure and/
or stabilize the patient;
• an uncooperative patient who requires limited (e.g.,
quadrant) treatment and sedation or general anesthesia
may not be an option because the patient does not meet
sedation criteria or because of a long operating room
wait time, financial considerations, and/or parental
preferences after other options have been discussed;
• a sedated patient who requires limited stabilization to
help reduce untoward movements during treatment; and
• a patient with SHCN who exhibits uncontrolled move-
ments that would be harmful or significantly interfere
with the quality of care.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 343
BEST PRACTICES: PROTECTIVE STABILIZATION
Contraindications: Protective stabilization is contraindicated
for:
• a cooperative non-sedated patient;
• an uncooperative patient when there is not a clear need to
provide treatment at that particular visit;
• a patient who cannot be immobilized safely due to asso-
ciated medical, psychological, or physical conditions;
• a patient with a history of physical or psychological
trauma, including physical or sexual abuse or other
trauma that would place the individual at greater
psychological risk during restraint;
• a patient with non-emergent treatment needs in order
to accomplish full mouth or multiple quadrant dental
rehabilitation;
• the practitioner’s convenience; and
• a dental team without requisite knowledge and skills in
patient selection and restraining techniques to prevent
or minimize psychological stress and/or decrease risk of
physical injury to the patient, the parent, and the staff.
Risks. The provider should consider the patient’s emotional
and cognitive developmental levels and should be aware
of potential physical and psychological effects of protective
stabilization. The majority of restraint-related injuries consist
of minor bruises and scratches, although other more serious
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
while placed on the board as they may roll out of the chair.38 A
rigid stabilization board may not allow for complete extension
of the neck and, therefore, may compromise airway patency,
especially in young children or sedated patients. 54 Proper
training and use of a neck roll may minimize this risk.28,37
Significant release of adrenal catecholamines may occur in
patients who experience increased agitation when restrained by
staff members or protective stabilizing equipment.41 Excessive
catecholamine release may sensitize the heart and cause rhythm
disturbances.41
The dental provider should acknowledge and abide by the
principle to “do no harm” when considering completion of
excessive amounts of treatment while the patient is immo-
bilized with protective stabilization.55 The physical and psy-
chological health of the patient should override other factors
(e.g., practitioner convenience, financial compensation).55
Documentation. The patient’s record must include:
• indication for stabilization.
• type of stabilization.
• informed consent for protective stabilization.
• reason for parental exclusion during protective stabili-
zation (when applicable).
• the duration of application of stabilization.
344 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• behavior evaluation/rating during stabilization.
• any untoward outcomes, such as skin markings.
• management implications for future appointments.
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15. Wells MHJ, McTigue DJ, Casamassimo PS, Adair S.
Gender shifts and effects on behavior guidance. Pediatr
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16. Bimstein E, Azari A, Riley JL. Predoctoral and postdoc-
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24. State of Colorado Department of Regulatory Agencies.
Board of Dental Examiners. 3CCR709-1. Rules and
Regulations. Rule XV. Pediatric Case Management and
Protective Stabilization. 2016. Available at: “https://www.
sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersion
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25. Romer M. Consent, restraint, and people with special
needs: A review. Spec Care Dentist 2009;29(1):58-66.
26. Seale NS, Behavior Management Conference Panel III–
Legal issues associated with managing children’s behavior
in the dental office. Pediatr Dent 2004;26(2):175-9.
27. Crock C, Olsson C, Phillips R, et al. General anesthesia
or conscious sedation for painful procedures in childhood
cancer: The family’s perspective. Arch Dis Child 2003;
88(3):253-7.
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28. Townsend JA. Protective stabilization in the dental setting.
In: Nelson TM, Webb JR, eds. Dental Care for Children
with Special Needs. Cham, Switzerland: Springer Nature;
2019:318-44.
29. Reid KI. Informed consent in dentistry. J Law Med Ethics
2017;45(1):77-94.
30. American Academy of Pediatric Dentistry. Informed
consent. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:470-3.
31. American Academy of Pediatrics Committee on Bioethics.
Policy statement: Informed consent in decision-making
in pediatric practice. Pediatrics 2016;138(2):e20161484.
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138/2/e20161484.long”. Accessed September 20, 2020.
32. Katz AL, Webb SA, American Academy of Pediatrics
Committee on Bioethics. Technical report: Informed
consent in decision-making in pediatric practice. Pediatrics
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33. Newton JT. Restrictive behaviour management proce-
dures with people with intellectual disabilities who require
dental treatment. J Appl Res Intellect Disabil 2009;22
(2):118-25. Available at: “https://onlinelibrary.wiley.com/
doi/abs/10.1111/j.1468-3148.2008.00478.x”. September
24, 2020.
34. Spatz ES, Krumholz HM, Moulton BW. The new era of
informed consent: Getting to a reasonable patient stan-
dard through shared decision making. J Am Med Assoc
2016;315(19):2063-4.
35. Sfikis P. A duty to disclose: Issues to consider in securing
informed consent. J Am Dent Assoc 2003;134(10):1329-33.
36. Frankel RI. The Papoose Board and mothers’ attitudes
following its use. Pediatr Dent 1991;13(5):284-8.
37. Southern Association of Institutional Dentists. Managing
maladaptive behaviors—The use of dental restraints and
positioning devices. Self-study course; Module 6:1-24.
Available at: “https://7b3143db-1f23-4037-bea3-8ded-
b61ea866.filesusr.com/ugd/aeccd5_42dbd36b13da44259
c2ecb807d68126c.pdf ”. Accessed July 19, 2020.
38. Fenton SJ. Revisiting the issue of physical restraint in
dentistry. Spec Care Dentist 1989;9(6):183.
39. Vessey JA, Carlson KL, McGill J. Use of distraction with
children during an acute pain experience. Nurs Res 1994;
43(6):369-72.
40. Fein JA, Daugherty RJ. Restraint techniques and issues.
In: King C, Henretig FM, eds. Textbook of Pediatric
Emergency Procedures. 2nd ed. Philadelphia, Pa.:
Lippincott Williams and Wilkins; 2008:15-22.
41. Mohr WK, Petti TA, Mohr BD. Adverse effects associ-
ated with physical restraint. Can J Psychiatry 2003;48
(5):330-7.
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42. Weddell JA, Sanders BJ, Jones JE. Dental problems
of children with special health care needs. In: Dean JA,
ed. McDonald and Avery’s Dentistry for the Child and
Adolescent, 10th ed. St. Louis, Mo.: Mosby Elsevier;
2016:519-22.
43. Kemp F. Alternatives: A review of non-pharmacologic
approaches to increasing the cooperation of patients with
special needs to inherently unpleasant dental procedures.
Behav Anal Today 2005;6(2):88-108.
44. Friedman C. Treatment considerations: Alternative be-
havioral support strategies. In: Raposa KA, Pearlman SP,
eds. Treating the Dental Patient with a Developmental
Disorder. Hoboken, N.J.: Wiley-Blackwell; 2012:73-95.
45. Lyons RA. Treatment considerations: Behavioral supports.
In: Raposa KA, Pearlman SP, eds. Treating the Dental
Patient with a Developmental Disorder. Hoboken, N.J.:
Wiley-Blackwell; 2012:43-72.
46. Tesini DA. Providing comprehensive quality dental
care to children with autism spectrum disorder. Inside
Dental Assisting 2014;10(2):22-7. Available at: “http://
pathfindersforautism.org/docs/Providing%20Compre
hensive,%20Quality%20Dental.pdf ”. Accessed July 19,
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47. Tesini D, Fetter C. D-Termined Program© of Repetitive
Tasking and Familiarization in Dentistry [book on DVD].
Hampton, N.H.: Specialized Care Co.; 2004.
48. Tesini DA. The D-Termined Program© of familiariza-
tion and repetitive tasking. Practical Reviews in Pediatric
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49. Al Humaid J, Tesini D, Finkelman M, Loo CY. Effective-
ness of the D-Termined Program© of repetitive tasking
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Dent Child 2016;83(1):16-21.
346 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
50. Chen HY, Yang H, Chi HJ, Chen HM. Physiologic and
behavioral effects of papoose board on anxiety in dental
patients with special needs. J Formos Med Assoc 2014;
113(2):94-101. Available at: “https://reader.elsevier.com/
reader/sd/pii/S0929664612002744?token=DD2081FC3
CA1588E38A4C6CAF53C1981D7BDE0424C5102C
856B55EED5246F4F827C8F9AD0E6A00A57EE03F
83084ED926&originRegion=us-east-1&originCreation
=20211029163237.” Accessed October 29, 2021.
51. Shapiro M, Sgan-Cohen HD, Parusa S, Melmed RN.
Influence of adapted environment on the anxiety of
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www.jpeds.com/action/showPdf?pii=S0022-3476%
2808%2900883-4”. Accessed October 29, 2021.
52. de Castro, AM, de Oliveira FS, de Paiva Novaes MS,
Araujo Ferreira DC. Behavior guidance techniques in
pediatric dentistry: Attitudes of parents of children with
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53. Spreat S, Lipinski D, Hill J, Halpin ME. Safety indices
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54. Adair SM, Durr DP. Modification of Papoose Board
restraint to facilitate airway management of the sedated
®
pediatric dental patient. Pediatr Dent 1987;9(2):163-5.
55. American Dental Association. Principles of Ethics and
Code of Professional Conduct. With official advisory
opinions revised to November 2018. Available at: “https:
//www.ada.org/~/media/ADA/Member%20Center/Ethics/
Code_Of_Ethics_Book_With_Advisory_Opinions_Revised
_to_November_2018.pdf?la=en”. Accessed July 19, 2020.
 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
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:347-52.

Abstract
This best practice presents recommendations regarding use of local anesthesia to control pain during pediatric dental procedures.
Considerations in the use of topical and local anesthetics include: the patient’s medical history, developmental status, age, and weight; planned
procedures; risk for methemoglobinemia; formulations of injectable anesthetic agents with and without vasoconstrictor as well as contra-
indications for their use; and selection of syringes and needle length and gauge. Guidance for documentation of local anesthesia addresses
anesthetic selection and dose administered in addition to injection type and location and postoperative instructions. Potential complications
such as toxicity, paresthesia, allergy, and postoperative self-induced soft tissue injury are discussed. Recommendations also are provided for
alternative delivery methods, use with sedation or general anesthesia, and use during pregnancy. Safety precautions emphasize calculating
maximum dosage based on the patient’s weight, adjusting local anesthetic dosage when additional analgesic or sedative agents are used,
considering systemic absorption and the possibility of methemoglobinemia from topical anesthetic use, and bending of needles at the hub
increases risk for breakage. Management of pain is an important component of oral health care and can result in a more positive patient
experience.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations on using local anesthetics in the management of dental pain for
pediatric patients and persons with special health care needs.

KEYWORDS: ANALGESICS; ANESTHESIA, GENERAL; ANESTHESIA, LOCAL; DELIVERY OF HEALTH CARE; METHEMOGLOBINEMIA; PAIN MANAGEMENT;
PEDIATRIC DENTISTRY

Purpose
The American Academy of Pediatric Dentistry (AAPD)
intends this document to help practitioners make decisions
when using local anesthesia to control pain in infants, chil-
dren, adolescents, and individuals with special health care
needs during the delivery of oral health care.
Methods
Recommendations on local anesthesia were developed by the
Council on Clinical Affairs and adopted in 20051, and last
revised in 2015.2 This update is based upon a literature search
®
of the Pubmed /MEDLINE database using the terms: local
anesthesia AND dentistry AND systematic review, topical
anesthesia AND dentistry, buffered anesthesia AND dentistry.
Additionally, Handbook of Local Anesthesia, 7th edition3 con-
tributed significantly to this revision. When data did not
appear sufficient or were inconclusive, recommendations were
based upon expert and/or consensus opinion by experienced
researchers and clinicians.
Background
Local anesthesia is the temporary loss of sensation including
pain in one part of the body produced by a topically-applied
or injected agent without depressing the level of conscious-
ness. Local anesthetics act within the neural fibers to inhibit
the rapid ionic influx of sodium necessary for neuron impulse
generation.4,5 This helps to prevent transmission of pain sensa-
tion during procedures, which can serve to build trust and
foster the relationship of the patient and dentist, allay fear and
anxiety, and promote a positive dental attitude. The technique
of local anesthetic administration is an important considera-
tion in pediatric patient behavior guidance.6 Age-appropriate
nonthreatening terminology, distraction, topical anesthetics,
proper injection technique, and pharmacologic managment
can help the patient have a positive experience during admin-
istration of local anesthesia.6,7 In pediatric dentistry, the dental
professional should be aware of proper dosage (based on body
weight) to minimize the chance of toxicity and the prolonged
duration of anesthesia, which can lead to self-inflicted tongue
or soft tissue trauma.8 Knowledge of gross and neuroanatomy
of the head and neck allows for proper placement of the
anesthetic solution and helps minimize complications (e.g.,
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ADA: American Den-
tal Association. CNS: Central nervous system. CVS: Cardiovascular
system. FDA: U.S. Food and Drug Administration. kg: killogram.
lb: pound. mg: milligram. mm: millimeter. mL: milliliter. PDL:
Periodontal ligament.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 347

 BEST PRACTICES: USE OF LOCAL ANESTHESIA

hematoma, trismus, intravascular injection).8,9 Familiarity with an abnormal elevation in body temperature during general
the patient’s medical history is essential to decrease the risk anesthesia with inhalation anesthetics or succinylcholine.13
of aggravating a medical condition while rendering dental If a local anesthetic is injected into an area of infection, its
care. Medical consultation should be obtained as needed. onset will be delayed or even prevented.7,8 The inflammatory
Many local anesthetic agents are available to facilitate process in an area of infection lowers the pH of the extra-
management of pain in the dental patient. There are two gen- cellular tissue, inhibiting anesthetic action as little of the
eral types of local anesthetic chemical formulations: (1) esters active free base form of the anesthetic is allowed to cross into
(e.g., procaine, benzocaine, tetracaine); and (2) amides (e.g., the nerve sheath to prevent conduction of nerve impulses.8
lidocaine, mepivacaine, prilocaine, articaine).10 Additionally, endocarditis prophylaxis (antibiotics) is not
Vasoconstrictors (e.g., epinephrine, levonordefrin, norepine- recommended for routine local anesthetic injections through
phrine) are added to local anesthetics to constrict blood vessels noninfected tissue in patients considered at risk.14
in the area of injection. This lowers the rate of absorption of
the local anesthetic into the blood stream, thereby lowering Topical anesthetics
the risk of toxicity and prolonging the anesthetic action in the The application of a topical anesthetic may help minimize
area.11 Epinephrine is a relative contraindication in patients discomfort caused during administration of local anesthesia.
with hyperthyroidism, and dose of local anesthetics with Single drugs often used as topical anesthetics in dentistry in-
epinephrine should be limited.12 Patients with significant clude 20 percent benzocaine, five percent lidocaine, and four
cardiovascular disease, thyroid dysfunction, diabetes, or sulfite percent tetracaine.15 Topical anesthetics are effective on surface
sensitivity and those receiving monoamine oxidase inhibitors, tissues (up to two to three millimeters in depth) to reduce pain
tricyclic antidepressants, antipsychotic drugs, norepinephrine, from needle penetration of the oral mucosa.4,15 These agents
or phenothiazines may require a medical consultation to are available in gel, liquid, ointment, patch, and aerosol forms.
determine the need for a local anesthetic without vasoconstric- The United States Food and Drug Administration (FDA) has
tor.13 When halogenated gases are used for general anesthesia, issued warnings about the use of compounded topical anes-
the myocardium is sensitized to epinephrine, and such thetics16 and the risk of methemoglobinemia.17 Compounded
situations dictate caution with use of a local anesthetic.13 topical anesthetics are custom-made medications that may bypass
Amide-type local anesthetics no longer are contraindicated the FDA’s drug approval process.16 These products may contain
in patients with a family history of malignant hyperthermia, very high combined levels of both amide and ester agents.
Exposure to high concentrations of
local anesthetics can lead to serious
Table. INJECTABLE LOCAL ANESTHETICS ( Adapted from Coté CJ et al.32 ) adverse reactions, as indicated in the
FDA's warning.16 Acquired methemo-
Anesthetic Duration Maximum doseB mg anesthetic/ mg vasoconstrictor/ globinemia is a serious but rare condition
in minutesA
mg/kg mg/lb 1.7 mL cartridge 1.7 mL cartridge
that occurs when the ferrous iron in
Lidocaine c 90-200 4.4 2 the hemoglobin molecule is oxidized to
2%+1:50,000 epinephrine 34 0.034 mg
the ferric state. This molecule is known
34 0.017 mg
as methemoglobin, which is incapable
2%+1:100,000 epinephrine
of carrying oxygen.18 Risk of acquired
Articaine 60-230 7 3.2 methemoglobinemia has been associated
4%+1:100,000 epinephrine 68 0.017 mg primarily with two local anesthetics:
4%+1:200,000 epinephrine 68 0.0085 mg prilocaine and benzocaine.13 Benzocaine
Mepivacaine D 120-240 4.4 2 is contraindicated in patients with a
3% plain 51 — history of methemoglobinemia and
2%+1:20,000 levonordefrin 34 0.085 mg should not be used in children younger
E
than two years of age.17
Bupivacaine 180-600 1.3 0.6
0.5%+1:200,000 epinephrine 8.5 0.0085 mg Selection of syringes and needles
The American Dental Association
A Duration of anesthesia varies greatly depending on concentration, total dose, and site of administration; use (ADA) has long standing standards
of epinephrine; and the patient’s age.
B
for aspirating syringes for use in the
Use lowest total dose that provides effective anesthesia. Lower doses should be used in very vascular areas.
Doses should be decreased by 30 percent in infants younger than six months. For improved safety, AAPD, administration of local anesthesia.19-21
in conjunction with the American Academy of Pediatrics, recommends a dosing schedule for dental pro- Needle selection should allow for pro-
cedures that is more conservative that the manufacturer’s recommended dose (MRD). found local anesthesia and adequate
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. aspiration. 19,20 Needle gauges range
D Use in pediatric patients under four years of age is not recommended. from size 23 to 30, with the lower
E The prolonged anesthesia of bupivacaine can increase risk of self-inflicted soft tissue injury. numbers having the larger inner diameter.

348 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Needles with lower number provide for less deflection as
the needle passes through soft tissues and for more reliable
aspiration. 20 The depth of insertion varies not only by
injection technique but also by the age and size of the patient.
Dental needles are available in three lengths: long (32
millimeters [mm]), short (20 mm), and ultrashort (10 mm).
Most needle fractures occur during the administration of
inferior alveolar nerve block with 30-gauge needles.22 Breakage
can occur when a needle is inserted to the hub, when the
needle is weakened due to bending it before insertion into the
soft tissues, or by patient movement after the needle is inserted.21-23
Injectable local anesthetic agents
Local amide anesthetics available for dental usage include
lidocaine, mepivacaine, articaine, prilocaine, and bupivacaine
(Table). Absolute contraindications for local anesthetics in-
clude a documented local anesthetic allergy.15 True allergy to
an amide is exceedingly rare.15 Allergy to one amide does not
rule 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, use of a local
anesthetic without a vasoconstrictor is indicated.24 Local anes-
thetics without vasoconstrictors can undergo rapid systemic
absorption which may result in overdose.24
While the prolonged effect of a long-acting local anesthetic
(i.e., bupivacaine) can be beneficial for post-operative pain in
adults, the concomitant increased risk of self-inflicted injury
infers that it is contraindicated for the child or the physically
or intellectually disabled patient.15 Claims have been made
that articaine can diffuse through hard and soft tissue from
a buccal infiltration to provide lingual or palatal soft tissue
anesthesia.15 Systematic reviews comparing articaine versus li-
docaine have concluded they present the same efficacy with
no differences in patient-reported pain25 and that articaine
is more effective in anesthetic success in mandibular first per-
manent molar areas26 as well as superior for inferior alveolar
nerve block in patient with irreversible pulpitis27.
Prilocaine is contraindicated in patients with methe-
moglobinemia, sickle cell anemia, anemia, or symptoms of
hypoxia or in patients receiving acetaminophen or phenacetin,
since both medications elevate methemoglobin levels.15
The effect of adjusting the pH of local anesthetics in den-
tistry has become of interest because the acidic nature of local
anesthetics (adjusted to approximately pH of 4.5 to prolong
shelf life) may cause pain during infiltration and delayed on-
set. One systematic review found that local anesthesia buffered
with sodium bicarbonate was 2.3 times more likely to achieve
successful anesthesia than nonbuffered local anesthesia for
participants with a clinical diagnosis of symptomatic irre-
versible pulpitis requiring endodontic treatment.28 Another
systematic review found that the pH adjustment was not
effective in reducing pain of intraoral injections in normal or
inflamed tissues or reducing the time of anesthesia onset, but
it had a slight reduction on the onset time with inferior
BEST PRACTICES: USE OF LOCAL ANESTHESIA
alveolar injections for pulpitis.29 This review concluded that
the reduced time of onset may not be clinically relevant con-
sidering the time required to prepare the buffered agent.29
Similar results were found in children ages six to 12 years old.30
Documentation of local anesthesia
The patient record is an essential component of the delivery
of competent and quality oral health care.31 Following each
appointment, an entry is made in the record that accurately
and objectively summarizes that visit. Appropriate documen-
tation includes specific information relative to the administra-
tion of local anesthesia. This would include, at a minimum,
the type and dosage of local anesthetic administered.31
Documentation also may include the type of injection(s)
administered (e.g., infiltration, block, intraosseous), needle
selection, and patient’s reaction to the injection. For example,
local anesthesia administration might be recorded as: man-
dibular block with 27-short; 34 milligrams (mg) two percent
lidocaine with 0.017 mg epinephrine [or 1/100,000 epine-
phrine]; tolerated procedure well. In patients for whom the
maximum dosage of local anesthetic may be a concern (e.g.,
young patients, those undergoing sedation), the body weight
should be documented preoperatively. Because there may be
enhanced sedative effects when local anesthetics are admin-
istered in conjunction with sedative drugs, recording doses of
all agents on a time-based record can help ensure patient
safety.32 Local anesthesia documentation also should include
that post-injection instructions were reviewed with the patient
and parent.
Local anesthetic complications
Toxicity (overdose)
Younger pediatric patients are at greater risk for adverse drug
events.8 Most adverse drug reactions develop either during the
injection or within five to 10 minutes.18 Local anesthetic sys-
temic toxicity can result from high blood levels caused by a
single inadvertent intravascular injection or repeated injec-
tions.6 Local anesthetic causes a biphasic reaction (excitation
followed by depression) in the central nervous system (CNS).33
The classic overdose reaction to local anesthetic is generalized
tonic-clinic convulsion.33 Early subjective indications of
toxicity involve the CNS and include dizziness, anxiety, and
confusion. This may be followed by diplopia, tinnitus, drow-
siness, and circumoral numbness or tingling. Objective signs
may include muscle twitching, tremors, talkativeness, slowed
speech, and shivering, followed by overt seizure activity.
Unconsciousness and respiratory arrest may occur.10
The cardiovascular system (CVS) response to local anesthetic
toxicity also is biphasic. Initially, the CVS is subject to stimu-
lation; heart rate and blood pressure may increase. As plasma
levels of the anesthetic increase, however, vasodilatation occurs
followed by depression of the myocardium with subsequent
fall in blood pressure. Bradycardia and cardiac arrest may
follow. The cardiodepressant effects of local anesthetics are not
seen until there is a significantly elevated level in the blood.15
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 349
BEST PRACTICES: USE OF LOCAL ANESTHESIA
Local anesthetic toxicity can be prevented by careful in-
jection technique, watchful observation of the patient, and
knowledge of the maximum dosage based on body weight. It
should be recognized that half the volume of a four percent
local anesthetic should be used compared to a two percent
solution with the same dosing recommendation. Practitioners
should aspirate before agent delivery during every injection and
inject slowly.15 Aspiration during injections decreases the risk
of an intravascular injection, and a slow injection technique
reduces tissue distortion and related discomfort. After the in-
jection, the doctor, hygienist, or assistant should remain with
the patient while the anesthetic begins to take effect. Early rec-
ognition of a toxic response is critical for effective management.
When signs or symptoms of toxicity are noted, administration
of the local anesthetic agent should be discontinued. Additional
emergency management, including patient rescue and activation
of emergency medical services, is based on the severity of the
reaction.4
Allergy to local anesthesia
Allergic reactions are not dose related but are due to the pa-
tient’s heightened capacity to react to even a small dose and
can manifest in a variety of ways, some of which include
urticaria, dermatitis, angioedema, fever, photosensitivity, or
anaphylaxis.15,24 Emergency management is dependent on the
rate and severity of the reaction.
Paresthesia
Paresthesia is persistent anesthesia beyond the expected dura-
tion. Trauma to the nerve can result in paresthesia and,
among other etiologies, can be caused by the needle during
the injection.34 Patients who initially experience an electric shock
sensation during injection may have persistent anesthesia.34
Paresthesia has been reported to be more common with four
percent solutions such as articaine and prilocaine compared
to those of lower concentrations.35
Postoperative soft tissue injury
Self-induced soft tissue trauma (lip and cheek biting) is an
unfortunate clinical complication of local anesthetic use in
the oral cavity. Most lesions of this nature are self-limiting and
heal without complications, although bleeding and infection
are possible.34 The use of bilateral mandibular blocks does not
increase the risk of soft tissue trauma when compared to uni-
lateral mandibular blocks or ipsilateral maxillary infiltration.34
Advising the patient/caregiver of a realistic duration of
numbness and post-operative precautions is necessary to de-
crease risk of self-induced soft tissue trauma. Visual examples
may help stress the importance of observation during the
period of numbness. For all local anesthetics, the duration of
soft tissue anesthesia is greater than dentinal or osseous anes-
thesia. Use of phentolamine mesylate injections in patients
over age six years or at least 15 kilograms (kg) has been shown
to reduce the duration of effects of local anesthetic by about
47 percent in the maxilla and 67 percent in the mandible.36,37
350 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
However, there is no research demonstrating a relationship
between reduction in soft tissue trauma and the use of shorter
acting local anesthetics.
Alternative techniques for delivery of local anesthesia
Most local anesthesia procedures in pediatric dentistry involve
traditional methods of infiltration or nerve block techniques
with a dental syringe, disposable cartridges, and needles as
described so far. Several alternative techniques, however, are
available. These include computer-controlled local anesthetic
delivery, periodontal injection techniques, needleless systems,
and intraseptal or intrapulpal injection. Such techniques may
improve comfort of injection by better control of the adminis-
tration rate, pressure, and location of anesthetic solutions and
result in more successful and controlled anesthesia.38,39
The mandibular bone of a child usually is less dense than
that of an adult, permitting more rapid and complete diffusion
of the anesthetic.8 Mandibular buccal infiltration anesthesia is
as effective as inferior nerve block anesthesia for some oper-
ative procedures.8 In patients with bleeding disorders, the
periodontal ligament (PDL) injection minimizes the potential
for postoperative bleeding of soft tissue vessels.13 The use of the
PDL injection or intraosseous methods is contraindicated in
the presence of inflammation or infection at the injection site.38
Local anesthesia with sedation and general anesthesia
Local anesthetics and sedative agents both depress the CNS.
Therefore, it is recommended that the dose of local anes-
thesia be adjusted downward when sedating children with
opioids.40
For patients undergoing general anesthesia, the anesthesia
care provider needs to be aware of the concomitant use of a
local anesthetic containing epinephrine, as epinephrine can
produce dysrhythmias when used with halogenated hydrocar-
bons (e.g., halothane).4 Local anesthesia has been reported to
reduce pain in the postoperative recovery period after general
anesthesia.41
Local anesthesia and pregnancy
The use of local anesthesia during pregnancy is considered
safe.42 The FDA has established a drug classification system
based on their risks to pregnant women and their fetuses.43 In
respect to the five categories (A, B, C, D, and X) established
by the FDA, lidocaine is considered in Category B, the safest
of the local anesthetics.44 Lidocaine is considered to be safe
for use during breastfeeding.45
Recommendations
1. Selection of local anesthetic agents should be based
on the patient’s medical history and mental/
developmental status, the anticipated duration of the
dental procedure, and the planned administration
of other agents (e.g., nitrous oxide, sedative agents,
general anesthesia).

2. Administration of local anesthetic should be based
on the body weight of the patient, not to exceed
AAPD recommendations in mg/kg found in Table.
Use lowest total dose that provides effective
anesthesia.
3. A topical anesthetic may be used prior to the injec-
tion of a local anesthetic to reduce discomfort asso-
ciated with needle penetration. Systemic absorption
of the drugs in topical anesthetics must be consid-
ered when calculating the total amount of anesthetic
administered.
4. Benzocaine is contraindicated in patients with a
history of methemoglobinemia and should not be
used in children younger than two years of age.
5. Documentation of local anesthesia administration
would include, at a minimum, the type and dosage
of local anesthetic. If the local anesthetic was admin-
istered in conjunction with sedative drugs, the doses
of all agents must be noted on a time-based record.
Safety and risks
1. In the Table, the long-established pediatric dental
maximum dose for lidocaine is 4.4 mg/kg; however,
seven mg/kg maximum dose for lidocaine is the
manufacturer’s recommended dose.
2. Compounded topical anesthetics may contain very
high combined levels of both amide and ester agents
which can lead to serious adverse reactions.
3. Reduce local anesthesia dose when combined with
sedative medications.
4. Half the volume should be used for four percent
anesthetic solutions compared to two percent solu-
tions with the same dosing recommendation.
5. Manufacturers do not recommend articaine use in
pediatric dental patients younger than four years old.
6. Needles should not be bent or inserted to their hub
to avoid breakage.
References
1. American Academy of Pediatric Dentistry. Appropriate
use of local anesthesia for pediatric dental patients.
Pediatr Dent 2005;27(Suppl):101-6.
2. American Academy of Pediatric Dentistry. Use of local
anesthesia for pediatric dental patients. Pediatr Dent
2015;37(special issue):199-205.
3. Malamed SF. Handbook of Local Anesthesia. 7th ed. St.
Louis, Mo.: Mosby; 2020.
4. Ogle OE, Mahjoubi G. Local anesthesia: Agents, techni-
ques, and complications. Dent Clin North Am 2012;
56(1):133-48.
5. Malamed SF. Neurophysiology. In: Handbook of Local
Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:2-26.
6. Jones JE, Dean JA. Local anesthesia and pain control for
the child and adolescent. In: Dean JA, ed. McDonald
and Avery’s Dentistry for the Child and Adolescent.
10th ed. St Louis, Mo.: Mosby; 2016:274-85.
BEST PRACTICES: USE OF LOCAL ANESTHESIA
7. Malamed SF. Basic injection technique. In: Handbook of
Local Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:
173-85.
8. Malamed SF. Anesthetic considerations in dental special-
ties. In: Handbook of Local Anesthesia. 7th ed. St. Louis,
Mo.: Mosby; 2020:289-307.
9. Malamed SF. Anatomic considerations. In: Handbook of
Local Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:
186-203.
10. Moore PA, Hersh EV. Local anesthetics: Pharmacology
and toxicity. Dent Clin North Am 2010;54(4):587-99.
11. Malamed SF. Pharmacology of vasoconstrictors. In:
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.:
Mosby; 2020:41-56.
12. Budenz AW. Local anesthetics and medically complex
patients. J Cal Dent Assoc 2000;28(8):611-9. Available
at: “https://www.endoexperience.com/filecabinet/Clin
ical%20Endodontics/Anesthesia/Local%20anesthesia
%20and%20med%20compromised%20pts%20JCDA%
202000.pdf ”. Accessed July 15, 2020.
13. Malamed SF. Physical and psychological evaluation. In:
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.:
Mosby; 2020:134-72.
14. Wilson W, Taubert KA, Gevitz P, et al. Prevention of
infective endocarditis: Guidelines from the American
Heart Association. Circulation e-published April 19,
2007. Available at: “https://www.ahajournals.org/doi/
10.1161/CIRCULATIONAHA.106.183095?url_ver
=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr
_pub%20%200pubmed”. Accessed September 24, 2020.
Correction Circulation 2007;116:e376-e377.
15. Malamed SF. Clinical action of specific agents. In:
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.:
Mosby; 2020:57-85.
16. U.S. Food and Drug Administration. FDA news. FDA
warns five firms to stop compounding topical anesthetic
creams, December 2006. Available at: “https://www.
docguide.com/fda-warns-five-firms-stop-compounding-
topical-anesthetic-creams”. Accessed September 24, 2020.
17. U.S. Food and Drug Administration. Risk of serious and
potentially fatal blood disorder prompts FDA action on
oral over-the-counter benzocaine products used for teeth-
ing and mouth pain and prescription local anesthetics.
May 31, 2018. Available at: “https://www.fda.gov/drugs/
drug-safety-and-availability/risk-serious-and-potentially
-fatal-blood-disorder-prompts-fda-action-oral-over-counter
-benzocaine”. Accessed September 24, 2020.
18. Trapp L, Will J. Acquired methemoglobinemia revisited.
Dent Clin North Am 2010;549(4):665-75.
19. American Dental Association Council on Dental Materials
and Devices. New American National Standards Institute/
American Dental Association specification no. 34 for
dental aspirating syringes. J Am Dent Assoc 1978;97(2):
236-8.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 351
BEST PRACTICES: USE OF LOCAL ANESTHESIA
20. American Dental Association Council on Dental Mate-
rials, Instruments, and Equipment. Addendum to
American National Standards Institute/American Dental
Association specification No. 34 for dental aspirating
syringes. J Am Dent Assoc 1982;104(1):69-70.
21. Malamed SF. The needle. In: Handbook of Local Anes-
thesia. 7th ed. St. Louis, Mo.: Mosby; 2020:99-100.
22. Progrel MA. Broken local anesthetic needles: A case series
of 16 patients, with recommendations. J Am Dent Assoc
2009;140(12):1517-22.
23. Malamed SF, Reed KL, Poorsattar S. Needle breakage:
Incidence and prevention. Dent Clin North Am 2010;
54(4):745-56.
24. Malamed SF. Systemic complications. In: Handbook of
Local Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:
330-60.
25. Tong HJ, Alzahrani FS, Sim YF, et al. Anaesthetic efficacy
of articaine versus lidocaine in children’s dentistry: A
systematic review and meta-analysis. Int J Paediatr Dent
2018;28(4):347-60.
26. Katyal V. The efficacy and safety of articaine versus ligno-
caine in dental treatment: A meta-analysis. J Dent 2010;
38(4):307-17.
27. de Geus JL, da Costa KN, Wambier LM, et al. Different
anesthetics on the efficacy of inferior alveolar nerve block
in patients with irreversible pulpitis. J Am Dent Assoc
2020;151(2):87-97.
28. Kattan S, Lee S-M, Hersh EV, Karabucak B. Do buffered
local anesthetics provide more successful anesthesia than
non-buffered solutions in patients with pulpally involved
teeth requiring dental therapy?: A systematic review. J
Am Dent Assoc 2019;150(3):165-7.
29. Aulestia-Viera PV, Braga MM, Borsatti MA. The effect of
adjusting the pH of local anaesthetics in dentistry: A
systematic review and meta-analysis. Int Endod J 2018;
51(8):862-76.
30. Chopra R, Jindal G, Sachdev V, Sandhu M. Double-
blind crossover study to compare pain experience during
inferior alveolar nerve block administration using buffered
two percent lidocaine in children. Pediatr Dent 2016;38
(1):25-9.
31. American Academy of Pediatric Dentistry. Guideline on
record-keeping. Pediatr Dent 2017;16(6):389-96.
32. Coté CJ, Wilson S. American Academy of Pediatric Den-
tistry, American Academy of Pediatrics. Guidelines for
monitoring and management of pediatric patients before,
during, and after sedation for diagnostic and therapeutic
procedures. Pediatr Dent 2019;41(4):E26-E52.
33. Malamed SF. Pharmacology of local anesthetics. In:
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.:
Mosby; 2020:41-56.
352 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
34. Malamed SF. Local complications. In: Handbook of
Local Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:
308-29.
35. Garisto GA, Gaffen AS, Lawrence HP, et al. Occurrence
of paresthesia after dental local anesthetic administration
in the United States. J Am Dent Assoc 2010;141(7):
836-44.
36. Tavares M, Goodson MJ, Studen-Pavlovich D, et al. Re-
versal of soft-tissue local anesthesia with phentolamine
mesylate in pediatric patients. J Am Dent Assoc 2008;
139(8):1095-104.
37. Hersh EV, Moore PA, Papas AS, et al. Reversal of soft-
tissue local anesthesia with phentolamine mesylate in
adolescents and adults. J Am Dent Assoc 2008;139(8):
1080-93.
38. Malamed SF. Supplemental injection techniques. In:
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.:
Mosby; 2020:268-88.
39. Clark TM, Yagiela JA. Advanced techniques and arma-
mentarium for dental local anesthesia. Dent Clin North
Am 2010;54(4):757-68.
40. Becker DE, Reed KL. Essentials of local anesthetic
pharmacology. Anesth Prog 2006;53(3):98-109.
41. Kaufman E, Epstein JB, Gorsky M, Jackson DL, Kadari A.
Preemptive analgesia and local anesthesia as a supplement
to general anesthesia: A review. Anes Progress 2005;52
(1):29-38.
42. Oral Health Care During Pregnancy Expert Workgroup.
Oral Health Care During Pregnancy: A National Sum-
mary of a Consensus Statement. Washington, D.C.: Na-
tional Maternal and Child Oral Health Resource Center;
2012. Available at: “https://www.mchoralhealth.org/
PDFs/OralHealthPregnancyConsensus.pdf ”. Accessed
September 24, 2020.
43. U.S. Food and Drug Administration. Content and format
of labeling for human prescription drug and biological
products; Requirements for pregnancy and lactation
labeling; Final Rule FDA-2006-N-0515. Department of
Health and Human Services. Available at: “https://www.
fda.gov/media/90279/download”. Accessed September
24, 2020.
44. Lee JM, Shin TJ. Use of local anesthetics for dental
treatment during pregnancy: Safety for parturient. J
Dent Anesth Pain Med 2017;17(2):81-90.
45. Drugs and Lactation Database (LactMed). Lidocaine.
Bethesda, Md.: National Library of Medicine; 2006. Up-
dated January 7, 2019. Available at: “https://www.ncbi.
nlm.nih.gov/books/NBK501230/”. Accessed September
24, 2020.
 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
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:353-8.

Abstract
The goal of this best practice is to provide dental professionals with recommendations on the safe and appropriate use of nitrous oxide/
oxygen analgesia/anxiolysis for treating children. Recommendations for use of nitrous oxide/oxygen address indications and contraindications
considering the advantages and disadvantages of this inhalation method of analgesia/anxiolysis management. Factors to consider before
using nitrous oxide/oxygen for pediatric patient treatment include: the patient’s physical and emotional development, medical and dental
histories, and dental treatment needed; alternative behavior guidance options; credentials and training of the dentist and other dental
personnel; equipment and facilities; administration techniques and monitoring of use; potential adverse effects and outcomes; and employee
occupational safety. Documentation of its use is discussed. Judicious use of nitrous oxide/oxygen can provide a safe and effective method of
controlling anxiety associated with dental treatment in infants, children, adolescents, and persons with special health care needs.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and recommendations for dental professionals regarding development of safe practices in using
nitrous oxide/oxygen analgesia/anxiolysis for pediatric dental patients.

KEYWORDS: CHILD, ADOLESCENT, ANALGESIA, ANXIETY, ANTI-ANXIETY, HEALTH CARE DELIVERY, OXYGEN, NITROUS OXIDE

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes nitrous oxide/oxygen inhalation as a safe and
effective technique to reduce anxiety, produce analgesia, and
enhance effective communication between a patient and health
care provider. The need to diagnose and treat, as well as the
safety of the patient and practitioner, should be considered
before using nitrous oxide. By producing this guideline, the
AAPD intends to assist the dental profession in developing
appropriate practices in the use of nitrous oxide/oxygen
analgesia/anxiolysis for pediatric patients.
Methods
These recommendations were developed by the Council on
Clinical Affairs and adopted in 2005. This document is a
revision of the previous version, last revised in 2013. The
revision is based on a review of the current dental and medical
literature related to nitrous oxide use. A search was conducted
®
using the database of PubMed /MEDLINE with the
parameters: nitrous oxide [MESH] OR nitrous oxide reductase
[Supplementary Concept], publication date from January 1,
2012; humans; child: birth-18 years. Thirty-nine articles met
these criteria, and applicable articles were chosen and added
to the references from the previous document. Additionally,
the American Dental Association’s Guideline for the Use of
Sedation and General Anesthesia by Dentists 1 and the American
Dental Association’s Oral Health Topics – Nitrous Oxide Dental
Best Practices for Nitrous Oxide-Oxygen Use 2 were reviewed.
When data did not appear sufficient or were inconclusive,
recommendations were based upon expert and/or consensus
opinion by experienced researchers and clinicians.
Background
Dentists have expertise in providing anxiety and pain control
for their patients. While anxiety and pain can be modified by
psychological techniques, in many instances pharmacological
approaches are required.1 The outcome of pharmacological ap-
proaches is variable and depends upon each patient’s response
to various drugs. The clinical effect of nitrous oxide/oxygen
inhalation, however, is more predictable among the majority
of the population. When used for analgesia/anxiolysis, nitrous
oxide/oxygen inhalation allows for diminution or elimination
of pain and anxiety in a conscious patient, while entailing
minimum risk. 3 The patient responds normally to verbal
commands.4 All vital signs are stable, there is no significant
risk of losing protective reflexes, and the patient is able to
return to preprocedure mobility. In children, analgesia/
anxiolysis may expedite the delivery of procedures that are
not particularly uncomfortable, but require that the patient
not move.3 It also may allow the patient to tolerate unpleasant
procedures by reducing or relieving anxiety, discomfort,
or pain. Furthermore, it increases reaction time and reduces
pressure-induced pain, but does not affect pulpal sensitivity,
as shown in a double blind, crossover study.5
Nitrous oxide is a colorless and virtually odorless gas with
a faint, sweet smell. It is an effective analgesic/anxiolytic agent
causing central nervous system (CNS) depression and euphoria
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CNS: Central nervous
system. GABAA: Gamma-aminobutyric acid type A. L/min: Liters
per minute.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 353

BEST PRACTICES: USE OF NITROUS OXIDE
with little effect on the respiratory system.6,7 Nitrous oxide has
multiple mechanisms of action. The analgesic effect of nitrous
oxide appears to be initiated by neuronal release of endoge-
nous opioid peptides with subsequent activation of opioid
receptors and descending gamma-aminobutyric acid type A
(GABAA) receptors and noradrenergic pathways that modu-
late nociceptive processing at the spinal level. The anxiolytic
effect involves activation of the GABAA receptor either directly
or indirectly through the benzodiazepine binding site. 8,9
Nitrous oxide has rapid uptake, being absorbed quickly from
the alveoli and held in a simple solution in the serum. It is
relatively insoluble, passing down a gradient into other tissues
and cells in the body, such as the CNS. It is excreted quickly
from the lungs. Nitrous oxide causes minor depression in
cardiac output while peripheral resistance is slightly increased,
thereby maintaining the blood pressure.5 This is of particular
advantage in treating patients with cerebrovascular system
disorders.
Nitrous oxide is absorbed rapidly, allowing for both rapid
onset and recovery (two to three minutes). It causes minimal
impairment of any reflexes, thus protecting the cough reflex.6
It exhibits a superior safety profile with no recorded fatalities
or cases of serious morbidity when used within recommended
concentrations.10-13
The decision to use nitrous oxide/oxygen analgesia/anxiolysis
must take into consideration alternative behavioral guidance
modalities, the patient’s dental needs, the effect on the quality
of dental care, the patient’s emotional development, and the
patient’s physical considerations. Nitrous oxide generally is
acceptable to children and can be titrated easily. Most children
are enthusiastic about the administration of nitrous oxide/
oxygen; many children report feeling a tingling or warm
sensation.14 Objectively, children may appear with their hands
open, legs limp, and a trancelike expression.14 For some pa-
tients, however, the feeling of losing control may be troubling,
and children with claustrophobia may find the nasal hood
confining and unpleasant.15
Nitrous oxide has been associated with bioenvironmental
concerns because of its contribution to the greenhouse effect.16
Nitrous oxide is emitted naturally by bacteria in soils and
oceans; it is produced by humans through the burning of
fossil fuels and forests and the agricultural practices of soil
cultivation and nitrogen fertilization. Altogether, nitrous oxide
contributes about five percent to the greenhouse effect.17,18
However, only a small fraction of the total nitrous released into
the atmosphere (0.35 to two percent) is actually the result of
medical applications of nitrous oxide gas.18
The objectives of nitrous oxide/oxygen inhalation include:
• reduce or eliminate anxiety.
• reduce untoward movement and reaction to dental
treatment.
• enhance communication and patient cooperation.
• raise the pain reaction threshold.
• increase tolerance for longer appointments.
354 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• aid in treatment of the mentally/physically disabled or
medically compromised patient.
• reduce gagging.
• potentiate the effect of sedatives.
Disadvantages of nitrous oxide/oxygen inhalation may include:6
• lack of potency.
• dependant largely on psychological reassurance.
• interference of the nasal hood with injection to an-
terior maxillary region.
• patient must be able to breathe through the nose.
• nitrous oxide pollution and potential occupational
exposure health hazards.
Recommendations
Indications for use of nitrous oxide/oxygen analgesia/anxiolysis
include:
• a fearful, anxious, or obstreperous patient.
• certain patients with special health care needs.
• a patient whose gag reflex interferes with dental care.
• a patient for whom profound local anesthesia cannot
be obtained.
• a cooperative child undergoing a lengthy dental
procedure.
Review of the patient’s medical history should be performed
prior to the decision to use nitrous oxide/oxygen analgesia/
anxiolysis. This assessment should include:
• allergies and previous allergic or adverse drug reactions.
• current medications including dose, time, route, and
site of administration.
• diseases, disorders, or physical abnormalities and
pregnancy status.
• previous hospitalization to include the date and
purpose.
• recent illnesses (e.g., cold or congestion) that may
compromise the airway.
Contraindications for use of nitrous oxide/oxygen inhalation
may include:
• some chronic obstructive pulmonary diseases.19
• current upper respiratory tract infections.20
• recent middle ear disturbance/surgery.20
• severe emotional disturbances or drug-related de-
pendencies.20
• first trimester of pregnancy.21
• treatment with bleomycin sulfate.22
• methylenetetrahydrofolate reductase deficiency.23
• cobalamin (vitamin B12) deficiency.9
Whenever possible, appropriate medical specialists should
be consulted before administering analgesic/anxiolytic agents
to patients with significant underlying medical conditions
(e.g., severe obstructive pulmonary disease, congestive heart
failure, sickle cell disease24, acute otitis media, recent tympanic

membrane graft25, acute severe head injury26). In addition,
consultation with the prenatal medical provider should pre-
cede use of nitrous oxide/oxygen analgesia/anxiolysis during
pregnancy.27
Technique of nitrous oxide/oxygen administration
Nitrous oxide/oxygen must be administered only by appro-
priately licensed individuals, or under the direct supervision
thereof, according to state law. The practitioner responsible for
the treatment of the patient and/or the administration of
analgesic/anxiolytic agents must be trained in the use of such
agents and techniques and appropriate emergency response.
Selection of an appropriately sized nasal hood should be
made. A flow rate of five to six litres per minute (L/min)
generally is acceptable to most patients. The flow rate can
be adjusted after observation of the reservoir bag. The bag
should pulsate gently with each breath and should not
be either over- or underinflated. Introduction of 100 percent
oxygen for one to two minutes followed by titration of ni-
trous oxide in 10 percent intervals is recommended. During
nitrous oxide/oxygen analgesia/anxiolysis, the concentration
of nitrous oxide should not routinely exceed 50 percent.
Studies have demonstrated that gas concentrations dispensed
by the flow meter vary significantly from the end-expired
alveolar gas concentrations; it is the latter that is responsible
for the clinical effects. 28,29 To achieve sedation, clinicians
should keep the patient’s talking and mouth breathing to a
minimum, and the scavenging vacuum should not be so
strong as to prevent adequate ventilation of the lungs with
nitrous oxide.30 A review of records of patients undergoing
nitrous oxide-oxygen inhalation sedation demonstrated that
the typical patient requires from 30 to 40 percent nitrous
oxide to achieve ideal sedation.31 Nitrous oxide concentration
may be decreased during easier procedures (e.g., restorations)
and increased during more stimulating ones (e.g., extraction,
injection of local anesthetic). One study found that there
was no benefit to continuous administration of nitrous oxide
after profound anesthesia had been achieved. 32 During
treatment, it is important to continue the visual monitoring
of the patient’s respiratory rate and level of consciousness.
The effects of nitrous oxide largely are dependent on psycho-
logical reassurance.33 Therefore, it is important to continue
traditional behavior guidance techniques during treatment.
Once the nitrous oxide flow is terminated, 100 percent oxygen
should be administered until the patient has returned to
pretreatment status.34 The patient must return to pretreatment
responsiveness before discharge.
Monitoring
The response of patients to commands during procedures per-
formed with analgesia/anxiolysis serves as a guide to their level
of consciousness. Clinical observation of the patient must be
performed during any dental procedure. During nitrous oxide/
oxygen analgesia/anxiolysis, continual clinical observation of
the patient’s responsiveness, color, and respiratory rate and
BEST PRACTICES: USE OF NITROUS OXIDE
rhythm must be performed. Spoken responses provide an
indication that the patient is breathing.3 If any other pharma-
cologic agent is used in addition to nitrous oxide/oxygen and
a local anesthetic, monitoring guidelines for the appropriate
level of sedation must be followed.4
Adverse effects of nitrous oxide/oxygen inhalation
Nitrous oxide/oxygen analgesia/anxiolysis has an excellent
safety record. When administered by trained personnel on
carefully selected patients with appropriate equipment and
technique, nitrous oxide is a safe and effective agent for
providing pharmacological guidance of behavior in children.
Acute and chronic adverse effects of nitrous oxide on the
patient are rare.35 The most common adverse effects, occurring
in 0.5-1.2 percent of patients, are nausea and vomiting.36,37 A
higher incidence is noted with longer administration of nitrous
oxide/oxygen, fluctuations in nitrous oxide levels, lack of ti-
tration, increased concentrations of nitrous oxide, and a heavy
meal prior to administration of nitrous oxide.6,29,30 Fasting is
not required for patients undergoing nitrous oxide analgesia/
anxiolysis. The practitioner, however, may recommend that
only a light meal be consumed in the two hours prior to the
administration of nitrous oxide.38
Studies have reported negative outcomes associated with
use of nitrous oxide greater than 50 percent and as an anes-
thetic during major surgery.39,40 Although rare, silent regurgi-
tation and subsequent aspiration need to be considered with
nitrous oxide/oxygen sedation. The concern lies in whether
pharyngeal-laryngeal reflexes remain intact. This problem can
be avoided by not allowing the patient to go into an uncons-
cious state.41 Diffusion hypoxia can occur as a result of rapid
release of nitrous oxide from the blood stream into the alveoli,
thereby diluting the concentration of oxygen. This may lead
to headache, disorientation, and nausea and can be avoided
by administering 100 percent oxygen once the nitrous oxide
flow is terminated.6 While the standard recommendation is to
administer 100 percent oxygen at the end of the procedure,
several studies have questioned the necessity for this step in
nitrous oxide protocols in healthy patients.42-45
Documentation
Informed consent must be obtained from the parent and
documented in the patient’s record prior to administration
of nitrous oxide/oxygen. The practitioner should provide
instructions to the parent regarding pretreatment dietary pre-
cautions, if indicated. In addition, the patient’s record should
include indication for use of nitrous oxide/oxygen inhalation,
nitrous oxide dosage (i.e., percent nitrous oxide/oxygen and/
or flow rate), duration of the procedure, and post treatment
oxygenation procedure.
Facilities/personnel/equipment
All newly installed facilities for delivering nitrous oxide/
oxygen must be checked for proper gas delivery and fail-safe
function prior to use. Inhalation equipment must have the
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 355
BEST PRACTICES: USE OF NITROUS OXIDE
capacity for delivering 100 percent, and never less than 30
percent, oxygen concentration at a flow rate appropiate to the
child’s size. If nitrous oxide/oxygen delivery equipment capable
of delivering more than 70 percent nitrous oxide and less
than 30 percent oxygen is used, an inline oxygen analyzer
must be used. Additionally, inhalation equipment must have
a fail-safe system that is checked and calibrated regularly
according to the practitioner’s state laws and regulations. 46
The system components, including the reservoir bag, should
be inspected routinely for cracks, wear, and tears. If detected,
repairs should be made immediately. Pressure connections
should be tested for leaks when delivery system is turned
on and each time a tank is changed. Consult state and
federal guidelines regarding storage of compressed gas tanks.
Additional locks at the tanks or mixer/delivery level are
available from many manufacturers to deter individuals
from accessing nitrous oxide inappropriately.46 The equipment
must have an appropriate scavenging system to minimize
room air contamination and occupational risk.
The practitioner who utilizes nitrous oxide/oxygen analgesia/
anxiolysis for a pediatric dental patient shall possess appropri-
ate training and skills and have available the proper facilities,
personnel, and equipment to manage any reasonably foresee-
able emergency. The practitioner is responsible for managing
the potential complications associated with the intended level
of sedation and the next deeper level. Therefore, because
moderate sedation may occur, practitioners should have the
appropriate training and emergency equipment to manage
this. 4,34 Training and certification in basic life support are
required for all clinical personnel. These individuals should
participate in periodic review of the office’s emergency protocol,
the emergency drug cart, and simulated exercises to assure
proper emergency management response.
An emergency cart (kit) must be readily accessible. Emer-
gency equipment must be able to accommodate children of
all ages and sizes. It should include equipment to resuscitate
a nonbreathing, unconscious patient and provide continuous
support until trained emergency personnel arrive. A positive-
pressure oxygen delivery system capable of administering
greater than 90 percent oxygen at a 10 L/min flow for at least
60 minutes (650 L, “E” cylinder) must be available. When a
self-inflating bag valve mask device is used for delivering posi-
tive pressure oxygen, a 15 L/min flow is recommended. There
should be documentation that all emergency equipment and
drugs are checked and maintained on a regularly scheduled
basis.4 Where state law mandates equipment and facilities,
such statutes should supersede these recommendations.
Occupational safety
In the medical literature, long-term exposure to nitrous oxide
used as a general anesthetic has been linked to bone marrow
suppression and reproductive system disturbances.10,49-51 How-
ever, it has been shown that appropriate scavenging is effective
in reducing these reproductive system effects.21,52 In an effort
to reduce occupational health hazards associated with nitrous
356 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
oxide, the AAPD recommends exposure to ambient nitrous
oxide be minimized through the use of effective scavenging
systems and periodic evaluation and maintenance of the
delivery and scavenging systems.53-55 Clinicians should try to
minimize the patient’s talking and mouth breathing during
nitrous oxide administration to prevent expired gas from
contaminating the operatory.30
References
1. American Dental Association. Guideline for the use
of sedation and general anesthesia by dentists. 2016.
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Education%20and%20Careers/Files/ADA_Sedation_Use
_Guidelines”. Accessed June 29, 2018.
2. American Dental Association. Oral Health Topics –
Nitrous oxide: dental best practices for nitrous oxide-
oxygen. Available at: “https://www.ada.org/en/member
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29, 2018.
3. Apfelbaum JL, Gross JB, Connis RT, et al. Practice
guidelines for moderate procedural sedation and anal-
gesia 2018: A report by the American Society of
Anesthesiologists Task Force on Moderate Procedural
Sedation and Analgesia, the American Association of
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437-79.
4. Coté CJ, Wilson S, American Academy of Pediatric
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5. Groenbaek A, Svensson P, Vaeth M, Hansen I, Poulsen S.
A placebo-controlled, double-blind, crossover trial on
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Paediatr Dent 2014;24(1):69-75.
6. Paterson SA, Tahmassebi JF. Pediatric dentistry in the new
millennium: 3. Use of inhalation sedation in pediatric
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7. Saxen M. Pharmacologic management of patient be-
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Elsevier; 2016:9-18.
8. Emmanouil DE, Quock RM. Advances in understand-
ing the actions of nitrous oxide. Anesth Prog 2007;54
(1):9-18.
9. Sanders RDB, Weimann J, Maze M. Biologic effects
of nitrous oxide: A mechanistic and toxicologic review.
Anesthesiology 2008;109(4):707-22.
10. Foley J. A prospective study of the use of nitrous oxide
inhalation sedation for dental treatment in anxious
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11. Holyroyd I. Conscious sedation in pediatric dentistry:
A short review of the current UK guidelines and the
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Paediatr Anaesth 2008;18(1):13-7.
12. Lyratzopoulos G, Blain KM. Inhalation sedation with
nitrous oxide as an alternative to dental general anesthesia
for children. J Public Health Med 2003;25(4):303-12.
13. Wilson S, Gosnell E. Survey of American Academy of
Pediatric Dentistry on nitrous oxide and sedation: 20
years later. Pediatr Dent 2016;38(5):385-92.
14. Houpt M, Limb R, Livingston R. Clinical effects of
nitrous oxide conscious sedation in children. Pediatr
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15. Wilson S. Management of child patient behavior:
Quality of care, fear and anxiety, and the child patient.
J Endod 2013;39(3s):S73-S77.
16. Yasny J, White J. Environmental implications of anes-
thetic gases. Anesth Prog 2012;59(4):154-8.
17. Levering NJ, Welie JVM. Current status of nitrous oxide
as a behavior management practice routine in pediatric
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18. McGain F. Why anaesthetists should no longer use
nitrous oxide. Anaesth Intensive Care 2007;35(5):808-9.
19. Duncan GH, Moore P. Nitrous oxide and the dental
patient: A review of adverse reactions. J Am Dent Assoc
1984;108(2):213-9.
20. Clark MS, Brunick AL. N 2O and its interaction with
the body. In: Handbook of Nitrous Oxide and Oxygen
Sedation. 4th ed. St. Louis, Mo.: Elsevier Mosby; 2015:
90-8.
21. Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz
DA, Wilcox AJ. Nitrous oxide and spontaneous abortion
in female dental assistants. Am J Epidemiol 1995;141
(6):531-7.
22. Fleming P, Walker PO, Priest JR. Bleomycin therapy: A
contraindication to the use of nitrous oxide-oxygen
psychosedation in the dental office. Pediatr Dent 1988;
10(4):345-6.
23. Selzer R, Rosenblatt D, Laxova R, Hogan K. Adverse
effect of nitrous oxide in a child with 5, 10-methylene-
tetrahydrofolate reductase deficiency. N Engl J Med
2003;349(1):45-50.
24. Ogundipe O, Pearson MW, Slater NG, Adepegba T,
Westerdale N. Sickle cell disease and nitrous oxide-
induced neuropathy. Clin Lab Haematol 1999;21(6):
409-12.
25. Fish BM, Banerjee AR, Jennings CR, et al. Effect of
anaesthetic agents on tympanometry and middle-ear
effusions. J Laryngol Otol 2000;114(5):336-8.
26. Moss E, McDowall DG. ICP increase with 50% nitrous
oxide in oxygen in severe head injuries during controlled
ventilation. Br J Anaest 1979;51(8):757-61.
27. American Academy of Pediatric Dentistry. Oral health-
care for the pregnant adolescent. Pediatr Dent 2017;39
(6):221-8.
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28. Klein U, Robinson TJ, Allshouse A. End-expired nitrous
oxide concentrations compared to flowmeter settings
during operative dental treatment in children. Pediatr
Dent 2011;33(1):56-62.
29. Klein U, Bucklin BA, Poulton TJ, Bozinov D. Nitrous
oxide concentrations in the posterior nasopharynx during
administration by nasal mask. Pediatr Dent 2004;26(5):
410-6.
30. Malamed SF. Inhalation sedation: Techniques of admin-
istration. In: Sedation: A Guide to Patient Management.
6th ed. St. Louis, Mo.: Mosby Elsevier; 2018:227-52.
31. Malamed SF, Clark MS. Nitrous oxide-oxygen: A new
look at a very old technique. J Calif Dent Assoc 2003;
31(5):397-403.
32. Guelmann M, Brackett R, Beavers N, Primosch RE. Ef-
fect of continuous versus interrupted administration of
nitrous oxide-oxygen inhalation on behavior of anxious
pediatric dental patients: A pilot study. J Clin Pediatr
Dent 2012;37(1):77-82.
33. Clark MS, Brunick AL. N2O/O2 sedation in pediatric
dentistry. In: Handbook of Nitrous Oxide and Oxygen
Sedation. 4th ed. St. Louis, Mo.: Elsevier Mosby; 2015:
164-86.
34. Clark MS. Contemporary issues surrounding nitrous
oxide. In: Malamed SF, ed. Sedation: A Guide to Patient
Management. 6th ed. St. Louis, Mo.: Mosby Elsevier;
2018:253-63.
35. Donaldson D, Meechan JG. The hazards of chronic
exposure to nitrous oxide: An update. Br Dent J 1995;
178(3):95-100.
36. Kupietzky A, Tal E, Shapira J, Ram D. Fasting state and
episodes of vomiting in children receiving nitrous oxide
for dental treatment. Pediatr Dent 2008;30(5):414-9.
37. Galeotti A, Garret Bernardin A, D’Anto V, et al. Inhalation
conscious sedation with nitrous oxide and oxygen as alter-
native to general anesthesia in precooperative, fearful, and
disabled pediatric dental patients: A large survey on 688
working sessions. Biomed Res Int 2016;2016:7289310.
38. Hosey MT. UK National Clinical Guidelines in Paedi-
atric Dentistry. Managing anxious children: The use of
conscious sedation in paediatric dentistry. Int J Paediatr
Dent 2002;12(5):359-72.
39. Schmitt EL, Baum VC. Nitrous oxide in pediatric anes-
thesia: Friend or foe? Curr Opin Anaesthesiol 2008;21
(2):356-9.
40. Zeir JL, Doescher JS. Seizures temporarily associated with
nitrous oxide administration for pediatric procedural
sedation. J Child Neurol 2010;25(12):1517-20.
41. Hogue D, Ternisky M, Iranour B. The response to
nitrous oxide analgesia in children. ASDC J Dent Child
1971;38(2):129-33.
42. Dunn-Russell T, Adair S, Sams DR, Russell CM, Barenie
JT. Oxygen saturation and diffusion hypoxia in children
following nitrous oxide sedation. Ped Dent 1993;16(2):
88-92.
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43. Quarnstrom FC, Milgrom P, Bishop MJ, DeRouen TA.
Clinical study of diffusion hypoxia after nitrous oxide
analgesia. Anesth Prog 1991;38(1):21-3.
44. Khinda V, Bhuria P, Khinda P, Kallar S, Brar G. Com-
parative evaluation of diffusion hypoxia and psychomotor
skills with or without postsedation oxygenation following
administration of nitrous oxide in children undergoing
dental procedures: A clinical study. J Indian Soc Pedod
Prev Dent 2016;34(3):217-22.
45. Clark MS, Brunick AL. Anatomy and physiology of
respiration and airway management. In: Handbook of
Nitrous Oxide and Oxygen Sedation. 4th ed. St. Louis,
Mo.: Elsevier Mosby; 2015:84-6.
46. Donaldson M, Donaldson D, Quarnstrom F. Nitrous
oxide-oxygen administration: When safety features are
no longer safe. J Am Dental Assoc 2012;143(2):134-43.
47. Chrysikopoulou A, Matheson P, Miles M, Shey Z, Houpt
M. Effectiveness of two nitrous oxide scavenging nasal
hoods during routine pediatric dental treatment. Pediatr
Dent 2006;28(3):242-7.
48. Freilich MM, Alexander L, Sandor GKB, Judd P. Effec-
tiveness of 2 scavenger mask systems for reducing
exposure to nitrous oxide in a hospital-based pediatric
dental clinic: A pilot study. J Can Dent Assoc 2007;73
(7):615.
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49. Corcetti M, Serwint JR. Inhalants. Pediatr Rev 2008;
29(1):33-4.
50. Lehmberg J, Waldner M, Baethmann, Eberhard UHL.
Inflammatory response to nitrous oxide in the central
nervous system. Brain Res 2008;1246:88-95.
51. Luhmann JD, Kennedy RM. Nitrous oxide in the pedi-
atric emergency department. Clin Pediatr Emerg Med
2000;1(4):285-9.
52. Rowland AS, Baird DD, Shore DL, et al. Reduced fertility
among women employed as dental assistants exposed to
high levels of nitrous oxide. N Engl J Med 1992;327(14):
993-7.
53. American Academy of Pediatric Dentistry. Policy on
minimizing occupational health hazards associated with
nitrous oxide. Pediatr Dent 2018;40(6):104-5.
54. Rademaker AM, McGlothlin JD, Moenning JE, Bagnoli
M, Carlson G, Griffin C. Evaluation of two nitrous oxide
scavenging systems using infrared thermography to
visualize and control emissions. J Am Dent Assoc 2009;
140(2):190-9.
55. National Institute for Occupational Safety and Health.
Control of nitrous oxide in dental operatories. 1996.
Available at: “https://www.cdc.gov/niosh/docs/hazard
control/hc3.html”. Accessed July 6, 2018.
 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
sedation for diagnostic and therapeutic procedures. Pediatr Dent
Latest Revision 2019;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
performed on pediatric patients outside of the traditional
operating room setting has increased in the past several decades.
As a consequence of this change and the increased awareness
of the importance of providing analgesia and anxiolysis, the
need for sedation for procedures in physicians’ offices, dental
offices, subspecialty procedure suites, imaging facilities, emer-
gency departments, other inpatient hospital settings, and
ambulatory surgery centers also has increased markedly.1-52 In
recognition of this need for both elective and emergency use
of sedation in nontraditional settings, the American Academy
of Pediatrics (AAP) and the American Academy of Pediatric
Dentistry (AAPD) have published a series of guidelines for the
monitoring and management of pediatric patients during and
after sedation for a procedure.53-58 The purpose of this updated
report is to unify the guidelines for sedation used by medical
and dental practitioners; to add clarifications regarding moni-
toring modalities, particularly regarding continuous expired
carbon dioxide measurement; to provide updated information
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
Copyright © 2019 by American Academy of Pediatrics and American Academy of
Pediatric Dentistry. All rights reserved. This report is being published concurrently
in Pediatrics 2019;143(6):e20191000. The articles are identical. Either citation can be
used when citing this article.
* The 2019 revision was limited to Deep sedation/General anesthesia—Personnel.
Commission, the American Society of Anesthesiologists
(ASA), and the AAPD.56,57,59-61
This revised statement reflects the current understanding of
appropriate monitoring needs of pediatric patients both during
and after sedation for a procedure.3,4,11,18,20,21,23,24,33,39,41,44,47,51,62-73
The monitoring and care outlined may be exceeded at any
time on the basis of the judgment of the responsible practi-
tioner. Although intended to encourage high-quality patient
care, adherence to the recommendations in this document
cannot guarantee a specific patient outcome. However, struc-
tured sedation protocols designed to incorporate these safety
principles have been widely implemented and shown to reduce
morbidity. 11,23,24,27,30-33,35,39,41,44,47,51,74-84 These practice recom-
mendations are proffered with the awareness that, regardless of
the intended level of sedation or route of drug administration,
the sedation of a pediatric patient represents a continuum and
may result in respiratory depression, laryngospasm, impaired
airway patency, apnea, loss of the patient’s protective airway
reflexes, and cardiovascular instability.38,43,45,47,48,59,62,63,85-112
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy of
Pediatric Dentistry. APLS: Advanced Pediatric Life Support. ASA:
American Society of Anesthesiologists. BIS: Bispectral index. CPAP:
Continuous positive airway pressure. ECG: Electrocardiography. EEG:
Electroencephalogram / electroencephalography. EMS: Emergency
medical services. LMA: Laryngeal mask airway. MRI: Magnetic
resonance imaging. OSA: Obstructive sleep apnea. PALS: Pediatric
advanced life support.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 359

BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION

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

360 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


Figure 2. Suggested management of laryngospasm.
Figure 3. Suggested management of apnea.
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
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-
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
obstruction. 62,63,242 In particular, promethazine (Phenergan;
Wyeth Pharmaceuticals, Philadelphia, Pa.) has a “black box
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 361
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
warning” regarding fatal respiratory depression in children
younger than 2 years. 243 Although the liquid formulation of
chloral hydrate is no longer commercially available, some hos-
pital pharmacies now are compounding their own formulations.
Low-dose chloral hydrate (10–25 mg/kg), in combination with
other sedating medications, is used commonly in pediatric
dental practice.
General Guidelines
Candidates
Patients who are in ASA classes I and II are frequently considered
appropriate candidates for minimal, moderate, or deep sedation
(see Supplemental Appendix 2). Children in ASA classes III
and IV, children with special needs, and those with anatomic
airway abnormalities or moderate to severe tonsillar hyper-
trophy present issues that require additional and individual con-
sideration, particularly for moderate and deep sedation.68,244-249
Practitioners are encouraged to consult with appropriate sub-
specialists and/or an anesthesiologist for patients at increased
risk ofexperiencing adverse sedation events because of their
underlying medical/surgical conditions.
Responsible person
The pediatric patient shall be accompanied to and from the
treatment facility by a parent, legal guardian, or other respon-
sible person. It is preferable to have 2 adults accompany
children who are still in car safety seats if transportation to
and from a treatment facility is provided by 1 of the adults.250
Facilities
The practitioner who uses sedation must have immediately avail-
able facilities, personnel, and equipment to manage emergency
and rescue situations. The most common serious complications
of sedation involve compromise of the airway or depressed re-
spirations resulting in airway obstruction, hypoventilation,
laryngospasm, hypoxemia, and apnea. Hypotension and cardio-
pulmonary arrest may occur, usually from the inadequate
recognition and treatment of respiratory compromise.42,48,92,97,
99,125,132,139-155 Other rare complications also may include seizures,
vomiting, and allergic reactions. Facilities providing pediatric
sedation should monitor for, and be prepared to treat, such
complications.
Back-up emergency services
A protocol for immediate access to back-up emergency services
shall be clearly outlined. For nonhospital facilities, a protocol
for the immediate activation of the EMS system for life-
threatening complications must be established and maintained.44
It should be understood that the availability of EMS does not
replace the practitioner’s responsibility to provide initial rescue
for life-threatening complications.
On-site monitoring, rescue drugs, and equipment
An emergency cart or kit must be immediately accessible. This
cart or kit must contain the necessary ageand size-appropriate
equipment (oral and nasal airways, bag-valve-mask device,
LMAs or other supraglottic devices, laryngoscope blades,
tracheal tubes, face masks, blood pressure cuffs, intravenous
catheters, etc) to resuscitate a nonbreathing and unconscious
child. The contents of the kit must allow for the provision of
continuous life support while the patient is being transported
to a medical/dental facility or to another area within the facil-
ity. All equipment and drugs must be checked and maintained
362 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
on a scheduled basis (see Supplemental Appendices 3 and 4
for suggested drugs and emergency life support equipment
to consider before the need for rescue occurs). Monitoring
devices, such as electrocardiography (ECG) machines, pulse
oximeters with size-appropriate probes, end-tidal carbon
dioxide monitors, and defibrillators with sizeappropriate
patches/paddles, must have a safety and function check on a
regular basis as required by local or state regulation. The use
of emergency checklists is recommended, and these should
be immediately available at all sedation locations; they can be
obtained from http://www.pedsanesthesia.org/.
Documentation
Documentation prior to sedation shall include, but not be
limited to, the following recommendations:
1. Informed consent: The patient record shall document
that appropriate informed consent was obtained accord-
ing to local, state, and institutional requirements.251,252
2. Instructions and information provided to the responsible
person: The practitioner shall provide verbal and/or writ-
ten instructions to the responsible person. Information
shall include objectives of the sedation and anticipated
changes in behavior during and after sedation.163,253-255 Spe-
cial instructions shall be given to the adult responsible for
infants and toddlers who will be transported home in a
car safety seat regarding the need to carefully observe the
child’s head position to avoid airway obstruction. Tran-
sportation in a car safety seat poses a particular risk for
infants who have received medications known to have a
long half-life, such as chloral hydrate, intramuscular pento-
barbital, or phenothiazine because deaths after procedural
sedation have been reported.62,63,238,242,256,257 Consideration
for a longer period of observation shall be given if the
responsible person’s ability to observe the child is limited
(e.g., only 1 adult who also has to drive). Another indica-
tion for prolonged observation would be a child with an
anatomic airway problem, an underlying medical condition
such as significant obstructive sleep apnea (OSA), or a
former preterm infant younger than 60 weeks’ post-
conceptional age. A 24-hour telephone number for the
practitioner or his or her associates shall be provided to
all patients and their families. Instructions shall include
limitations of activities and appropriate dietary precautions.
Dietary precautions
Agents used for sedation have the potential to impair protective
airway reflexes, particularly during deep sedation. Although
a rare occurrence, pulmonary aspiration may occur if the
child regurgitates and cannot protect his or her airway.95,127,258
Therefore, the practitioner should evaluate preceding food
and fluid intake before administering sedation. It is likely that
the risk of aspiration during procedural sedation differs from
that during general anesthesia involving tracheal intubation
or other airway manipulations. 259,260 However, the absolute
risk of aspiration during elective procedural sedation is not
yet known; the reported incidence varies from ~1 in 825 to
~1 in 30,037.95,127,129,173,244,261 Therefore, standard practice for
fasting before elective sedation generally follows the same
guidelines as for elective general anesthesia; this requirement is
particularly important for solids, because aspiration of clear
gastric contents causes less pulmonary injury than aspiration
of particulate gastric contents.262,263

For emergency procedures in children undergoing general
anesthesia, the reported incidence of pulmonary aspiration of
gastric contents from 1 institution is ~1 in 373 compared with
~1 in 4544 for elective anesthetics.262 Because there are few
published studies with adequate statistical power to provide
guidance to the practitioner regarding the safety or risk of pul-
monary aspiration of gastric contents during procedural se-
dation,95,127,129,173,244,259-261,264-268 it is unknown whether the risk
of aspiration is reduced when airway manipulation is not
performed/ anticipated (e.g., moderate sedation). However, if a
deeply sedated child requires intervention for airway obstruc-
tion, apnea, or laryngospasm, there is concern that these rescue
maneuvers could increase the risk of pulmonary aspiration of
gastric contents. For children requiring urgent/emergent se-
dation who do not meet elective fasting guidelines, the risks
of sedation and possible aspiration are as-yet unknown and
must be balanced against the benefits of performing the
procedure promptly. For example, a prudent practitioner would
be unlikely to administer deep sedation to a child with a minor
condition who just ate a large meal; conversely, it is not justi-
fiable to withhold sedation/analgesia from the child in signi-
ficant pain from a displaced fracture who had a small snack a
few hours earlier. Several emergency department studies have
reported a low to zero incidence of pulmonary aspiration
despite variable fasting periods260,264,268; however, each of these
reports have, for the most part, clearly balanced the urgency
of the procedure with the need for and depth of sedation.268,269
Although emergency medicine studies and practice guidelines
generally support a less restrictive approach to fasting for brief
urgent/ emergent procedures, such as care of wounds, joint
dislocation, chest tube placement, etc, in healthy children,
further research in many thousands of patients would be de-
sirable to better define the relationships between various fasting
intervals and sedation complications.262-270
Before elective sedation
Children undergoing sedation for elective procedures generally
should follow the same fasting guidelines as those for general
Table 1. APPROPRIATE INTAKE OF FOOD AND LIQUIDS BEFORE
ELECTIVE SEDATION
Ingested material Minimum
fasting period (h)
Clear liquids: water, fruit juices without pulp, carbonated beverages,
2
clear tea, black coffee
Human milk 4 factors that may warrant additional consultation before
Infant formula
6
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
Light meal: a light meal typically consists of toast and clear liquids. 6
Meals that include fried or fatty foods or meat may prolong
gastric emptying time. Both the amount and type of foods
ingested must be considered when determining an appropriate
fasting period.
Source: American Society of Anesthesiologists. Practice guidelines for preoperative fasting
and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application
to healthy patients undergoing elective procedures. An updated report by the American
Society of Anesthesiologists Committee on Standards and Practice Parameters. Available at:
“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
possible aspiration; see also Mace et al.272 and Green et al.273
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
anesthesia (Table 1).271 It is permissible for routine necessary
medications (e.g., antiseizure medications) to be taken with a
sip of clear liquid or water on the day of the procedure.
For the emergency patient
The practitioner must always balance the possible risks of se-
dating nonfasted patients with the benefits of and necessity for
completing the procedure. In particular, patients with a history
of recent oral intake or with other known risk factors, such
as trauma, decreased level of consciousness, extreme obesity
(BMI ≥95% for age and sex), pregnancy, or bowel motility
dysfunction, require careful evaluation before the administration
of sedatives. When proper fasting has not been ensured, the
increased risks of sedation must be carefully weighed against its
benefits, and the lightest effective sedation should be used. In
this circumstance, additional techniques for achieving analgesia
and patient cooperation, such as distraction, guided imagery,
video games, topical and local anesthetics, hematoma block or
nerve blocks, and other techniques advised by child life spe-
cialists, are particularly helpful and should be considered.29,49,
182-201,274,275
The use of agents with less risk of depressing protective
airway reflexes, such as ketamine, or moderate sedation, which
would also maintain protective reflexes, may be preferred.276
Some emergency patients requiring deep sedation (e.g., a trau-
ma patient who just ate a full meal or a child with a bowel
obstruction) may need to be intubated to protect their airway
before they can be sedated.
Use of immobilization devices (Protective stabilization)
Immobilization devices, such as papoose boards, must be ap-
plied in such a way as to avoid airway obstruction or chest
restriction.277-281 The child’s head position and respiratory ex-
cursions should be checked frequently to ensure airway patency.
If an immobilization device is used, a hand or foot should be
kept exposed, and the child should never be left unattended.
If sedating medications are administered in conjunction with
an immobilization device, monitoring must be used at a level
consistent with the level of sedation achieved.
Documentation at the time of sedation
1. Health evaluation: Before sedation, a health evaluation
shall be performed by an appropriately licensed practi-
tioner and reviewed by the sedation team at the time of
treatment for possible interval changes.282 The purpose of
this evaluation is not only to document baseline status
but also to determine whether the patient has specific risk
sedation. This evaluation also facilitates the identification
of patients who will require more advanced airway or car-
or types of medications used for procedural sedation.
An important concern for the practitioner is the wide-
spread use of medications that may interfere with drug
absorption or metabolism and therefore enhance or shorten
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
the cytochrome P450 system, resulting in prolonged drug
effect and altered (increased or decreased) blood drug con-
centrations (midazolam, cyclosporine, tacrolimus). 283-292
Kava may increase the effects of sedatives by potentiating
g-aminobutyric acid inhibitory neurotransmission and
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 363
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
may increase acetaminophen-induced liver toxicity. 293-295
Valerian may itself produce sedation that apparently is
mediated through the modulation of g-aminobutyric acid
neurotransmission and receptor function.291,296-299 Drugs
such as erythromycin, cimetidine, and others may also
inhibit the cytochrome P450 system, resulting in prolonged
sedation with midazolam as well as other medications
competing for the same enzyme systems. 300-304 Medica-
tions used to treat HIV infection, some anticonvulsants,
immunosuppressive drugs, and some psychotropic medica-
tions (often used to treat children with autism spectrum
disorder) may also produce clinically important drug-drug
interactions. 305-314 Therefore, a careful drug history is a
vital part of the safe sedation of children. The practitioner
should consult various sources (a pharmacist, textbooks,
online services, or handheld databases) for specific in-
formation on drug interactions.315-319 The US Food and
Drug Administration issued a warning in February 2013
regarding the use of codeine for postoperative pain man-
agement in children undergoing tonsillectomy, particularly
those with OSA. The safety issue is that some children
have duplicated cytochromes that allow greater than ex-
pected conversion of the prodrug codeine to morphine,
thus resulting in potential overdose; codeine should be
avoided for postprocedure analgesia.320-324
The health evaluation should include the following:
• age and weight (in kg) and gestational age at birth
(preterm infants may have associated sequelae such as
apnea of prematurity); and
• health history, including (1) food and medication aller-
gies and previous allergic or adverse drug reactions; (2)
medication/drug history, including dosage, time, route,
and site of administration for prescription, over-the-
counter, herbal, or illicit drugs; (3) relevant diseases,
physical abnormalities (including genetic syndromes),
neurologic impairments that might increase the potential
for airway obstruction, obesity, a history of snoring or
OSA, 325-328 or cervical spine instability in Down syn-
drome, Marfan syndrome, skeletal dysplasia, and other
conditions; (4) pregnancy status (as many as 1% of
menarchal females presenting for general anesthesia at
children’s hospitals are pregnant)329-331 because of concerns
for the potential adverse effects of most sedating and
anesthetic drugs on the fetus 329,332-338; (5) history of
prematurity (may be associated with subglottic stenosis
or propensity to apnea after sedation); (6) history of any
seizure disorder; (7) summary of previous relevant hospi-
talizations; (8) history of sedation or general anesthesia
and any complications or unexpected responses; and (9)
relevant family history, particularly related to anesthesia
(e.g., muscular dystrophy, malignant hyperthermia,
pseudocholinesterase deficiency).
The review of systems should focus on abnormalities of
cardiac, pulmonary, renal, or hepatic function that might alter
the child’s expected responses to sedating/ analgesic medica-
tions. A specific query regarding signs and symptoms of
sleep-disordered breathing and OSA may be helpful. Children
with severe OSA who have experienced repeated episodes of
desaturation will likely have altered mu receptors and be
analgesic at opioid levels one-third to one-half those of a child
without OSA325-328,339,340; lower titrated doses of opioids should
364 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
be used in this population. Such a detailed history will help to
determine which patients may benefit from a higher level of
care by an appropriately skilled health care provider, such as
an anesthesiologist. The health evaluation should also include:
• vital signs, including heart rate, blood pressure, respira-
tory rate, room air oxygen saturation, and temperature
(for some children who are very upset or noncooperative,
this may not be possible and a note should be written
to document this circumstance);
• physical examination, including a focused evaluation of
the airway (tonsillar hypertrophy, abnormal anatomy
[e.g., mandibular hypoplasia], high Mallampati score
[i.e., ability to visualize only the hard palate or tip of
the uvula]) to determine whether there is an increased
risk of airway obstruction74,341-344;
• physical status evaluation (ASA classification [see
Appendix 2]); and
• name, address, and telephone number of the child’s
home or parent’s, or caregiver’s cell phone; additional
information such as the patient’s personal care provider
or medical home is also encouraged.
For hospitalized patients, the current hospital record may
suffice for adequate documentation of presedation health;
however, a note shall be written documenting that the chart
was reviewed, positive findings were noted, and a management
plan was formulated. If the clinical or emergency condition of
the patient precludes acquiring complete information before
sedation, this health evaluation should be obtained as soon as
feasible.
2. Prescriptions. When prescriptions are used for sedation, a
copy of the prescription or a note describing the content
of the prescription should be in the patient’s chart along
with a description of the instructions that were given to the
responsible person. Prescription medications intended to
accomplish procedural sedation must not be administered
without the safety net of direct supervision by trained
medical/dental personnel. The administration of sedating
medications at home poses an unacceptable risk, particu-
larly for infants and preschool-aged children traveling in
car safety seats because deaths as a result of this practice
have been reported.63,257
Documentation during treatment
The patient’s chart shall contain a time-based record that includes
the name, route, site, time, dosage/kilogram, and patient effect
of administered drugs. Before sedation, a “time out” should
be performed to confirm the patient’s name, procedure to be
performed, and laterality and site of the procedure.59 During
administration, the inspired concentrations of oxygen and in-
halation sedation agents and the duration of their administra-
tion shall be documented. Before drug administration, special
attention must be paid to the calculation of dosage (i.e., mg/kg);
for obese patients, most drug doses should likely be adjusted
lower to ideal body weight rather than actual weight.345 When
a programmable pump is used for the infusion of sedating
medications, the dose/kilogram per minute or hour and the
child’s weight in kilograms should be double-checked and
confirmed by a separate individual. The patient’s chart shall
contain documentation at the time of treatment that the
patient’s level of consciousness and responsiveness, heart rate,
blood pressure, respiratory rate, expired carbon dioxide values,

and oxygen saturation were monitored. Standard vital signs
should be further documented at appropriate intervals during
recovery until the patient attains predetermined discharge criteria
(see Appendix 1). A variety of sedation scoring systems are
available that may aid this process.212,238,346-348 Adverse events
and their treatment shall be documented.
Documentation after treatment
A dedicated and properly equipped recovery area is recom-
mended (see Appendices 3 and 4). The time and condition of
the child at discharge from thetreatment area or facility shall
be documented, which should include documentation that the
child’s level of consciousness and oxygen saturation in room
air have returned to a state that is safe for discharge by recog-
nized criteria (see Appendix 1). Patients receiving supplemental
oxygen before the procedure should have a similar oxygen
need after the procedure. Because some sedation medications
are known to have a long half-life and may delay a patient’s
complete return to baseline or pose the risk of reseda-
tion62,104,256,349,350 and because some patients will have complex
multiorgan medical conditions, a longer period of observation
in a less intense observation area (e.g., a step-down observation
area) before discharge from medical/dental supervision may
be indicated.239 Several scales to evaluate recovery have been
devised and validated. 212,346-348,351,352 A simple evaluation tool
may be the ability of the infant or child to remain awake for at
least 20 minutes when placed in a quiet environment.238
Continuous quality improvement
The essence of medical error reduction is a careful examination
of index events and root-cause analysis of how the event could
be avoided in the future.353-359 Therefore, each facility should
maintain records that track all adverse events and significant
interventions, such as desaturation; apnea; laryngospasm; need
for airway interventions, including the need for placement of
supraglottic devices such as an oral airway, nasal trumpet, or
LMA; positive-pressure ventilation; prolonged sedation; un-
anticipated use of reversal agents; unplanned or prolonged
hospital admission; sedation failures; inability to complete the
procedure; and unsatisfactory sedation, analgesia, or anxiolysis.360
Such events can then be examined for the assessment of risk
reduction and improvement in patient/family satisfaction.
Preparation for sedation procedures
Part of the safety net of sedation is using a systematic approach
so as to not overlook having an important drug, piece of
equipment, or monitor immediately available at the time of
a developing emergency. To avoid this problem, it is helpful
to use an acronym that allows the same setup and checklist
for every procedure. A commonly used acronym useful in
planning and preparation for a procedure is SOAPME, which
represents the following:
S = Size-appropriate suction catheters and a functioning suc-
tion apparatus (e.g., Yankauer-type suction)
O = an adequate Oxygen supply and functioning flow meters
or other devices to allow its delivery
A = size-appropriate Airway equipment (e.g., bag-valve-mask
or equivalent device [functioning]), nasopharyngeal and
oropharyngeal airways, LMA, laryngoscope blades (checked
and functioning), endotracheal tubes, stylets, face mask
P = Pharmacy: all the basic drugs needed to support life
during an emergency, including antagonists as indicated
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
M = Monitors: functioning pulse oximeter with size-appropriate
oximeter probes,361,362 end-tidal carbon dioxide monitor,
and other monitors as appropriate for the procedure
(e.g., noninvasive blood pressure, ECG, stethoscope)
E = special Equipment or drugs for a particular case (e.g.,
defibrillator)
Specific guidelines for intended level of sedation
Minimal sedation
Minimal sedation (old terminology, “anxiolysis”) is a drug-
induced state during which patients respond normally to verbal
commands. Although cognitive function and coordination
may be impaired, ventilatory and cardiovascular functions are
unaffected. Children who have received minimal sedation
generally will not require more than observation and intermittent
assessment of their level of sedation. Some children will become
moderately sedated despite the intended level of minimal
sedation; should this occur, then the guidelines for moderate
sedation apply.85,363
Moderate sedation
Moderate sedation (old terminology, “conscious sedation” or
“sedation/ analgesia”) is a drug-induced depression of conscious-
ness during which patients respond purposefully to verbal
commands or after light tactile stimulation. No interventions
are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually
maintained. The caveat that loss of consciousness should be
unlikely is a particularly important aspect of the definition of
moderate sedation; drugs and techniques used should carry a
margin of safety wide enough to render unintended loss of cons-
ciousness unlikely. Because the patient who receives moderate
sedation may progress into a state of deep sedation and obtun-
dation, the practitioner should be prepared to increase the level
of vigilance corresponding to what is necessary for deep sedation.85
Personnel
The practitioner. The practitioner responsible for the treatment
of the patient and/or the administration of drugs for sedation
must be competent to use such techniques, to provide the level
of monitoring described in these guidelines, and to manage
complications of these techniques (i.e., to be able to rescue
the patient). Because the level of intended sedation may be ex-
ceeded, the practitioner must be sufficiently skilled to rescue
a child with apnea, laryngospasm, and/or airway obstruction,
including the ability to open the airway, suction secretions,
provide CPAP, and perform successful bag-valve-mask venti-
lation should the child progress to a level of deep sedation.
Training in, and maintenance of, advanced pediatric airway
skills is required (e.g., pediatric advanced life support [PALS]);
regular skills reinforcement with simulation is strongly en-
couraged.79,80,128,130,217-220,364
Support personnel. The use of moderate sedation shall include
the provision of a person, in addition to the practitioner,
whose responsibility is to monitor appropriate physiologic
parameters and to assist in any supportive or resuscitation mea-
sures, if required. This individual may also be responsible for
assisting with interruptible patient-related tasks of short
duration, such as holding an instrument or troubleshooting
equipment.60 This individual should be trained in and capable
of providing advanced airway skills (e.g., PALS). The support
person shall have specific assignments in the event of an
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 365
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
emergency and current knowledge of the emergency cart
inventory. The practitioner and all ancillary personnel should
participate in periodic reviews, simulation of rare emergencies,
and practice drills of the facility’s emergency protocol to ensure
proper function of the equipment and coordination of staff roles
in such emergencies.133,365-367 It is recommended that at least
1 practitioner be skilled in obtaining vascular access in children.
Monitoring and documentation
Baseline. Before the administration of sedative medications, a
baseline determination of vital signs shall be documented. For
some children who are very upset or uncooperative, this may
not be possible, and a note should be written to document this
circumstance.
During the procedure. The physician/dentist or his or her
designee shall document the name, route, site, time of admin-
istration, and dosage of all drugs administered. If sedation is
being directed by a physician who is not personally administering
the medications, then recommended practice is for the qualified
health care provider administering the medication to confirm the
dose verbally before administration. There shall be continuous
monitoring of oxygensaturation and heart rate; when bidirec-
tional verbal communication between the provider and patient
is appropriate and possible (i.e., patient is developmentally able
and purposefully communicates), monitoring of ventilation by
(1) capnography (preferred) or (2) amplified, audible pretracheal
stethoscope (e.g., Bluetooth technology) 368-371 or precordial
stethoscope is strongly recommended. If bidirectional verbal
communication is not appropriate or not possible, monitoring
of ventilation by capnography (preferred), amplified, audible
pretracheal stethoscope, or precordial stethoscope is required.
Heart rate, respiratory rate, blood pressure, oxygen saturation, and
expired carbon dioxide values should be recorded, at minimum,
every 10 minutes in a time-based record. Note that the exact
value of expired carbon dioxide is less important than simple
assessment of continuous respiratory gas exchange. In some
situations in which there is excessive patient agitation or lack of
cooperation or during certain procedures such as bronchoscopy,
dentistry, or repair of facial lacerations capnography may not be
feasible, and this situation should be documented. For unco-
operative children, it is often helpful to defer the initiation of
capnography until the child becomes sedated. Similarly, the
stimulation of blood pressure cuff inflation may cause arousal
or agitation; in such cases, blood pressure monitoring may be
counterproductive and may be documented at less frequent
intervals (e.g., 10–15 minutes, assuming the patient remains
stable, well oxygenated, and well perfused). Immobilization de-
vices (protective stabilization) should be checked to prevent
airway obstruction or chest restriction. If a restraint device is
used, a hand or foot should be kept exposed. The child’s head po-
sition should be continuously assessed to ensure airway patency.
After the procedure. The child who has received moderate se-
dation must be observed in a suitably equipped recovery area,
which must have a functioning suction apparatus as well as the
capacity to deliver 90% oxygen and positive-pressure ventilation
(bag-valve mask) with an adequate oxygen capacity as well as
age- and size-appropriate rescue equipment and devices. The
patient’s vital signs should be recorded at specific intervals (e.g.,
every 10–15 minutes). If the patient is not fully alert, oxygen
saturation and heart rate monitoring shall be used continuously
until appropriate discharge criteria are met (see Appendix 1).
366 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Because sedation medications with a long half-life may delay
the patient’s complete return to baseline or pose the risk of
resedation, some patients might benefit from a longer period
of less intense observation (e.g., a step-down observation area
where multiple patients can be observed simultaneously) before
discharge from medical/dental supervision (see section entitled
“Documentation Before Sedation” above). 62,256,349,350 A simple
evaluation tool may be the ability of the infant or child to
remain awake for at least 20 minutes when placed in a quiet
environment. 238 Patients who have received reversal agents,
such as flumazenil or naloxone, will require a longer period of
observation, because the duration of the drugs administered may
exceed the duration of the antagonist, resulting in re-sedation.
Deep sedation/General anesthesia
“Deep sedation” (“deep sedation/ analgesia”) is a drug-induced
depression of consciousness during which patients cannot be
easily aroused but respond purposefully after repeated verbal
or painful stimulation (e.g., purposefully pushing away the
noxious stimuli). Reflex withdrawal from a painful stimulus is
not considered a purposeful response and is more consistent
with a state of general anesthesia. The ability to independently
maintain ventilatory function may be impaired. Patients may
require assistance in maintaining a patent airway, and sponta-
neous ventilation may be inadequate. Cardiovascular function is
usually maintained. A state of deep sedation may be accompa-
nied by partial or complete loss of protective airway reflexes.
Patients may pass from a state of deep sedation to the state of
general anesthesia. In some situations, such as during MRI, one
is not usually able to assess responses to stimulation, because
this would defeat the purpose of sedation, and one should
assume that such patients are deeply sedated.
“General anesthesia” is a drug-induced loss of conscious-
ness during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in
maintaining a patent airway, and positive-pressure ventilation
may be required because of depressed spontaneous ventilation
or drug-induced depression of neuromuscular function. Car-
diovascular function may be impaired.
Personnel
During deep sedation and/or general anesthesia of a pediatric
patient in a dental facility, there must be at least 2 individu-
als present with the patient throughout the procedure. These
2 individuals must have appropriate training and up-to-date
certification in patient rescue, as delineated below, including
drug administration and PALS or Advanced Pediatric Life
Support (APLS). One of these 2 must be an independent
observer who is independent of performing or assisting with
the dental procedure. This individual’s sole responsibility is to
administer drugs and constantly observe the patient’s vital signs,
depth of sedation, airway patency, and adequacy of ventilation.
The independent observer must, at a minimum, be trained in
PALS (or APLS) and capable of managing any airway, venti-
latory, or cardiovascular emergency event resulting from the
deep sedation and/or general anesthesia. The independent
observer must be trained and skilled to establish intravenous
access and draw up and administer rescue medications. The
independent observer must have the training and skills to
rescue a nonbreathing child; a child with airway obstruction; or
a child with hypotension, anaphylaxis, or cardiorespiratory arrest,
including the ability to open the airway, suction secretions,

provide CPAP, insert supraglottic devices (oral airway, nasal
trumpet, or laryngeal mask airway), and perform successful
bag-valve-mask ventilation, tracheal intubation, and cardiopul-
monary resuscitation. The independent observer in the dental
facility, as permitted by state regulation, must be 1 of the
following: a physician anesthesiologist, a certified registered
nurse anesthetist, a second oral surgeon, or a dentist anesthe-
siologist. The second individual, who is the practitioner in the
dental facility performing the procedure, must be trained in
PALS (or APLS) and capable of providing skilled assistance
to the independent observer with the rescue of a child experi-
encing any of the adverse events described above.
Table 2. COMPARISON OF MODERATE AND DEEP SEDATION EQUIPMENT
AND PERSONNEL REQUIREMENTS
Moderate sedation Deep sedation
Personnel An observer who will monitor the An independent observer whose
patient but who may also assist only responsibility is to continu-
with interruptible tasks; should be ously monitor the patient; trained
trained in PALS in PALS
Responsible practitioner Skilled to rescue a child with apnea, Skilled to rescue a child with apnea,
laryngospasm, and/or airway ob-
struction including the ability to
open the airway, suction secretions,
provide CPAP, and perform suc-
cessful bag-valve-mask ventilation;
recommended that at least 1 prac-
titioner should be skilled in ob-
taining vascular access in children;
trained in PALS
Monitoring Pulse oximetry
ECG recommended
Heart rate
Blood pressure
Respiration
Capnography recommended
Other equipment Suction equipment, adequate oxy-
gen source/supply
Documentation Name, route, site, time of adminis-
tration, and dosage of all drugs ad-
ministered
Continuous oxygen saturation, heart
rate, and ventilation (capnography
recommended); parameter s
recorded every 10 minutes
Emergency checklists Recommended
Rescue car t properly Required
s t o c ke d w i t h r e s c u e
drugs and age- and size-
appropriate equipment
(see Appendices 3 and 4)
Dedicated recovery area Recommended; initial recording
with rescue cart properly of vital signs may be needed at
s t o c ke d w i t h r e s c u e least every 10 minutes until the
drugs and age- and size- child begins to awaken, then re-
appropriate equipment cording intervals may be increased
(see Appendices 3 and 4)
and dedicated recovery
p e r s o n n e l; a d e q u a te
oxygen supply
Discharge criteria See Appendix 1
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
During deep sedation and/or general anesthesia of a
pediatric patient in a hospital or surgicenter setting, at least 2
individuals must be present with the patient throughout the
procedure with skills in patient rescue and up-to-date PALS
(or APLS) certification, as delineated above. One of these indi-
viduals may either administer drugs or direct their adminis-
tration by the skilled independent observer. The skills of the
individual directing or administering sedation and/or anesthesia
medications must include those described in the previous
paragraph. Providers who may fulfill the role of the skilled
independent observer in a hospital or surgicenter, as permitted
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
the requisite licensure, training, and competencies;
a certified registered nurse anesthetist or certified
anesthesiology assistant; or a nurse with advanced
emergency management skills, such as several
years of experience in the emergency department,
pediatric recovery room, or intensive care setting
(i.e., nurses who are experienced with assisting the
individual administering or directing sedation with
patient rescue during life-threatening emergencies).
laryngospasm, and/or airway ob-
struction, including the ability to
open the airway, suction secretions, Equipment
provide CPAP, perform successful In addition to the equipment needed for moderate
bag-valve-mask ventilation, tra-
cheal intubation, and cardiopulmo- sedation, an ECG monitor and a defibrillator for
nary resuscitation; training in PALS use in pediatric patients should be readily available.
is required; at least 1 practitioner
skilled in obtaining vascular access
in children immediately available Vascular access
Patients receiving deep sedation should have an
Pulse oximetry intravenous line placed at the start of the proce-
ECG required dure or have a person skilled in establishing vascular
Heart rate
Blood pressure
access in pediatric patients immediately available.
Respiration
Capnography required Monitoring
A competent individual shall observe the patient
Suction equipment, adequate oxygen continuously. Monitoring shall include all param-
source/supply, defibrillator required
eters described for moderate sedation. Vital signs,
Name, route, site, time of adminis- including heart rate, respiratory rate, blood pressure,
tration, and dosage of all drugs oxygen saturation, and expired carbon dioxide,
administered; continuous oxygen
saturation, heart rate, and ventila-
must be documented at least every 5 minutes in a
tion (capnography required); para- time-based record. Capnography should be used
meters recorded at least every 5 for almost all deeply sedated children because of
minutes
the increased risk of airway/ventilation compro-
Recommended mise. Capnography may not be feasible if the
patient is agitated or uncooperative during the initial
Required phases of sedation or during certain procedures,
such as bronchoscopy or repair of facial lacerations,
and this circumstance should be documented. For
uncooperative children, the capnography monitor
Recommended; initial recording
may be placed once the child becomes sedated.
of vital signs may be needed for at Note that if supplemental oxygen is administered,
least 5-minute intervals until the the capnograph may underestimate the true expired
child begins to awaken, then re-
cording intervals may be increased
carbon dioxide value; of more importance than
to 10–15 minutes the numeric reading of exhaled carbon dioxide
is the assurance of continuous respiratory gas ex-
change (i.e., continuous waveform). Capnography is
particularly useful for patients who are difficult to
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 REFERENCE MANUAL OF PEDIATRIC DENTISTRY 367
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION

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.

368 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


should be used when injecting into vascular tissues.401 If high
doses or injection of amide local anesthetics (bupivacaine and
ropivacaine) into vascular tissues is anticipated, then the
immediate availability of a 20% lipid emulsion for the
treatment of local anesthetic toxicity is recommended (Tables
3 and 5). 402-409 Topical local anesthetics are commonly used
and encouraged, but the practitioner should avoid applying
excessive doses to mucosal surfaces where systemic uptake and
possible toxicity (seizures, methemoglobinemia) could result
and to remain within the manufacturer’s recommendations
regarding allowable surface area application.410-415
Pulse oximetry
Newer pulse oximeters are less susceptible to motion artifacts
and may be more useful than older oximeters that do not
contain updated software. 416-420 Oximeters that change tone
with changes in hemoglobin saturation provide immediate aural
warning to everyone within hearing distance. The oximeter
probe must be properly positioned; clip-on devices are easy to
displace, which may produce artifactual data (under- or over-
estimation of oxygen saturation).361,362
Capnography
Expired carbon dioxide monitoring is valuable to diagnose the
simple presence or absence of respirations, airway obstruction,
or respiratory depression, particularly in patients sedated in
less-accessible locations, such as in MRI machines or darkened
rooms. 64,66,67,72,90,96,110,159-162,164-170,372-375,421-427 In patients recei-
ving supplemental oxygen, capnography facilitates the recog-
nition of apnea or airway obstruction several minutes before
the situation would be detected just by pulse oximetry. In
this situation, desaturation would be delayed due to increased
oxygen reserves; capnography would enable earlier interven-
tion.161 One study in children sedated in the emergency de-
partment found that the use of capnography reduced the
incidence of hypoventilation and desaturation (7% to 1%).174
The use of expired carbon dioxide monitoring devices is now
required for almost all deeply sedated children (with rare
exceptions), particularly in situations in which other means
of assessing the adequacy of ventilation are limited. Several
manufacturers have produced nasal cannulae that allow simul-
taneous delivery of oxygen and measurement of expired carbon
dioxide values.421,422,427 Although these devices can have a high
degree of false-positive alarms, they are also very accurate for
the detection of complete airway obstruction or apnea.164,168,169
Taping the sampling line under the nares under an oxygen face
mask or nasal hood will provide similar information. The exact
measured value is less important than the simple answer to
the question: Is the child exchanging air with each breath?
Processed EEG (Bispectral Index)
Although not new to the anesthesia community, the processed
EEG (bispectral index [BIS]) monitor is slowly finding its way
into the sedation literature.428 Several studies have attempted
to use BIS monitoring as a means of noninvasively assessing
the depth of sedation. This technology was designed to examine
EEG signals and, through a variety of algorithms, correlate a
number with depth of unconsciousness: that is, the lower the
number, the deeper the sedation. Unfortunately, these algor-
ithms are based on adult patients and have not been validated
in children of varying ages and varying brain development.
Although the readings correspond quite well with the depth
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
of propofol sedation, the numbers may paradoxically go up
rather than down with sevoflurane and ketamine because of
central excitation despite a state of general anesthesia or deep
sedation.429,430 Opioids and benzodiazepines have minimal and
variable effects on the BIS. Dexmedetomidine has minimal
effect with EEG patterns, consistent with stage 2 sleep.431 Several
sedation studies have examined the utility of this device and
degree of correlation with standard sedation scales.347,363,432-435 It
appears that there is some correlation with BIS values in mod-
erate sedation, but there is not a reliable ability to distinguish
between deep sedation and moderate sedation or deep sedation
from general anesthesia.432 Presently, it would appear that BIS
monitoring might provide useful information only when used
for sedation with propofol363; in general, it is still considered
a research tool and not recommended for routine use.
Adjuncts to airway management and resuscitation
The vast majority of sedation complications can be managed
with simple maneuvers, such as supplemental oxygen, opening
the airway, suctioning, placement of an oral or nasopharyngeal
airway, and bag-mask-valve ventilation. Rarely, tracheal intu-
bation is required for more prolonged ventilatory support. In
addition to standard tracheal intubation techniques, a number
of supraglottic devices are available for the management of
patients with abnormal airway anatomy or airway obstruction.
Examples include the LMA, the cuffed oropharyngeal airway,
and a variety of kits to perform an emergency cricothyrotomy.436,437
The largest clinical experience in pediatrics is with the
LMA, which is available in multiple sizes, including those for
late preterm and term neonates. The use of the LMA is now
an essential addition to advanced airway training courses, and
familiarity with insertion techniques can be life-saving. 438-442
The LMA can also serve as a bridge to secure airway manage-
ment in children with anatomic airway abnormalities. 443,444
Practitioners are encouraged to gain experience with these
techniques as they become incorporated into PALS courses.
Another valuable emergency technique is intraosseous
needle placement for vascular access. Intraosseous needles are
available in several sizes; insertion can be lifesaving when rapid
intravenous access is difficult. A relatively new intraosseous
®
device (EZ-IO Vidacare, now part of Teleflex, Research
Triangle Park, N.C.) is similar to a hand-held battery-powered
drill. It allows rapid placement with minimal chance of mis-
placement; it also has a low-profile intravenous adapter.445-450
Familiarity with the use of these emergency techniques can be
gained by keeping current with resuscitation courses, such as
PALS and advanced pediatric life support.
Patient simulators
High-fidelity patient simulators are now available that allow
physicians, dentists, and other health care providers to practice
managing a variety of programmed adverse events, such as
apnea, bronchospasm, and laryngospasm. 133,220,450-452 The use
of such devices is encouraged to better train medical professionals
and teams to respond more effectively to rare events. 128,131,
451,453-455
One study that simulated the quality of cardiopul-
monary resuscitation compared standard management of
ventricular fibrillation versus rescue with the EZ-IO for the
rapid establishment of intravenous access and placement of
®
an LMA for establishing a patent airway in adults; the use of
these devices resulted in more rapid establishment of vascular
access and securing of the airway.456
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 369
BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
Monitoring during MRI
The powerful magnetic field and the generation of radiofre-
quency emissions necessitate the use of special equipment to
provide continuous patient monitoring throughout the MRI
scanning procedure. 457-459 MRI-compatible pulse oximeters
and capnographs capable of continuous function during scan-
ning should be used in any sedated or restrained pediatric
patient. Thermal injuries can result if appropriate precautions
are not taken; the practitioner is cautioned to avoid coiling of
all wires (oximeter, ECG) and to place the oximeter probe as
far from the magnetic coil as possible to diminish the possibil-
ity of injury. ECG monitoring during MRI has been associated
with thermal injury; special MRI-compatible ECG pads
are essential to allow safe monitoring. 460-463 If sedation is
achieved by using an infusion pump, then either an MRI-
compatible pump is required or the pump must be situated
outside of the room with long infusion tubing so as to main-
tain infusion accuracy. All equipment must be MRI com-
patible, including laryngoscope blades and handles, oxygen
tanks, and any ancillary equipment. All individuals, including
parents, must be screened for ferromagnetic materials, phones,
pagers, pens, credit cards, watches, surgical implants, pace-
makers, etc, before entry into the MRI suite.
Nitrous oxide
Inhalation sedation/analgesia equipment that delivers nitrous
oxide must have the capacity of delivering 100% and never less
than 25% oxygen concentration at a flow rate appropriate to
the size of the patient. Equipment that delivers variable ratios
of nitrous oxide >50% to oxygen that covers the mouth and
nose must be used in conjunction with a calibrated and func-
tional oxygen analyzer. All nitrous oxide-to-oxygen inhalation
devices should be calibrated in accordance with appropriate
state and local requirements. Consideration should be given to
the National Institute of Occupational Safety and Health
Standards for the scavenging of waste gases. 464 Newly con-
structed or reconstructed treatment facilities, especially those
with piped-in nitrous oxide and oxygen, must have appro-
priate state or local inspections to certify proper function of
inhalation sedation/analgesia systems before any delivery of
patient care.
Nitrous oxide in oxygen, with varying concentrations, has
been successfully used for many years to provide analgesia for a
variety of painful procedures in children.14,36,49,98,465– 493 The use
of nitrous oxide for minimal sedation is defined as the admin-
istration of nitrous oxide of ≤50% with the balance as oxygen,
without any other sedative, opioid, or other depressant drug
before or concurrent with the nitrous oxide to an otherwise
healthy patient in ASA class I or II. The patient is able to main-
tain verbal communication throughout the procedure. It
should be noted that although local anesthetics have sedative
properties, for purposes of this guideline they are not consid-
ered sedatives in this circumstance. If nitrous oxide in oxygen
is combined with other sedating medications, such as chloral
Funding: No external funding.
Potential conflict of interest: The authors have indicated they have no
potential conflicts of interest to disclose.
Financial disclosure: The authors have indicated they do not have a
financial relationship relevant to this article to disclose.
370 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
hydrate, midazolam, or an opioid, or if nitrous oxide is used
in concentrations >50%, the likelihood for moderate or
deep sedation increases.107,197,492,494,495 In this situation, the practi-
tioner is advised to institute the guidelines for moderate or
deep sedation, as indicated by the patient’s response.496
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449. Oksan D, Ayfer K. Powered intraosseous device (EZ-IO)
for critically ill patients. Indian Pediatr 2013;50(7):
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450. Santos D, Carron PN, Yersin B, Pasquier M. EZ-IO( )
intraosseous device implementation in a pre-hospital
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emergency service: A prospective study and review of the
literature. Resuscitation 2013;84(4):440-5.
451. Tan GM. A medical crisis management simulation activity
for pediatric dental residents and assistants. J Dent Educ
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452. Schinasi DA, Nadel FM, Hales R, Boswinkel JP, Donoghue
AJ. Assessing pediatric residents’ clinical performance in
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453. Rowe R, Cohen RA. An evaluation of a virtual reality
airway simulator. Anesth Analg 2002;95(1):62-6.
454. Medina LS, Racadio JM, Schwid HA. Computers in
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computerized simulator: A new approach to train and
evaluate radiologists’ responses to critical incidents. Pediatr
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455. Blike G, Cravero J, Nelson E. Same patients, same critical
events—different systems of care, different outcomes: Des-
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456. Reiter DA, Strother CG, Weingart SD. The quality of
cardiopulmonary resuscitation using supraglottic airways
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457. Schulte-Uentrop L, Goepfert MS. Anaesthesia or sedation
for MRI in children. Curr Opin Anaesthesiol 2010;23
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458. Schmidt MH, Downie J. Safety first: Recognizing and
managing the risks to child participants in magnetic
resonance imaging research. Account Res 2009;16(3):
153-73.
459. Chavhan GB, Babyn PS, Singh M, Vidarsson L, Shroff M.
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460. Kanal E, Shellock FG, Talagala L. Safety considerations
in MR imaging. Radiology 1990;176(3):593-606.
461. Shellock FG, Kanal E. Burns associated with the use of
monitoring equipment during MR procedures. J Magn
Reson Imaging 1996;6(1):271-2.
462. Shellock FG. Magnetic resonance safety update 2002: im-
plants and devices. J Magn Reson Imaging 2002;16(5):
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463. Dempsey MF, Condon B, Hadley DM. MRI safety review.
Semin Ultrasound CT MR 2002;23(5):392-401.
464. Department of Health and Human Services, Centers for
Disease Control and Prevention. Criteria for a Recom-
mended Standard: Waste Anesthetic Gases: Occupational
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able at: “http://www.cdc.gov/niosh/docs/2007-151/pdfs/
2007-151.pdf ”. Accessed May 27, 2016.
465. O’Sullivan I, Benger J. Nitrous oxide in emergency medi-
cine. Emerg Med J 2003;20(3):214-7.
466. Kennedy RM, Luhmann JD, Luhmann SJ. Emergency
department management of pain and anxiety related to
orthopedic fracture care: A guide to analgesic techniques
and procedural sedation in children. Paediatr Drugs 2004;
6(1):11-31.
467. Frampton A, Browne GJ, Lam LT, Cooper MG, Lane LG.
Nurse administered relative analgesia using high concen-
tration nitrous oxide to facilitate minor procedures in
children in an emergency department. Emerg Med J 2003;
20(5):410-3.
468. Everitt I, Younge P, Barnett P. Paediatric sedation in
emergency department: What is our practice? Emerg Med
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469. Krauss B. Continuous-flow nitrous oxide: Searching for
the ideal procedural anxiolytic for toddlers. Ann Emerg
Med 2001;37(1):61-2.
470. Otley CC, Nguyen TH. Conscious sedation of pediatric
patients with combination oral benzodiazepines and in-
haled nitrous oxide. Dermatol Surg 2000;26(11):1041-4.
471. Luhmann JD, Kennedy RM, Jaffe DM, McAllister JD.
Continuous-flow delivery of nitrous oxide and oxygen: A
safe and cost-effective technique for inhalation analgesia
and sedation of pediatric patients. Pediatr Emerg Care
1999;15(6):388-92.
472. Burton JH, Auble TE, Fuchs SM. Effectiveness of 50%
nitrous oxide/50% oxygen during laceration repair in
children. Acad Emerg Med 1998;5(2):112-7.
473. Gregory PR, Sullivan JA. Nitrous oxide compared with
intravenous regional anesthesia in pediatric forearm frac-
ture manipulation. J Pediatr Orthop 1996;16(2):187-91.
474. Hennrikus WL, Shin AY, Klingelberger CE. Self-administered
nitrous oxide and a hematoma block for analgesia in the
outpatient reduction of fractures in children. J Bone Joint
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475. Hennrikus WL, Simpson RB, Klingelberger CE, Reis MT.
Self-administered nitrous oxide analgesia for pediatric
fracture reductions. J Pediatr Orthop 1994;14(4):538-42.
476. Wattenmaker I, Kasser JR, McGravey A. Self-administered
nitrous oxide for fracture reduction in children in an
emergency room setting. J Orthop Trauma 1990;4(1):
35-8.
477. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia
in a pediatric emergency department. Ann Emerg Med
1989;18(2):177-81.
478. Kalach N, Barbier C, el Kohen R, et al. Tolerance of nitrous
oxide-oxygen sedation for painful procedures in emergency
pediatrics: Report of 600 cases [in French]. Arch Pediatr
2002;9(11):1213-5.
479. Michaud L, Gottrand F, Ganga-Zandzou PS, et al. Nitrous
oxide sedation in pediatric patients undergoing gastro-
intestinal endoscopy. J Pediatr Gastroenterol Nutr 1999;
28(3):310-4.
480. Baskett PJ. Analgesia for the dressing of burns in children:
A method using neuroleptanalgesia and Entonox. Postgrad
Med J 1972;48(557):138-42.
481. Veerkamp JS, van Amerongen WE, Hoogstraten J, Groen
HJ. Dental treatment of fearful children, using nitrous
oxide. Part I: Treatment times. ASDC J Dent Child 1991;
58(6):453-7.
482. Veerkamp JS, Gruythuysen RJ, van Amerongen WE,
Hoogstraten J. Dental treatment of fearful children using
nitrous oxide. Part 2: The parent’s point of view. ASDC J
Dent Child 1992;59(2):115-9.
483. Veerkamp JS, Gruythuysen RJ, van Amerongen WE,
Hoogstraten J. Dental treatment of fearful children using
nitrous oxide. Part 3: Anxiety during sequential visits.
ASDC J Dent Child 1993;60(3):175-82.
484. Veerkamp JS, Gruythuysen RJ, Hoogstraten J, van Amerongen
WE. Dental treatment of fearful children using nitrous
oxide. Part 4: Anxiety after two years. ASDC J Dent Child
1993;60(4):372-6.
485. Houpt MI, Limb R, Livingston RL. Clinical effects of
nitrous oxide conscious sedation in children. Pediatr Dent
2004;26(1):29-36.
486. Shapira J, Holan G, Guelmann M, Cahan S. Evaluation of
the effect of nitrous oxide and hydroxyzine in controlling
the behavior of the pediatric dental patient. Pediatr Dent
1992;14(3):167-70.
487. Primosch RE, Buzzi IM, Jerrell G. Effect of nitrous oxide-
oxygen inhalation with scavenging on behavioral and
physiological parameters during routine pediatric dental
treatment. Pediatr Dent 1999;21(7):417-20.
488. McCann W, Wilson S, Larsen P, Stehle B. The effects of
nitrous oxide on behavior and physiological parameters
during conscious sedation with a moderate dose of chloral
hydrate and hydroxyzine. Pediatr Dent 1996;18(1):35-41.
489. Wilson S, Matusak A, Casamassimo PS, Larsen P. The
effects of nitrous oxide on pediatric dental patients se-
dated with chloral hydrate and hydroxyzine. Pediatr Dent
1998;20(4):253-8.
490. Pedersen RS, Bayat A, Steen NP, Jacobsson ML. Nitrous
oxide provides safe and effective analgesia for minor
paediatric procedures—A systematic review [abstract].
Dan Med J 2013;60(6):A4627.
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491. Lee JH, Kim K, Kim TY, et al. A randomized comparison 495. Litman RS, Kottra JA, Verga KA, Berkowitz RJ, Ward
of nitrous oxide versus intravenous ketamine for lacera- DS. Chloral hydrate sedation: The additive sedative and
tion repair in children. Pediatr Emerg Care 2012;28(12): respiratory depressant effects of nitrous oxide. Anesth
1297-301. Analg 1998;86(4):724-728.
492. Seith RW, Theophilos T, Babl FE. Intranasal fentanyl 496. American Academy of Pediatric Dentistry, Council on
and highconcentration inhaled nitrous oxide for proce- Clinical Affairs. Guideline on use of nitrous oxide for
dural sedation: A prospective observational pilot study of pediatric dental patients. Chicago, Ill.: American Academy
adverseevents and depth of sedation. Acad Emerg Med of Pediatric Dentistry; 2013. Available at: “http://www.
2012;19(1):31-6. aapd.org/media/policies_guidelines/g_nitrous.pdf ”.
493. Klein U, Robinson TJ, Allshouse A. End-expired nitrous Accessed May 27, 2016.
oxide concentrations compared to flowmeter settings
during operative dental treatment in children. Pediatr
Dent 2011;33(1):56-62.
494. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Breathing
patterns and levels of consciousness in children during
administration of nitrous oxide after oral midazolam pre-
medication. J Oral Maxillofac Surg 1997;55(12):1372-7;
discussion: 1378-9.

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”.

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BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION

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.

386 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 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
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:387-91.

Abstract
This best practice provides recommendations for dentists who elect to use anesthesia providers in their office or other non-accredited
treatment facilities. The scope of this guidance covers personnel, facilities, quality assurance requirements, and documentation of patient
care. Anesthesia providers (dental or medical anesthesiologists, oral and maxillofacial surgeons, certified registered nurse anesthetists,
certified anesthesiologist assistants) must be licensed, credentialled, and certified in pediatric advanced life support (PALS) or advanced
pediatric life support (APLS). Facilities must meet all local, state, and federal laws, codes, and regulations regarding provision of anesthesia
services, controlled drug storage, fire prevention, safety and health, and accommodations for disabled individuals. A framework for patient
monitoring and required emergency equipment are described. This best practice includes recommendations for documenting indications
for deep sedation/general anesthesia, informed consent, patient/parent instructions, the patient’s preoperative health evaluation, a time
based anesthesia record, and recovery notes. Risk management and quality assurance measures are considered essential. Use of in-office
anesthesia providers offers alternatives and opportunities for safe, quality care for pediatric dental patients requiring deep sedation or
general anesthesia, especially when access to traditional surgical facilities is limited.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations to dental practitioners choosing to treat pediatric dental patients
in the dental office or other non-accredited ambulatory treatment center using deep sedation/general anesthesia delivered by licensed
anesthesia providers.

KEYWORDS: ADOLESCENTS, CHILD, ANESTHESIA, GENERAL; ANESTHESIOLOGISTS, DEEP SEDATION, DELIVERY OF HEALTH CARE, DENTAL OFFICES

Purpose version, last revised in 2018. The modification by the Council

The American Academy of Pediatric Dentistry (AAPD)
recognizes that there are pediatric dental patients for whom
routine dental care using non-pharmacologic behavior guidance
techniques is not a viable approach.1 The AAPD intends this
guideline to assist the dental practitioner who elects to use a
licensed anesthesia provider for the administration of deep
sedation/general anesthesia for pediatric dental patients in a
dental office or other facility outside of an accredited hospital
or ambulatory surgical center. This document discusses person-
nel, facilities, documentation, and quality assurance mechanisms
necessary to provide optimal and responsible patient care.
Methods
Recommendations on the use of anesthesia providers in
the administration of office-based deep sedation/general
anesthesia were developed by the Clinical Affairs Committee
– Sedation and General Anesthesia Subcommittee and
adopted in 2001. This document is a revision of the previous
of Clinical Affairs is limited to the section on personnel,
with changes based upon a review of the recently revised
Guidelines for Monitoring and Management of Pediatric Pa-
tients Before, During, and After Sedation for Diagnostic and
Therapeutic Procedures2, a joint publication of the AAPD and
the American Academy of Pediatrics. The last full revision
utilized current dental and medical literature pertaining to
deep sedation/general anesthesia of dental patients, including
®
a search of the PubMed /MEDLINE database using the
terms: office-based general anesthesia, pediatric sedation, deep
sedation, sleep dentistry, and dental sedation; fields: all; limits:
humans, all children from birth through age 18, English,
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. APLS: Advanced
pediatric life support. ASA: American Society of Anesthesiologists.
CAA: Certified anesthesiologst assistant. CO2: Carbon dioxide. CRNA:
Certified registered nurse anesthetist. PALS: Pediatric advanced life
support.

* The 201 9 revision was limited to the section on personnel.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 387

BEST PRACTICES: USE OF ANESTHESIA PROVIDERS
clinical trials, and literature reviews. When data did not
appear sufficient or were inconclusive, recommendations were
based upon expert and/or consensus opinion by experienced
researchers and clinicians.
Background
Pediatric dentists seek to provide oral health care to infants,
children, adolescents, and persons with special health care needs
in a manner that promotes excellence in quality of care and
concurrently induces a positive attitude in the patient toward
dental treatment. Behavior guidance techniques have allowed
most pediatric dental patients to receive treatment in the dental
office with minimal discomfort and without expressed fear.
Minimal or moderate sedation has allowed others who are less
compliant to receive treatment. Some children and individuals
with special care needs who have extensive oral healthcare
needs, acute situational anxiety, uncooperative age-appropriate
behavior, immature cognitive functioning, disabilities, or
medical conditions require deep sedation/general anesthesia to
receive dental treatment in a safe and humane fashion.3 Access
to hospital-based anesthesia services may be limited for a
variety of reasons, including restriction of coverage of by third-
party payors.3,4 Pediatric dentists and others who treat children
can provide for the administration of deep sedation/general
anesthesia by utilizing properly trained and currently licensed
anesthesia providers in their offices or other facilities outside
of the traditional surgical setting.
Office-based deep sedation/general anesthesia can provide
benefits for the patient and the dental team. Such benefits
may include:
• improved access to care;
• improved ease and efficiency of scheduling;
• decreased administrative procedures and facility fees when
compared to a surgical center or hospital;
• minimized likelihood of patient’s recall of procedures;
• decreased patient movement which may optimize quality
of care; and
• use of traditional dental delivery systems with access to
a full complement of dental equipment, instrumentation,
supplies, and auxiliary personnel.
The use of licensed anesthesia providers to administer deep
sedation/general anesthesia in the pediatric dental population
is an accepted treatment modality.2,5-8 Caution must be used in
patients younger than two years of age. Practitioners must
always be mindful of the increased risk associated with office-
based deep sedation/general anesthesia in the infant and
toddler populations. This level of pharmacologic behavioral
modification should only be used when the risk of orofacial
disease outweighs the benefits of monitoring, interim thera-
peutic restoration, or arresting medicaments to slow or stop
the progression of caries. The AAPD supports the provision of
deep sedation/general anesthesia when clinical indications have
been met and additional properly-trained and credentialed
personnel and appropriate facilities are used.1-3 In many cases,
388 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
the patient may be treated in an appropriate outpatient facility
(including the dental office) because the extensive medical
resources of a hospital may not be deemed necessary for deliv-
ering routine health care.
Recommendations
Clinicians may consider using deep sedation or general anes-
thesia in the office to facilitate the provision of oral health
care. Practitioners choosing to use these modalities must be
trained in rescue emergency procedures and be familiar with
their patient’s medical history, as well as the regulatory and
professional liability insurance requirements needed to provide
this level of pharmacologic behavior management. This
guideline does not supersede, nor is it to be used in deference
to, federal, state, and local credentialing and licensure laws,
regulations, and codes.
Personnel
Deep sedation/general anesthesia techniques in the dental
office require the presence of the following individuals
throughout the procedure2:
• licensed anesthesia provider who is independent of
performing or assisting with the dental procedure; and
• operating dentist.
It is the exclusive responsibility of the operating dentist,
when employing anesthesia providers to administer deep
sedation/general anesthesia, to verify and carefully review
their credentials and experience. Significant pediatric training,
including anesthesia care of the very young, and experience
in a dental setting are important considerations, especially
when caring for young pediatric and special needs populations.
In order to provide anesthesia services in an office-based
setting:
• the licensed anesthesia provider must be a licensed dental
and/or medical practitioner with current state certifica-
tion to independently administer deep sedation/general
anesthesia in a dental office. He/She must be in com-
pliance with state and local laws regarding anesthesia
practices. Laws vary from state to state and may supersede
any portion of this document.
• if state law permits a certified registered nurse anesthetist
(CRNA) or certified anesthesiologist assistant (CAA) to
function under the direct supervision of a dentist, the
dentist is required to have completed training in deep
sedation/general anesthesia and be licensed or permitted
for that level of pharmacologic management, appropriate
to state law. Furthermore, to maximize patient safety,
the dentist supervising the CRNA or CAA would not
simultaneously be providing dental treatment. The
CRNA or CAA must be licensed with current state certi-
fication to administer deep sedation/general anesthesia
in a dental office. He/She must be in compliance with
state and local laws regarding anesthesia practices. Laws
vary from state to state and may supersede any portion
of this document.
 BEST PRACTICES: USE OF ANESTHESIA PROVIDERS

The dentist and anesthesia care provider must be compliant
with Guideline on Monitoring and Management of Pediatric
Patients Before, During, and After Sedation for Diagnostic and
Therapeutic Procedures 2 or other appropriate guideline(s) of
the American Dental Association, the American Society of
Dental Anesthesiologists (ASDA), the American Society of
Anesthesiologists (ASA), and other organizations with recog-
nized professional expertise and stature. The recommendations
in this document may be exceeded at any time if the
change involves improved safety and/or is superseded by state
law.
The dentist and licensed anesthesia provider must collaborate
to enhance patient safety. Continuous and effective periopera-
tive communication and appropriately timed interventions are
essential in mitigating adverse events or outcomes. The dentist
introduces the concept of deep sedation/general anesthesia to
the parent, justifies its necessity, and provides appropriate pre-
operative instructions and informational materials. The dentist
or his/her designee coordinates medical consultations when
necessary and conveys pertinent information to the anesthesia
care provider. The anesthesia care provider explains potential
risks and obtains informed consent for sedation/anesthesia.
Office staff should understand their additional roles and
responsibilities and special considerations (e.g., loss of protec-
tive reflexes) associated with office-based deep sedation/general
anesthesia.
Both the licensed anesthesia provider and the operating
dentist must, at a minimum, have appropriate training and
up-to-date certification in patient rescue, including drug
administration and pediatric advanced life support (PALS) or
advanced pediatric life support (APLS).2 The licensed anes-
thesia provider’s sole responsibility is to administer drugs and
constantly monitor and record the patient’s vital signs, depth
of sedation, airway patency, and adequacy of ventilation.2 The
anesthesia provider must be skilled to establish intravenous
access and draw up and administer rescue medications, He
must have the training and skills to rescue a child with apnea,
laryngospasm, airway obstruction, hypotension, anaphylaxis, or
cardiopulmonary arrest, including the ability to open the airway,
suction secretions, provide constant positive airway pressure
(CPAP), insert supraglottic devices (oral airway, nasal trumpet,
or laryngeal mask airway), and perform successful bag-valve-
mask ventilation, tracheal intubation, and cardiopulmonary
resuscitation.2 As permitted by state regulation, the anesthesia
provider may be one of the following:
• dentist or physician anesthesiologist;
• certified registered nurse anesthetist; or
• an oral and maxillofacial surgeon.
The anesthesia provider would assume the lead during the
management of any perioperative emergencies. The dentist must
be capable of providing skilled assistance with the rescue of a
child experiencing any of the adverse events described above.2
It is the responsibility of the anesthesia provider to ensure that
the operating dentist and supportive staff are capable of pro-
viding skilled support and have an established emergency and
transport protocol in the event of an adverse incident.
Personnel experienced in post anesthetic recovery care and
trained in advanced resuscitative techniques (e.g., PALS) must
be in attendance and provide continuous respiratory and
cardiovascular monitoring during the recovery period.2 The
supervising anesthesia provider, not the operating dentist, shall
determine when the patient exhibits respiratory and cardio-
vascular stability and appropriate discharge criteria2 have been
met. The operating dentist must have up-to-date certification
in PALS or APLS, and his/her clinical staff must be well-versed
in emergency recognition, rescue, and emergency protocols in-
cluding maintaining cardiopulmonary resuscitation certification
for healthcare providers.6 Contact numbers for local emergency
medical and ambulance services must be readily available, and
a protocol for immediate access to back-up emergency services
must be clearly outlined.2 Emergency preparedness must be
updated and practiced on a regular (e.g., semi-annual) basis
to keep all staff members up to date on established protocols
(see Table).9
Facilities
A continuum extends from wakefulness across all levels of
sedation. Often these levels are not easily differentiated, and
patients may drift among them.10 When anesthesia care
providers are utilized for office-based administration of deep
sedation or general anesthesia, the facilities in which the dentist
practices must meet the guidelines and appropriate local, state,
and federal codes for administration of the deepest possible
level of sedation/anesthesia. Facilities must be in compliance
with applicable laws, codes, and regulations pertaining to
controlled drug storage, fire prevention, building construction
and occupancy, accommodations for the disabled, occupational
safety and health, and disposal of medical waste and hazardous
waste.2 The treatment room must accommodate the dentist and

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.

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BEST PRACTICES: USE OF ANESTHESIA PROVIDERS
auxiliaries, the patient, the anesthesia care provider, the dental
equipment, and all necessary anesthesia delivery equipment
along with appropriate monitors and emergency equipment.
Expeditious access to the patient, anesthesia machine (if
present), and monitoring equipment should be available at all
times.
It is beyond the scope of this document to dictate equipment
necessary for the provision of deep sedation/general anesthesia,
but equipment must be appropriate for the technique used
and consistent with the guidelines for anesthesia providers, in
accordance with governmental rules and regulations. Because
laws and codes vary from state to state, Guidelines for Monitor-
ing and Management of Pediatric Patients Before, During, and
After Sedation for Diagnostic and Therapeutic Procedures 2 should
be followed as the minimum requirements.
For deep sedation/general anesthesia, there must be contin-
uous monitoring of the patient’s level of consciousness and
responsiveness, heart rate, blood pressure, respiratory rate,
expired carbon dioxide (CO2) values, and oxygen saturation.2
When adequacy of ventilation is difficult to observe using
capnography, use of an amplified, audible precordial stetho-
®
scope (e.g., Bluetooth technology) is encouraged.2 In addition,
an electrocardiographic monitor and a defibrillator capable of
delivering an attenuated pediatric dose are required for deep
sedation/general anesthesia.2 Emergency equipment must be
readily accessible and should include Yankauer suction, drugs
necessary for rescue and resuscitation (including 100 percent
oxygen capable of being delivered by positive pressure at appro-
priate flow rates for up to one hour), and age-/size-appropriate
equipment to resuscitate and rescue a non-breathing and/or
unconscious pediatric dental patient and provide continuous
support while the patient is being transported to a medical
facility.2,5 The licensed practitioners are responsible for ensur-
ing that medications, equipment, and protocols are available
to treat malignant hyperthermia when triggering agents are
used.11 Recovery facilities must be available and suitably
equipped. Backup power sufficient to ensure patient safety
should be available in case of emergency power outage.2
Documentation
Prior to delivery of deep sedation/general anesthesia, patient
safety requires that appropriate documentation shall address
rationale for sedation/general anesthesia, anesthesia and
procedural informed consent, instructions to parent, dietary
precautions, preoperative health evaluation, and any prescrip-
tions along with the instructions given for their use.2 Because
laws and codes vary from state to state, Guidelines on
Monitoring and Management of Pediatric Patients Before, During,
and After Sedation for Diagnostic and Therapeutic Procedure 2
should be followed as minimum requirements for a time-based
anesthesia record.
• Vital signs: Pulse and respiratory rates, blood pressure,
heart rhythm, oxygen saturation, and expired CO2 must
be continuously monitored and recorded on a time-based
record throughout the procedure, initially every five
390 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
minutes and then, as the patient awakens, at 10-15 min-
ute intervals until the patient has met documented
discharge criteria.2
• Drugs: Name, dose, route, site, time of administration,
and patient effects (e.g., level of consciousness, patient
responsiveness) of all drugs, including local anesthesia,
must be documented.2 When anesthetic gases are admin-
istered, inspired concentration and duration of inhalation
agents and oxygen shall be documented.2
• Recovery: The condition of the patient, that discharge
criteria have been met, time of discharge, and into whose
care the discharge occurred must be documented. Re-
quiring the signature of the responsible adult to whom
the child has been discharged, verifying that he/she has
received and understands the post-operative instructions,
is encouraged.2
Various business/legal arrangements may exist between
the treating dentist and the anesthesia provider. Regardless,
because services were provided in the dental facility, the dental
staff must maintain all patient records, including time-based
anesthesia records, so that they may be readily available for
emergency or other needs. The dentist must assure that the
anesthesia provider also maintains patient records and that
they are readily available.
Risk management and quality assurance
Dentists who utilize office-based anesthesia care providers
must take all necessary measures to minimize risk to patients.
The dentist must be familiar with the ASA physical status
classification.12 Knowledge, preparation, and communication
between professionals are essential. Prior to subjecting a
patient to deep sedation/general anesthesia, the patient must
undergo a pre-operative health evaluation by an appropriate
and currently licensed medical or anesthesia provider.2,6 High-
risk patients should be treated in a facility properly equipped
and staffed to provide for their care.2,6 The dentist and
anesthesia care provider must communicate during treatment
to share concerns about the airway or other details of patient
safety. Furthermore, they must work together to develop and
document mechanisms of quality assurance.
Untoward and unexpected outcomes must be documented
and reviewed to monitor the quality of services provided.
This will decrease risk, allow for open and frank discussions,
document risk analysis and intervention, and improve the
quality of care for the pediatric dental patient.2,5
References
1. American Academy of Pediatric Dentistry. Behavior
guidance for the pediatric dental patient. Pediatr Dent
2018;40(6):254-67.
2. Coté CJ, Wilson S, American Academy of Pediatrics,
American Academy of Pediatric Dentistry. Guidelines for
monitoring and management of pediatric patients before,
during, and after sedation for diagnostic and therapeutic
procedures. Pediatr Dent 2019;41(4):E26-E52.

3. Glassman P, Caputo A, Dougherty N, et al. Special Care
Dentistry Association consensus statement on sedation,
anesthesia, and alternative techniques for people with spe-
cial needs. Spec Care Dentist 2009;29(1):2-8; quiz 67-8.
4. American Academy of Pediatric Dentistry. Policy on
third-party reimbursement of medical fees related to
sedation/general anesthesia for delivery of oral health
care services. Pediatr Dent 2018;40(6):117-9.
5. American Society of Anesthesiologists. Guidelines for
office-based anesthesia. 2009. Reaffirmed 2014. Available
at: “http://www.asahq.org/~/media/Sites/ASAHQ/Files/
Public/Resources/standards-guidelines/guidelines-for-
office-based-anesthesia.pdf ”. Accessed March 22, 2017.
6. American Dental Association. Guidelines for the use of
sedation and general anesthesia by dentists. 2016. Avail-
able at: “http://www.ada.org/en/~/media/ADA/Advocacy/
Files/anesthesia_use_guidelines”. Accessed March 22,
2017.
7. Nick D, Thompson L, Anderson D, Trapp L. The use
of general anesthesia to facilitate dental treatment. Gen
Dent 2003;51(5):464-8.
8. Wilson S. Pharmacologic behavior management for
pediatric dental treatment. Pediatr Clin North Am 2000;
47(5):1159-73.
BEST PRACTICES: USE OF ANESTHESIA PROVIDERS
9. World Health Organization. Hospital and health facility
emergency exercises. Guidance materials. WHO Press,
2010. Available at: “http://www.wpro.who.int/publica
tions/PUB_9789290614791/en/”. Accessed September
19, 2017.
10. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog
JH, Pediatric Sedation Research Consortium. The
incidence and nature of adverse events during pediatric
sedation/anesthesia with propofol for procedures outside
the operating room; A report from the Pediatric Sedation
Research Consortium. Anesth Analg 2009;108(3):
795-804.
11. Rosenberg H. Succinylcholine dantrolene controversy:
President’s report. Malignant Hyperthermia Association
of the United States. Available at: “http://www.mhaus.org
/blog/post/a8177/succinylcholine-dantrolene-controversy”.
Accessed March 22, 2017.
12. American Society of Dentist Anesthesiologists. ASA
physical status classification system. Available at: “https:
//www.asahq.org/resources/clinical-information/asa-
physical-status-classification-system”. Accessed March
22, 2017.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 391
BEST PRACTICES: PAIN MANAGEMENT

Pain Management in Infants, Children, Adolescents,

and Individuals with Special Health Care Needs
Revised How to Cite: American Academy of Pediatric Dentistry. Pain
2022 management in infants, children, adolescents, and individuals with
special health care needs. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:392-400.

Abstract
This statement provides dentists and stakeholders with current best practices for pediatric pain management. Infants, children, adolescents,
and individuals with special health care needs may experience pain resulting from dental/orofacial injury, infection, and dental procedures.
Dental pain is an inflammatory condition that can be categorized as somatic (i.e., periodontal, alveolar, mucosal) or visceral (i.e., pulpal).
Dental professionals should consider pain assessment for all patients. Inadequate pain management may lead to significant physical and
psychological consequences for patients. Perioperative pain management approaches include pre-emptive pain management (e.g., anes-
thetics), use of local anesthesia during general anesthesia for postoperative pain control, nonpharmacological anxiolytic interventions
(e.g., providing a calm environment, emotional support), distraction and imagery (e.g., counting, video games), and pharmacological pain
control agents including non-opioid analgesics (e.g., nonsteroidal anti-inflammatory drugs, acetaminophen) and opioid analgesics.
Acetaminophen and nonsteroidal anti-inflammatory medications are first line pharmacologic therapies for pain management. Use of
opioids for pediatric dental patients should be rare, and steps to mitigate opioid misuse are discussed.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and guidance on pain management in infants, children, adolescents, and individuals
with special health care needs.
KEYWORDS: PAIN MANAGEMENT; ACUTE PAIN; CHRONIC PAIN; PAIN, POSTOPERATIVE; FACIAL PAIN; TOOTHACHE

Purpose acetaminophen, adolescent and acetaminophen, pediatric and

The American Academy of Pediatric Dentistry (AAPD)
recognizes that infants, children, adolescents, and individuals
with special health care needs can and do experience pain
due to dental/orofacial injury, infection, and dental procedures,
and that inadequate pain management may have significant
physical and psychological consequences for the patient.
Appreciation of pediatric pain can help practitioners develop
clinical approaches to prevent or substantially relieve dental
pain. When pharmacological intervention is necessary to man-
age pain, the practitioner must understand the consequences,
morbidities, and toxicities associated with the use of specific
therapeutic agents. These recommendations are intended to
provide dental professionals and other stakeholders with cur-
rent best practices for pain management in pediatric dentistry.
Methods
This document was developed by the Council on Clinical
Affairs and adopted in 2018.1 It is based on a review of current
dental and medical literature pertaining to pain management
in pediatric dental patients. Review of existing federal and
professional pain management guidelines and consensus state-
ments were used to assist with this document. An electronic
®
search was conducted in the PubMed /MEDLINE database
using the terms: dental pain management, pediatric pain
assessment, pre-emptive analgesia, paracetamol, pediatric and
nonsteroidal anti-inflammatory drugs (NSAIDs), adolescent
and NSAIDs, pediatric and opioids, adolescent and opioids,
opioid risk, adolescent orofacial pain, pediatric and adolescent
chronic pain, nonpharmacologic pain management; fields: all;
limits: within the last 10 years, humans, English, systematic
review, and clinical trials. There were 3,698 articles that met
these criteria. Papers for review were chosen from this list
and from references within selected articles. When data did
not appear sufficient or were inconclusive, recommendations
were based upon expert and/or consensus opinion by experi-
enced researchers and clinicians.
Background
Pain is defined by the International Association of the Study
of Pain as “an unpleasant sensory and emotional experience
associated with, or resembling that associated with, actual or
ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
of Pediatric Dentistry. APAP: Acetyl-para-aminophenol. CDC: Centers
for Disease Control and Prevention. CNS: Central nervous system.
COX: Cyclooxygenase. FDA: U.S. Food and Drug Administration.
IV: Intravenous. NSAIDs: Nonsteroidal anti-inflammatory drugs.
U.S.: United States. WHO: World Health Organization.

392 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


potential tissue damage.”2 Their expanded definition includes
six items that provide further context to the complex topic
of pain: pain is always a personal experience; pain is different
from nociception; pain is learned through life experiences;
a person’s report of pain should be respected; pain can have
adverse effects on function and well-being; and verbal descrip-
tion is one of several behaviors used to express pain.2
Intraoral pain presenting as a toothache is a common
source of orofacial pain in children.3 An estimated 95 percent
of orofacial pain results from odontogenic causes4 and, accord-
ing to a recent systematic review and meta-analysis, an overall
pooled prevalence of toothache in children and adolescents
was 36.2 percent.3 Pain experienced during dental procedures
can be distressing for the provider, the child, and his parents
and can also lead to difficult behavior, dental fear, and avoid-
ance behavior in the child.5 Moreover, pain experience in
childhood may shape future pain experiences in adulthood.6
Pain from dental pulp arises when functional nerves are
stimulated by bacteria or trauma.7 Periodontal pain occurs
when infectious or traumatic insults to the gingiva, periodon-
tal ligament, and alveolar bone stimulate free nerve endings.7
Other sources of orofacial pain include temporomandibular
disorders (e.g., joint pain, masticatory muscle pain), headaches
(e.g., migraine, tension type), or other non-odontogenic causes
(e.g., pathologic jaw lesions, oral ulcers, neuralgia). Pain may
be divided into diagnostic categories such as somatic, visceral,
and neuropathic.8 Pain encountered in dentistry is typically
inflammatory and categorized as somatic (i.e., periodontal,
alveolar, mucosal) or visceral (i.e., pulpal) pain.7
Pain management includes pharmacologic and nonpharma-
cologic strategies to treat both acute and chronic pain. Due
to the increased appreciation for pediatric pain and because
of the national opioid crisis, recommendations for professional
education and approaches for therapeutic management are
being reviewed at the national, state, and local levels.9-12
Understanding nociception (i.e., pain processing) is essential
for the management of pain. Following tissue injury, infec-
tion, or invasive treatment, thermal, mechanical, and chemical
stimuli activate receptors on free nerve endings in vital struc-
tures in the orofacial region.13,14 In turn, sensory signals travel
along afferent trigeminal nerve fibers and relay information to
the brainstem and higher structures involved with the percep-
tion of pain.15 Under normal conditions the perception of pain
persists until the stimulus is removed.
Sensitization of central and peripheral nervous system cir-
cuits occurs following significant tissue damage or prolonged
neuronal stimulation.14 Terminal nerve endings at the site of
tissue injury exhibit an enhanced neuronal response to noxious
stimuli in the peripheral nervous system.14 This local increase
in nerve membrane excitability is referred to as peripheral
sensitization.14 The exaggerated response to stimuli in the
region of tissue damage is called primary hyperalgesia.14
Central sensitization refers to enhanced functional status
of pain circuits and pain processing at the level of the central
nervous system (CNS).14,16,17 Both secondary hyperalgesia,
BEST PRACTICES: PAIN MANAGEMENT
which is an increase in pain intensity to noxious stimuli out-
side of the area of tissue damage, and allodynia, which refers
to pain perception following innocuous stimuli such as light
touch, are characteristics of central sensitization.17 Modulation
of pain pathways occurs through CNS excitatory and inhibitory
processes. Ascending facilitating and descending inhibitory
processes enhance or suppress the pain experience, respectively.14
Both pharmacologic and nonpharmacologic methods target
these processes to alter pain processing.18,19
Pain assessment is an integral component of the dental
history and comprehensive evaluation. When symptoms or
signs of orofacial/dental pain are evident, a detailed pain
assessment helps the dentist to derive a clinical diagnosis,
develop a prioritized treatment plan, and better estimate anal-
gesic requirements for the patient. Pain is difficult to measure
due to its subjectivity, especially in children5,20, and often relies
on the report of parents or caregivers. In clinical practice, pain
assessment is largely nonstandardized and based on signs and
symptoms rather than specific tools.5
Pain can be assessed using self-report, behavioral (vocaliza-
tion, facial expression, body movement), and biological (heart
rate, transcutaneous oxygen, sweating, stress response) mea-
sures.21 Direct questioning or a structured, comprehensive pain
assessment can be clinically beneficial for pediatric and ado-
lescent patients.21,22 Conducting a structured interview begins
with asking specific questions regarding pain onset, provoking
factors, palliative factors, quality or character, region or location,
severity or intensity, timing or duration, and impact on daily
activities.23 Obtaining information through self-report can be
aided by asking the child to make comparisons, using tempo-
ral anchors and facilitating communication through objects
or gestures.21 Assessing behavioral reactions and physiologi-
cal reactions to pain are required in nonverbal patients, young
patients, and patients with special health care needs.21 Pain
experienced by children with special health care needs or
developmental disabilities is more challenging to assess accu-
rately, and assessment may benefit from the utilization of
scales that rely on observations such as vocalization, facial
expressions, and body movements.20 Validated instruments
available for assessing pain in verbal or nonverbal patients
®
include: Wong-Baker FACES , Faces Pain Scale (Revised),
visual analogue scale (VAS), numeric rating scale (NRS), Faces,
Legs, Activity, Cry, and Consolability score (FLACC), Revised
Faces, Legs, Activity, Cry and Consolability (r-FLACC), and
the McGill Pain Questionnaire.20,21,25 Additionally, ethnic,
cultural, and language factors may influence the expression
and assessment of pain.26
Pain also may be categorized as acute or chronic. Acute
pain that fails to respond to treatment may become chronic
over time.27 Chronic pain refers to pain that is dysfunctional
and persists beyond the time for typical tissue healing.2,28
Chronic pain is a costly public health problem that is difficult
to treat.29,30 Temporomandibular disorder (TMD) is an exam-
ple of a chronic pain condition encountered in dentistry.31
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 393
BEST PRACTICES: PAIN MANAGEMENT
Pain management
Pre-emptive pain management
Pre-emptive pain management refers to the administration of
an anesthetic agent, medication, or technique prior to a surgi-
cal event with the goal of decreasing pain. Goals of pre-emptive
pain management include attenuating central sensitization,
decreasing postoperative pain, improving recovery, and reduc-
ing postoperative analgesic consumption.15,19,32,33 Postoperative
pain management in pediatric patients has been suboptimal
in large part because parents frequently do not adequately
treat pain that is experienced at home34 and fear of adverse
events.35 Pain after dental treatment under general anesthesia
frequently is related to the total number of teeth treated.36
Nearly 50 percent of patients undergoing dental rehabilita-
tion describe moderate to severe pain37, and data supports
pre-emptive measures to optimize pain control for a variety
of dental and surgical procedures.23,32,38,39
Achieving profound anesthesia prior to initiating invasive
treatment decreases central sensitization.23 Topical anesthetics
are used in dentistry to minimize pain; yet, these medica-
ments alone may not be sufficient for dental procedures.40,41
Topical anesthetics and over-the-counter products containing
benzocaine have been used for minor procedures and to
manage oral pain, teething, and ulcers.42 However, benzo-
caine use in children has been linked to methemoglobinemia, a
life-threatening condition.42 In 2018, the United States (U.S.)
Food and Drug Administration (FDA) issued a post-market
warning against the use of these products for children younger
than two years and that the products must have warning labels
regarding methemoglobinemia.43 Local anesthetic administra-
tion techniques, the anesthetic’s properties, and the needle
used during injection may contribute to a patient’s pain
experience.44 Distraction techniques made at the time of the
injection (e.g., jiggling the patient’s cheek, applying pressure
to the palate with a mirror handle) take advantage of
Aß-fiber signal dominance and can significantly reduce the
intensity of pain-related C-fiber signaling.44,45 Buffering or
decreasing acidity of local anesthetic using sodium bicarbonate
can decrease injection site pain and postoperative discomfort
by increasing the pH of the anesthetic.46 A recent system-
atic review demonstrated lower pain scores following inferior
alveolar block injections in children when buffered versus
nonbuffered local anesthesia was used; however, there was
no difference in observer-reported pain behavior.46 Finally,
decreasing anesthetic delivery rate also has demonstrated pain
reduction during injection.47
The use of pre-emptive analgesics in conjunction with local
anesthetics has been shown to increase the ability to achieve
pulpal anesthesia in patients with irreversible pulpitis when
compared with placebo48 and to suppress the intensity of
injection pain and reduce pain following extractions32,39. The
pre-emptive analgesics most commonly used in dentistry are
NSAIDs (e.g., ibuprofen) and acetaminophen, either alone or
in combination.32 Analgesics with sedative properties are often
394 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
administered during the pre-, peri-, or postoperative periods
when moderate to severe pain is anticipated.49-52
Use of local anesthesia during general anesthesia
Although pain is not experienced during general anesthesia,
central sensitization occurs when peripheral nerves are stimu-
lated.23,53 Operating without local anesthesia may result in
priming of CNS neurons and increased future pain sensitivity.6
Central sensitization is minimized with pre-emptive analgesia
or anesthesia. For this reason, regional block or infiltration
anesthesia is commonly performed prior to surgical procedures
to decrease postoperative pain.15,55 However, pharmacologic
and cardiac considerations, along with avoiding the numb sen-
sation and potential for self-inflicted oral trauma, are reasons
providers may choose not to provide local anesthesia during
general anesthesia.55,56
Nonpharmacologic approaches to pain management
Studies suggest that nonpharmacologic interventions may be
effective alone or as adjuncts to pharmacological interventions
in managing procedure-related pain, anxiety, and distress with
minimal risk of adverse effects.57-60 Fear and anxiety activate
circuits within the CNS that facilitate pain.28 Creating a safe,
friendly environment may help a child feel more comfortable
and less stressed.60,61 The American Academy of Pediatrics
(AAP) and the American Pain Society recommend providers
reduce distress-producing stimulation and provide a calm
environment for procedures to improve pain management.10
Individual studies have shown the efficacy of psychologic
techniques, including preparation and information, parent
coaching or training, suggestion, memory alteration or change,
and coping self-statements.62-64
Distraction and imagery
Distraction is an effective method of pain management in the
pediatric population.26,65 It can be cognitive (e.g., counting,
nonprocedural talk) or behavioral (e.g., videos, games), both
of which aim to shift attention away from pain. Distraction
techniques such as bubbles, counting, conversation, music,
television, toys, and video games may be used by health care
providers or the child’s caregiver.60,61 Strong evidence supports
the efficacy of distraction techniques for needle-related pain
and distress in children and adolescents.66 Distraction is
significantly effective when measuring pulse rates, respiratory
rates, and self-reported pain.10 Distraction techniques may be
of great use with patients with special needs who have short-
ened attention spans and cannot understand verbal reasoning
or reassurance.62 Distraction, hypnosis, combined cognitive be-
havior therapy (CBT), and breathing interventions have been
effective in reducing children’s needle-related pain or distress,
or both.63
Imagery guides the child’s attention away from the pro-
cedure by harnessing imagination and storytelling. Imagery
in combination with distraction has been shown to decrease
postoperative pain in children.65,67

Hypnotherapy
Hypnotherapy aims to alter sensory experiences and dissoci-
ate from pain experiences, and hypnosis is best for children of
school age or older.63,68 There is evidence hypnotherapy is
effective in reducing needle-related pain and distress in children
and adolescents63,66,69; however, there is no evidence hypno-
therapy alone is capable of producing an anesthetic effect
necessary for invasive dental procedures.69
Virtual reality and smart phone applications
Using digital technology can provide distraction and reduction
in pain and distress for children undergoing painful proce-
dures.70,71 The use of virtual reality, video games, and smart-
phone applications has shown a reduction in self-reported
and observer-reported pain and distress during common
procedures such as venipuncture and dental and burn
treatments.70 Further studies are needed to assess the benefits
of distraction with a tablet compared to audiovisual glasses
during dental procedures.71
Other techniques
Studies have shown efficacies for pediatric pain management
with other techniques such as relaxation and breathing exer-
cises, transcutaneous electrical nerve stimulation, acupuncture,
counterstimulation, video modelling, and music therapies.64,65,
72-77
Additional research is needed on these interventions to
measure their effectiveness.76
Pharmacologic/therapeutic agents
Management of pain in children is changing rapidly as a result
of improvements in the appreciation of pediatric pain and
pharmacologic knowledge. However, randomized controlled
trials in children are lacking so the use of many pain medica-
tions is considered off label.78,79 Acetaminophen and ibuprofen
are recommended as first-line medication choices for the treat-
ment of acute pain in children.26,79-81 Both have been shown
to have good efficacy and safety and are also cost-effective anal-
gesics.81,82 The use of opioids in children carries risks.80,83,84
Non-opioid analgesics
Nonsteroidal anti-inflammatory drugs. NSAIDs are among
the most commonly used class of drugs and have anti-
inflammatory, analgesic, antipyretic, and antiplatelet proper-
ties.85 They inhibit prostaglandin synthesis, with specific action
on cyclooxygenase (COX), the enzyme responsible for
converting arachidonic acid into pro-inflammatory mediators
that drive postoperative pain, swelling, and hyperalgesia.51,83
Representatives of the major categories of NSAIDs are salicylic
acids (aspirin), acetic acids (ketorolac), proprionic acids
(ibuprofen, naproxen), and COX-2 selective inhibitor
(celecoxib). Ibuprofen in oral or intravenous (IV) form is a
safe and commonly used analgesic and antipyretic agent in
pediatrics.81,85 Ketorolac, an IV or intranasal NSAID, is useful
in treating moderate to severe acute pain in patients unable
or unwilling to swallow oral NSAIDs.8,53,86 Some adverse
BEST PRACTICES: PAIN MANAGEMENT
effects associated with NSAIDs include: rash, inhibition of
bone growth and healing, gastritis with pain and bleeding,
decreased renal blood flow and kidney dysfunction, reversible
inhibition of platelet function, hepatic dysfunction, and in-
creased incidence of cardiovascular events.8,87 A specific concern
with NSAIDs is the potential to exacerbate asthma due to a
shift in leukotrienes.79 Due to shared pathways, combined
NSAIDs and corticosteroid (e.g., prednisone) use may increase
the potential for gastrointestinal bleeding.88
Acetaminophen (acetyl-para-aminophenol [APAP], paracetamol).
Acetaminophen is an analgesic with efficacy for mild to
moderate pain and is an antipyretic.89 Unlike NSAIDs, aceta-
minophen is centrally acting and does not have anti-
inflammatory effects or an effect on gastric mucosal lining
or platelets.89 Its mechanism of action is the blockade of
prostaglandin and substance P production. Allergic reactions
are rare,87 but toxicity from overdose may result in acute liver
failure90. Acetaminophen can be administered in tablets,
capsules, and liquid but also is available as oral disintegrating
tablets, oral disintegrating films, and rectal and IV forms.51
Rectal administration has somewhat higher bioavailability
and faster onset than the oral route since it partially bypasses
hepatic metabolism.91
Opioid analgesics
Opioid analgesics have been used for many years to produce
profound pain relief in all age groups. Opioid analgesics are
considered for acute moderate to severe pain refractory to
other therapies. However, opioids only interrupt the nocicep-
tive pathway to inhibit pain perception and do not target
inflammation83, which is an integral part of managing dental
pain. Common uses in pediatric patients include pain associated
with cancer, sickle cell disease, osteogenesis imperfecta,
epidermolysis bullosa, and neuromuscular disease.92-94 Limited
studies are available regarding postoperative opioid use in
pediatric dentistry, perhaps because pediatric dental patients
rarely require opioid analgesics following dental treatment.51
However, opioid/non-opioid combination medications followed
by oxycodone and morphine were the most common analge-
sics prescribed to children during postoperative emergency
room encounters.95 Major concerns of opioid analgesics in the
pediatric population are efficacy, safety, misuse, and accidental
deaths.78,96,97
Opioids interact differentially with μ, g, and b receptors in
the central nervous system. Opioid agonists act on receptors
located in the brain, spinal cord, and digestive tract. Activation
of opioid receptors can cause respiratory depression, pupil
constriction (miosis), euphoria, sedation, physical dependence,
endocrine disruption, and suppression of opiate withdrawal.8
Pruritus (itching) may occur due to histamine release that
accompanies some opioid analgesics.49 Naloxone is a μ recep-
tor competitive antagonist usually administered parenterally to
counter opioid overdose.51 Pain medicine specialists (e.g. pain
physicians, anesthesiologists) are experienced in continuing,
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 395
BEST PRACTICES: PAIN MANAGEMENT
tapering, or discontinuation of opioids in patients who are
actively prescribed opioids for cancer or other pain.30,78
Codeine has more adverse effects and limited efficacy for
dental pain when compared to over-the-counter analgesics.83
Codeine, tramadol, and hydrocodone, and to a lesser extent
oxycodone and fentanyl, are broken down in the liver to
active metabolites by the highly variable cytochrome enzyme,
CYP2D6.98-100 Some opioid analgesics are ineffective in certain
children due to poor drug metabolism.57,99 Yet, other patients
known as hypermetabolizers hydrolyze prodrugs to their
active forms too quickly, potentially resulting in overdose,
respiratory depression, and even death.98,99 The FDA and AAP
issued warnings and safety communications on codeine and
tramadol over the past few years because of this.98,99 Hydro-
codone and oxycodone also rely on cytochrome p450 metabo-
lism and have the potential for similar adverse effects.100
Although systematic reviews have demonstrated that these
medications provide appropriate analgesia when compared
to placebo, evidence is not convincing they outperform non-
opioid analgesics, and safety concerns exist.101,102 In 2017, the
FDA issued a warning specifically for codeine and tramadol,
stating they are no longer considered safe to use in all patients
less than 12 years of age.98 Deaths have occurred in children
using these medicines for post tonsillectomy and/or adenoid-
ectomy pain management, general pain, sore or strep throat
pain, and cold and cough.98,99 The FDA warns that in the
12- through 17-year age group, these medications should not
be used in high-risk patients (e.g., those with obesity,
obstructive sleep apnea, lung tissue disease).98 Furthermore,
tramadol and codeine should not be used if breastfeeding
since active metabolites are present in breast milk.98
Although morphine causes respiratory depression and his-
tamine release, it consistently provides rapid relief of severe
pain for two to three hours.8 To that point, the potency of all
opioids is compared to morphine using a morphine milligram
equivalent dose.8 Considering the variability of drug metabo-
lism, safety concerns, and the experience of pain, the “right
dose” for everyone does not exist.8 For example, fentanyl is
100 times more potent than morphine, ultra-short acting, and
used for invasive procedures and sedations.8 Chest wall rigidity
is a well-known adverse reaction to fentanyl.8 Rapidly-acting
oxycodone has a longer half-life than morphine and is more
potent.8 Oxycodone is available as a single agent or is com-
bined with aspirin, ibuprofen, or acetaminophen. It comes in
tablets, capsules, oral solution, and oral concentrate, and use
is considered off label in children.51,95
Opioid concerns and Centers for Disease Control and
Prevention (CDC) and World Health Organization (WHO)
recommendations. Trends in opioid overdose, opioid misuse,
and concerns for opioid addiction prompted the CDC and
the WHO to issue guidelines for prescribing opioids for
chronic pain.103 The CDC guideline focuses on adults while
the WHO guideline relates specifically to children.103 Al-
though chronic pain is the focus of the guidelines, both aims
396 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
to improve prescribing practices and to ultimately benefit
patient safety, emotional well-being, and quality of life.30,103,104
The topics covered in the guidelines include limiting opioids
for moderate to severe pain, restricting opioid prescriptions
to three days, providing concurrent pharmacologic and non-
pharmacologic therapy, and following accepted protocols for
procurement, storage, and disposal of unused opioids.30,103 The
CDC guideline also advises against overlapping benzo-
diazepines and opioids prescriptions because of the increased
potential for respiratory depression.103
Deaths due to opioid overdoses reached record highs and
prompted the CDC to declare an opioid epidemic in 2011.97,105
The pediatric mortality rate for opioid poisoning increased
nearly threefold from 1999 to 2016, with nearly 9,000 chil-
dren and adolescents in the United States dying as a result
of opioids.105 A trend towards increased pediatric emergency
department visits due to opioid ingestion and a greater than
five-fold increase in overdose death rates in the 15-24-year age
group also have been demonstrated.105 Risky use of opioids
among children and adolescents is a growing trend, and the
concern for opioid use disorder in adolescents is significant.106,107
Since commercial opioids often are combined with acetamino-
phen, the potential for hepatotoxicity is an accompanying
concern.90 In 2016, the AAP released a policy statement that
recommended timely intervention to curb opioid use disorder
with the goal of eliminating long-term medical, psychiatric,
and social consequences of ongoing substance abuse.99
Opioid risk mitigation involves recognizing drug-seeking
behavior. 9 To address the potential risk of opioid misuse,
screening patients prior to prescribing opioids has been advo-
cated as standard practice.103 However, a standardized assess-
ment for adolescents has not been identified.78,108 Therefore, at
a minimum, a thorough review of medical history including
analgesics used in the past is indicated before prescribing.78
Despite the fact that screening of parents is recommended
by the AAP, this is not a common practice.109,110 Nonetheless,
screening is essential for identifying children at risk of opioid
exposure in the home. Children of parents who abuse opi-
oids are at an increased risk for neglect and often suffer from
parental instability and lack of structure in the home.110
For professionals who suspect patients have misuse issues,
the FDA, National Institutes of Health, National Institute on
Drug Abuse, the American Dental Association, and state pre-
scription drug monitoring programs have resources available
to review the history of prescriptions for controlled substances
which may decrease their diversion.111 Transparent discussion
about the potential for physical and/or psychological depen-
dence is a critical component of safe opioid practices in the
adolescent population.80,112 Furthermore, discussion regarding
the proper disposal of unused controlled medications is key to
reducing availability/diversion of opioids.80,112 Safeguarding of
opioids stored in offices for sedation can be accomplished by
following security requirements for dispensers of controlled
substances.113

Recommendations
Infants, children, and adolescents can and do experience pain
due to dental/orofacial injury, infection, and dental procedures.
Inadequate pain management may have significant physical and
psychological consequences for the patient. Adherence to the
following recommendations can help practitioners prevent or
substantially relieve pediatric dental pain and minimize risk of
associated morbidities. Practitioners should:
1. assess pain for all patients as part of the dental history.
2. avoid sensitization by using techniques to minimize
stimulation and tissue damage when providing dental treat-
ment.
3. achieve profound anesthesia prior to invasive treatment.
4. use pre-emptive analgesia when moderate to severe post-
operative pain is anticipated.
5. manage odontogenic and non-odontogenic pain with
combined nonpharmacologic (e.g., distraction) and
pharmacologic pain management.
6. use APAP/NSAIDs as first-line pharmacologic therapy for
pain management.
7. use caution and carefully assess benefits and risks of adverse
events when considering prescribing opioids for pain
management in children and adolescents.
8. minimize the risk of opioid misuse by screening patients
and parents regarding previous/current opioid use before
prescribing opioid analgesics.
9. utilize prescription monitoring databases and inform parents
to properly discard unused medications to avoid diversion
of controlled substances.
10. inform parents of risks associated with prescribed and over-
the-counter analgesic medications and anticipate and
manage adverse effects (e.g., asthma and NSAIDs, sedation
and opioids.)
11. seek expert consultation for patients with chronic pain or
other complicated pain condition.
12. be familiar with analgesic properties of agents when used
in conjunction with sedation or general anesthesia.
13. strongly advise against opioids in high-risk patients (e.g.,
obesity, obstructive sleep apnea, lung tissue disease, benzo-
diazepines use).
14. use an alternating schedule of APAP and NSAIDs for
multimodal pain management if single-agent therapy is
ineffective.
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opioid therapy. Clin Pharmacol Ther 2021;110(4):888-96.
101. Schnabel A, Reichl SU, Meyer-Frießem C, Zahn PK,
Pogatzki-Zahn E. Tramadol for postoperative pain treat-
ment in children. Cochrane Database Syst Rev 2015;(3):
CD009574. Available at: “https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC6464560/”. Accessed September 28,
2022.
102. Dancel R, Liles EA, Fiore D. Acute pain management in
hospitalized children. Rev Recent Clin Trials 2017;12(4):
277-83.
103. Dowell D, Haegerich TM, Chou R. CDC guideline for
prescribing opioids for chronic pain – United States,
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104. Tompkins DA, Hobelmann JG, Compton P. Providing
chronic pain management in the 5th vital sign era: Historical
and treatment perspectives in a modern-day medical
dilemma. Drug Alcohol Depend 2017;173(Suppl 1):S11-21.
105. DePhillips M, Watts J, Lowry J, Dowdy MD. Opioid
prescribing practices in pediatric acute care settings. Pediatr
Emerg Care 2019;35(1):16-21.
106. Allareddy V, Rampa S, Allareddy V. Opioid abuse in chil-
dren: An emerging public health crisis in the United States!
Pediatr Res 2017;82(4):562-3.
107. McCabe SE, West BT, Veliz P, et al. Trends in medical
and nonmedical use of prescription opioids among U.S.
adolescents: 1976-2015. Pediatrics 2017;139(4):e20162387.
108. Smith SM, Paillard F, McKeown A, et al. Instruments to
identify prescription medication misuse, abuse, and related
events in clinical trials: An ACTTION systematic review.
J Pain 2015;16(5):389-411.
109. Lane WG, Dubowitz H, Feigelman S, et al. Screening for
parental substance abuse in pediatric primary care. Ambul
Pediatr 2007;7(6):458-62.
110. Spehr MK, Coddington J, Ahmed A, Jones E. Parental
opioid abuse: Barriers to care, policy, and implications for
primary care pediatric providers. J Pediatr Healthcare 2017;
31(6):695-702.
111. National Institute of Health, National Institute on Drug
Abuse. Principles of adolescent substance use disorder
treatment: A research-based guide. NIH Publication
Number 14-7953. January, 2014. Available at: “https://nida.
nih.gov/publications/principles-adolescent-substance-use
-disorder-treatment-research-based-guide/principles-adolescent
-substance-use-disorder-treatment”. Accessed February 5,
2022.
112. American Academy of Pediatric Dentistry. Policy on sub-
stance misuse in adolescent patients. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:112-6.
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Chapter 2, Part 1303. Registration of Manufacturers,
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Accessed on March 13, 2022.
 BEST PRACTICES: RESTORATIVE DENTISTRY

Pediatric Restorative Dentistry

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Pediatric
2022 restorative dentistry. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:401-14.

Abstract
This best practice provides clinicians with guidance to form decisions about restorative dentistry, including when treatment is necessary and
which techniques and materials are appropriate for restorative dentistry in pediatric patients. Not every caries lesion requires restoration,
and restorative treatment of caries alone does not stop the disease process. Further, restorations have finite lifespans. Restorative approaches
and supporting evidence for the excavation and restoration of deep caries lesions, including complete excavation, stepwise (i.e., two-step)
excavation, partial (i.e., one-step) excavation, and no removal of caries prior to restoration, are discussed. Further research on long-term
effectiveness of resin infiltration for small, noncavitated interproximal lesions is recommended. The evidence for and against the use of
amalgam, composite, glass ionomer and resin-modified glass ionomer cements, compomers, stainless steel crowns, and anterior crowns
has been summarized. Practitioners should familiarize themselves with such evidence to inform their clinical decisions regarding pediatric
restorative dentistry.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and guidance regarding restorative dental care for children.
KEYWORDS: DENTISTRY, OPERATIVE, DENTAL MATERIALS, DENTAL RESTORATION, PERMANENT, DENTAL RESTORATION, TEMPORARY, EVIDENCE-BASED DENTISTRY

Purpose
The American Academy of Pediatric Dentistry (AAPD)
intends these recommendations to help practitioners make
decisions regarding restorative dentistry, including when it is
necessary to treat and what the appropriate materials and
techniques are for restorative dentistry in children and
adolescents.
Methods
These recommendations originally were developed by the
Restorative Dentistry Subcommittee of the Clinical Affairs
Committee and adopted in 1991.1 The last revision by the
Council on Clinical Affairs occurred in 2019. 2 A thorough
review of the scientific literature in the English language
pertaining to restorative dentistry in primary and permanent
teeth was completed to revise the previous version. Electronic
®
database searches using PubMed /MEDLINE, for the most
part between the years 2012-2022, were conducted using
the terms: dental caries, intracoronal restorations, restorative
treatment decisions, caries diagnosis, caries excavation, dental
amalgam, glass ionomers, resin-modified glass ionomers, con-
ventional glass ionomers, glass ionomer cements, atraumatic/
alternative restorative technique (ART), interim therapeutic
restoration (ITR), resin infiltration, resin-based composite,
dental composites, compomers, full coverage dental restora-
tions, stainless steel crowns (SSC), Hall technique, primary
molars, preformed metal crowns (PMC), strip crowns, pre-
veneered crowns, zirconia crowns, esthetic restorations;
parameters: humans, English, birth through age 18, clinical
trials, randomized controlled clinical trials (RCTs). This search
yielded 1,671 articles. Articles were screened by viewing titles
and abstracts. Articles were chosen for review from these
searches and from the references within selected articles. When
data did not appear sufficient or were inconclusive, recom-
mendations were based upon expert and/or consensus opinion
by experienced researchers and clinicians.
Full evaluation and abstraction included examination of the
clinical efficacy on specific restorative dentistry topics, research
methods, and potential for study bias (e.g., patient recruit-
ment, randomization, blinding, subject loss, sample size
estimates, conflicts of interest, statistics). Research that was
considered deficient or had high bias was eliminated. In topic
areas for which rigorous meta-analyses or systematic reviews
were available, only those clinical trial articles not covered by
the reviews were subjected to full evaluation and abstraction.
The assessment of evidence for each topic was based on
a modification of the grading of recommendations by the
American Dental Association (ADA): strong evidence (based
on well-executed RCTs, meta-analyses, or systematic reviews)
and evidence in favor (based on weaker evidence from clinical
trials).4
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. ADA: American
Dental Association. ART: Alternative restorative technique. BPA:
Bisphenol A. FDA: United States Food and Drug Administration.
GIC: Glass ionomer cement. HT: Hall technique. ITR: Interim thera-
peutic restoration. MIH: Molar-incisor hypomineralization. MTA:
Mineral trioxide aggregate. PMC: Preformed metal crown(s). RCTs:
Randomized controlled trials. RMGIC: Resin-modified glass ionomer
cement(s). SSC: Stainless steel crowns. UK: United Kingdom.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 401

BEST PRACTICES: RESTORATIVE DENTISTRY
Methods
Historically, the management of dental caries was based on
the belief that caries was a progressive disease that eventually
destroyed the tooth unless there was surgical or restorative
intervention.3 It is now recognized that restorative treatment
of dental caries alone does not stop the disease process and
that restorations have a finite lifespan.3 Conversely, some car-
ies lesions may not progress and, therefore, may not need
restoration.
Contemporary management of dental caries includes
identification of an individual’s risk for caries progression,
understanding of the disease process for that individual, and
active surveillance to assess disease progression.3 Management
with targeted preventive services and therapy such as silver
diamine fluoride is supplemented by restorative therapy when
indicated.3-5
Molar-incisor hypomineralization (MIH) is a developmen-
tal defect involving any number of the permanent first molars
and possibly the permanent incisors as well. This condition
presents esthetic and restorative challenges due to the range of
clinical variation, including hypersensitivity, altered resin bond
strength, potential for tooth structure loss, and a caries pre-
sentation that can be unusual.6,7 Restorative treatment options
and overall management of MIH depend on the degree of
affected teeth, potential for breakdown of tooth structure,
sensitivity, severity and quality of the dental defect in addition
to patient preferences and behavior.7,8
When to restore
Among the objectives of restorative treatment are to repair or
limit the damage from caries, protect and preserve the tooth
structure, and maintain pulp vitality whenever possible.
AAPD's Use of Vital Pulp Therapies in Primary Teeth with Deep
Caries Lesions9 and Pulp Therapy for Primary and Immature
Permanent Teeth10 state the treatment objective for a tooth
affected by caries is to maintain pulpal vitality, especially in
immature permanent teeth for continued apexogenesis.
Indications for restorative therapy have been examined only
superficially because such decisions generally have been regarded
as a function of clinical judgment.11 Decisions for when to
restore caries lesions should include – at least – clinical criteria
of visual detection of enamel cavitations, visual identification
of shadowing of the enamel, or radiographic recognition of
enlargement of lesions over time.3,12,13
The benefits of restorative therapy include removing cavi-
tations or defects to eliminate areas that are susceptible to
caries, stopping the progression of tooth demineralization,
restoring tooth structure and function, preventing the spread
of infection into the dental pulp, and preventing the shifting
of teeth due to loss of tooth structure. The risks of restorative
therapy include reducing the longevity of teeth by making
them more susceptible to fracture, recurrent lesions, restoration
failure, pulp exposure during caries excavation, and future
pulpal complications, in addition to the risk of iatrogenic
damage to adjacent teeth.14-16
402 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Primary teeth may be more susceptible to restoration fail-
ures than permanent teeth.17 Additionally, before restoration
of primary teeth, one needs to consider the length of time
until tooth exfoliation.
Recommendations:
1. Management of dental caries should include identification
of an individual’s risk for caries progression, understand-
ing of the disease process for that individual, and active
surveillance to assess disease progression and intervention
with appropriate preventive services, supplemented by
restorative therapy when indicated.
2. Decisions for when to restore caries lesions should
include – at least – clinical criteria of visual detection of
enamel cavitation, visual identification of shadowing of
the enamel, or radiographic recognition of progression
of lesions.
Deep caries excavation and restoration
Regarding the treatment of deep caries, three methods of caries
removal have been compared to complete excavation, where
all carious dentin is removed. Stepwise excavation is a two-
step caries removal process in which carious dentin is partially
removed at the first appointment, leaving caries over the pulp,
with placement of a temporary filling. At the second appoint-
ment, all remaining carious dentin is removed, and a final
restoration placed. 18 Partial, or one-step, caries excavation
removes part of the carious dentin but leaves caries over the
pulp, and subsequently places a base and final restoration.19,20
No removal of caries before restoration of primary molars in
children aged three to 10 years also has been reported.21
Evidence from multiple studies shows that frequency of
pulp exposures in primary and permanent teeth is significantly
reduced when using incomplete caries excavation compared
to complete excavation in teeth with a normal pulp or
reversible pulpitis. Two trials and a Cochrane review found
that partial excavation resulted in significantly fewer pulp
exposures compared to complete excavation.22-24 One five-year
RCT evaluated the pulpal vitality of teeth treated with
partial excavation compared to stepwise excavation and
found that the success rate was significantly higher in partial
excavation (80 percent) versus stepwise excavation (56
percent). 25 Two trials of stepwise excavation showed that
pulp exposure occurred more frequently from complete
excavation compared to stepwise excavation.18,23 Evidence
of a decrease in pulpal complications and postoperative pain
after incomplete caries excavation compared to complete
excavation in clinical trials is summarized in a meta-analysis.26
Additionally, a meta-analysis found the risk for permanent
restoration failure was similar for incompletely and completely
excavated teeth.26 With regard to the need to reopen a tooth
with partial excavation of caries, one RCT that compared
partial (one-step) to stepwise excavation in permanent mo-
lars found higher rates of success in maintaining pulp vitality
with partial excavation, suggesting there is no need to reopen
the cavity and perform a second excavation. 19 Interestingly,

two RCTs suggest that restoration without excavation can
arrest dental caries as long as a good seal of the final restora-
tion is maintained.21,27
Recommendations:
1. Multiple RCTs and systematic reviews determined that
incomplete caries excavation, either partial (one-step) or
stepwise (two-step) excavation, in primary and permanent
teeth with normal pulps or reversible pulpitis results in
fewer pulp exposures and fewer signs and symptoms
of pulpal disease than complete excavation. Incomplete
caries removal should be considered in primary and
permanent teeth with deep caries and normal pulp status
or reversible pulpitis when complete caries removal is
likely to result in pulp exposure.
2. Two systematic reviews reported that the rate of restoration
failure in permanent teeth is no higher after incomplete
rather than complete caries excavation.
3. Numerous studies concluded that partial (one-step)
excavation followed by placement of final restoration
leads to higher success in maintaining pulp vitality in
permanent teeth than stepwise (two-step) excavation.
Resin infiltration
Resin infiltration is used primarily to arrest the progression
of noncavitated interproximal caries lesions.28,29 The aim of
the resin infiltration technique is to allow penetration of a low
viscosity resin into the porous lesion body of enamel caries.28
Once polymerized, this resin serves as a barrier to acids and
theoretically prevents lesion progression.30,31
A systematic review and meta-analysis that evaluated the
effectiveness of enamel infiltration in preventing initial caries
progression in proximal surfaces of primary and permanent
teeth found infiltration was significantly more effective
than placebo treatment.32 In randomized clinical trials, resin
infiltration, when used as an adjunct to preventive measures,
was found to be more effective in reducing the radiographic
progression of early or incipient proximal lesions on primary
molars than preventive measures alone over a 24 month
period.33-36 Current ADA clinical practice guidelines for non-
restorative treatment for noncavitated interproximal caries
lesions conditionally recommends enamel infiltration for
treatment of these lesions, (low to very low certainty).37 Few
RCTs evaluate the long-term effectiveness of resin infiltration.
An additional use of resin infiltration has been suggested to
restore white-spot lesions. Based on a RCT, resin infiltration
significantly improved the clinical appearance of such white-
spot lesions and visually reduced their size.38
Recommendations:
1. Resin infiltration is indicated as an adjunct to preventive
measures for primary and permanent teeth with small,
noncavitated interproximal caries lesions to reduce lesion
progression and for white-spot lesions to improve their
clinical appearance.
2. Further research regarding long-term effectiveness of
resin infiltration is needed.
BEST PRACTICES: RESTORATIVE DENTISTRY
Dental amalgam
Dental amalgam contains a mixture of metals such as silver,
copper, and tin, in addition to approximately 50 percent
mercury.39 Use of dental amalgam has declined, perhaps due
to the controversy surrounding perceived health effects of
mercury vapor, environmental concerns from its mercury
content, and increased demand for esthetic alternatives.40
Two independent RCTs in children have examined the
effects of mercury release from amalgam restorations and
found no effect on the central and peripheral nervous systems
and kidney function.41,42 However, in 2009, the United States
Food and Drug Administration (FDA) issued a final rule that
reclassified dental amalgam to a Class II device (having some
risk) and designated guidance that included warning labels
regarding: (1) possible harm of mercury vapors; (2) disclosure
of mercury content; and (3) contraindications for persons with
known mercury sensitivity.39 Also in this final rule, the FDA
noted information regarding dental amalgam and the long-
term health outcomes in pregnant women, developing fetuses,
and children under the age of six is limited.39
In 2020, the FDA published recommendations on the use
of dental amalgam in certain populations considered high-risk,
such as pregnant women, women planning to become preg-
nant, nursing women, children under six years old, and
people with pre-existing neurological disease.43 The FDA
recommended providers avoid the use of dental amalgam in
these high-risk populations and consider alternative restora-
tive materials.43 However, the ADA immediately reaffirmed
that amalgam is a durable, safe, and effective restorative option
and that the FDA's recommendations did not cite any new
scientific evidence.44 The ADA encourages providers to review
all options for restorations with their patients and review the
risks and benefits of amalgam.44 Both organizations recom-
mend that existing amalgam fillings in good condition should
not be removed or replaced unless medically necessary.43,44
With regard to clinical efficacy of dental amalgam, results
comparing longevity of amalgam to other restorative materials
are inconsistent. Most meta-analyses, evidence-based reviews,
and RCTs report comparable durability of dental amalgam to
other restorative materials,45-50 yet others show greater longev-
ity for amalgam.51,52 The comparability appears to be especially
true when the restorations are placed in controlled environ-
ments such as university settings.45
Class I amalgam restorations in primary teeth have shown
in a systematic review and two RCTs to have a success rate of
85 to 96 percent for up to seven years, with an average annual
failure rate of 3.2 percent.17,49,52 Efficacy of Class I amalgam
restorations in permanent teeth of children has been shown
in two independent RCTs to range from 89.8 to 98.8 percent
for up to seven years.49,51
With regard to Class II restorations in primary molars, a
2015 systematic review recommended that amalgam could be
utilized in preparations that do not extend beyond proximal
line angles.53 For Class II restorations in permanent teeth, one
meta-analysis and one evidence-based review conclude that
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 403
BEST PRACTICES: RESTORATIVE DENTISTRY
the mean annual failure rates of amalgam and composite are
equal at 2.3 percent.45,48 The meta-analysis comparing amal-
gam and composite Class II restorations in permanent teeth
suggests that higher replacement rates of composite in general
practice settings can be attributed partly to general practi-
tioners’ confusion of marginal staining for marginal caries and
their subsequent premature replacements.45 Otherwise, this
meta-analysis concludes that the median success rate of com-
posite and amalgam are statistically equivalent after ten years,
at 92 percent and 94 percent respectively.45
The limitation of many of the clinical trials that compare
dental amalgam to other restorative materials is that the study
period often is short (24 to 36 months), at which time interval
all materials reportedly perform similarly.54-58 Some of these
studies also may be at risk for bias, due to lack of true ran-
domization, inability of blinding of investigators, and, in some
cases, financial support by the manufacturers of the dental
materials being studied.
Recommendations:
1. Dental amalgam may be used to restore Class I and Class
II cavity restorations in primary and permanent teeth.
2. Providers should review the risks and benefits of amal-
gam restorations with patients.
Composites
Resin-based composite restorations were introduced in dentistry
about a half century ago as an esthetic restorative material59,60,
and composites increasingly are used in place of amalgam for
the restoration of caries lesions.45,61 Composites consist of a
resin matrix and chemically bonded fillers.45 They are classified
according to their filler size, because filler size affects physical
properties, polishability/esthetics, polymerization depth, and
polymerization shrinkage.62 Hybrid resins combine a mixture
of particle sizes for improved strength while retaining esthetics. 63
The smaller filler particle size allows greater polishability and
esthetics, while larger size provides strength. Flowable resins
have a lower volumetric filler percentage than hybrid resins.64
Several factors contribute to the longevity of resin compo-
sites, including operator experience, restoration size, and tooth
position.51 Resins are technique sensitive and require longer
placement time than amalgams.65 In cases where isolation or
patient cooperation is in question, resin-based composite may
not be the restorative material of choice.65,66 Additionally, com-
posite may not be the ideal restorative material for primary
posterior teeth requiring large multisurface restorations or
high-risk patients with poor oral hygiene, numerous carious
teeth, and demineralization.65
Bisphenol A (BPA) and its derivatives are components of
resin-based dental sealants and composites. Trace amounts of
BPA derivatives are released from dental resins through salivary
enzymatic hydrolysis and increase from baseline at 24 hours
posttreatment, but return to baseline by 14 days and remain at
baseline six months after treatment.67 Evidence is accumulating
that certain BPA derivatives may pose health risks attributable
to their endocrine-disrupting properties, but no established
404 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
thresholds for safety and exposure have been determined.67 BPA
exposure reduction is achieved by cleaning filling surfaces with
pumice and cotton roll and rinsing. Additionally, potential
exposure can be reduced by using a rubber dam.68 Considering
the proven benefits of resin-based dental materials and minimal
exposure to BPA and its derivatives, continued use of these
products, while taking precautions to minimize BPA exposure,
has been recommended.69
There is strong evidence from a meta-analysis of 59 RCTs
of Class I and II composite and amalgam restorations show-
ing an overall success rate about 90 percent after 10 years for
both materials, with rubber dam use significantly increasing
restoration longevity.45 Strong evidence from RCTs comparing
composite restorations to amalgam restorations showed the
main reason for restoration failure in both materials was
recurrent caries.49,51,68
In primary teeth, there is strong evidence that composite
materials for Class I restorations are successful.17,49 One RCT
showed success of Class II composite restorations in primary
teeth that were expected to exfoliate within two years.56 An-
other RCT comparing total caries removal versus selective
caries removal with composite restorations showed a statistic-
ally significant higher survival rate with total caries removal
after 36 months (81 percent to 57 percent).70 In permanent
molars, composite replacement after 3.4 years was no different
than amalgam,49 but after seven to 10 years the replacement
rate was higher for composite.66 Secondary caries rate was
reported as 3.5 times greater for composite versus amalgam.51 A
meta-analysis concluded that etching and bonding of enamel
and dentin significantly decreases marginal staining and
detectable margins in composite restorations. 45 Regarding
different types of composites (i.e., packable, hybrid, nano-
filled, macrofilled, microfilled), evidence showing similar
overall clinical performance for these is strong.71-74
Recommendations:
1. Resin-based composites can be used as Class I and Class
II restorations in primary and permanent molars.
2. Evidence from a meta-analysis shows enamel and
dentin bonding agents decrease marginal staining and de-
tectable margins for the different types of composites.
3. Precautions should be used in conjunction with place-
ment of resin-based composites to help minimize BPA
exposure.
Glass-ionomer cements (GIC)
Glass-ionomers cements have been used in dentistry as
restorative cements, cavity liner/base, and luting cement since
the early 1970s.75 Originally, glass-ionomer materials had long
setting times and low fracture strength and exhibited poor
wear resistance.76 Advancements in conventional glass ionomer
formulation led to better properties, including the formation
of resin-modified glass ionomers. These products showed
improvement in handling characteristics, decreased setting
time, increased strength, and improved wear resistance.77,78 All
glass ionomers have several properties that make them favorable

for use in children including chemical bonding to both
enamel and dentin, thermal expansion similar to that of tooth
structure, biocompatibility, uptake and release of fluoride, and
decreased moisture sensitivity when compared to resins.76
Fluoride is released from glass ionomer and taken up by the
surrounding enamel and dentin, resulting in teeth that are less
susceptible to acid challenge.79,80 Glass ionomers can act as a
reservoir of fluoride, as uptake can occur from dentifrices,
mouth rinses, and topical fluoride applications.81,82 This fluoride
protection, useful in patients at high risk for caries, has led to
the use of glass ionomers as luting cement for SSCs, space
maintainers, and orthodontic bands.83
One RCT showed the overall median time from treatment
to failure of conventional glass-ionomer restored primary teeth
was 1.2 years.52 Based on findings of a systematic review and
meta-analysis, conventional glass ionomers have not been rec-
ommended for Class II restorations in primary molars.84,85
Conventional glass-ionomer restorations have other draw-
backs such as poor anatomical form and marginal integrity.86,87
Composite restorations were more successful than GICs where
moisture control was not a problem.85
Resin-modified glass-ionomer cements (RMGIC), with
the acid-base polymerization supplemented by a second,
light-cure polymerization, have been shown to be efficacious
in primary teeth.88 Based on a meta-analysis, RMGIC is more
successful than conventional glass ionomer as a restorative
material.85 A systematic review supports the use of RMGIC
in small to moderate sized Class II cavities.84 Class II RMGIC
restorations are able to withstand occlusal forces on primary
molars for at least one year. 85 Because of fluoride release,
RMGIC may be considered for Class I and Class II restora-
tions of primary molars in a high caries risk population. 87
Conditioning dentin improves the success rate of RMGIC.84
According to one RCT, cavosurface beveling leads to high
marginal failure in RMGIC restorations and is not recom-
mended.68
With regard to permanent teeth, a meta-analysis review
reported significantly fewer caries lesions on single-surface
glass ionomer restorations in permanent teeth after six years as
compared to restorations with amalgam.87 Data from a meta-
analysis show that RMGIC is more caries preventive than
composite resin with or without fluoride.89 Another meta-
analysis showed that cervical restorations (Class V) with glass
ionomers may have a good retention rate but poor esthetics.45
For Class II restorations in permanent teeth, one RCT showed
unacceptable high failure rates of conventional glass ionomers,
irrespective of cavity size.91 However, a high dropout rate in
this study limits significance.91
Silver diamine fluoride (SDF) application has been used
prior to or in conjunction with GIC and RMGIC restorations
in primary and permanent teeth. A systematic review and
meta-analysis that evaluated the influence of SDF on the
dentin bonding of adhesive materials included eleven and
ten studies, respectively. 92 The systematic review found
that prior application of SDF does not have a negative effect
BEST PRACTICES: RESTORATIVE DENTISTRY
on the bond strength between glass ionomer cement and
dentin.92 Another systematic review of thirteen studies that
examined the effect of SDF application on the bond strength
between dentin and adhesives and dentin and glass-ionomer
cements was inconclusive due to the inconsistent results
from the included studies.93 Further research examining the
effect of SDF application to the bond strength of glass
ionomers, as well as the advantages of its use prior to the
application of glass ionomers, is needed.
Glass ionomers can be utilized for caries control in pa-
tients with high caries risk and for restoration repair.76 Other
applications of glass ionomers in which fluoride release has
advantages are for ITR and ART. These procedures have similar
techniques but different therapeutic goals. ITR may be used
in very young patients,94 uncooperative patients, or patients
with special health care needs50 for whom traditional cavity
preparation or placement of traditional dental restorations
is not feasible or needs to be postponed. Additionally, ITR
may be used for caries control in children with multiple
open caries lesions, prior to definitive restoration of the teeth.95
In-vitro, leaving caries-affected dentin does not jeopardize the
bonding of glass ionomercements to the primary tooth
dentin.96 ART, endorsed by the World Health Organization
and the International Association for Dental Research, is
a means of restoring and preventing caries in populations
that have little access to traditional dental care and functions
as definitive treatment.97
According to a meta-analysis, single-surface ART restora-
tions had a high survival percentage over the first three years
in primary teeth and over the first five years in permanent
teeth. 98 One RCT supported single-surface restorations
irrespective of the cavity size and also reported higher success
in non-occlusal posterior ART compared to occlusal posterior
ART.99 With regard to multisurface ART restorations, there
is conflicting evidence. Based on a meta-analysis, ART restora-
tions presented similar survival rates to conventional approaches
using composite or amalgam for Class II restorations in
primary teeth. 100,101 Multisurface ART restorations in
primary teeth exhibited a medium survival percentage over
two years.98 A recent RCT that compared modified ART to
preformed metal crowns on primary teeth reported major
failures on 21 percent of modified ART restorations at six
months and 34 percent at twelve months.102 More research
is needed on the survival percentage of multisurface ART
restorations in permanent teeth.
Recommendations:
1. GICs may be used for Class I restorations in primary
teeth.
2. RMGICs may be used for Class I restorations, and
expert opinion supports Class II restorations in primary
teeth.
3. Evidence is insufficient to support the use of conven-
tional or RMGICs as long-term restorative material in
permanent teeth.
Recommendations continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 405
BEST PRACTICES: RESTORATIVE DENTISTRY
4. ITR/ART using high-viscosity glass-ionomer cements
may be used as single surface temporary restoration for
both primary and permanent teeth. Additionally, ITR
may be used for caries control in children with multiple
open caries lesions, prior to definitive restoration of the
teeth.
5. Further research examining the effect of SDF applica-
tion on the bond strength of glass ionomers to dentin
is needed.
Compomers
Polyacid-modified resin-based composites, or compomers, were
introduced into dentistry in the mid-1990s. They contain
72 percent (by weight) strontium fluorosilicate glass and the
average particle size is 2.5 micrometers.103 Moisture is attracted
to both acid functional monomer and basic ionomer-type
in the material. This moisture can trigger a reaction that
releases fluoride and buffers acidic environments.104,105 Consid-
ering the ability to release fluoride, esthetic value, and simple
handling properties, compomer can be useful in pediatric
dentistry.103
Based on a 2007 RCT, the longevity of Class I compomer
restorations in primary teeth was not statistically different
compared to amalgam, but compomers were found to need
replacement more frequently due to recurrent caries.49 In Class
II compomer restorations in primary teeth, the risk of develop-
ing secondary caries and failure did not increase over a two-
year period in primary molars. 57,106 Compomers also have
reported comparable clinical performance to composite with
respect to color matching, cavosurface discoloration, ana-
tomical form, and marginal integrity and secondary caries.107,108
Compomers are available in a variety of nonconventional
colors which, when polymerized, can cause varying pulp
chamber temperatures. 109,110 Most RCTs showed that com-
pomer tends to have better physical properties compared to
GIC and RMGIC in primary teeth, but no significant
difference was found in cariostatic effects of compomer
compared to these materials.52,106,111-114
Recommendations:
1. Compomers can be an alternative to other restorative
materials in the primary dentition in Class I and Class
II restorations.
2. There is not enough data comparing compomers to other
restorative materials in permanent teeth of children.
Bioactive materials
A recently recognized category of materials is termed bioactive.
Bioactive restorative materials release ions (typically calcium,
fluoride, or phosphate115) yet, at times, antibacterial mono-
mers, silver particles, or strontium particles.116 The materials
also can absorb ions at their surface. Although they may not
meet true ionic equilibrium, the ion exchange still can help
prevent adjacent tooth demineralization and enhance reminer-
alization.117,118
406 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Bioactive dental restorative materials are available for seal-
ants, adhesive bonding agents, cements, resin-based restorations,
GIC and RMGIC restorations, as well as pulp capping agents.
Since each bioactive material interacts with hard tissue
differently, a modified surface treatment may be required.119
Recommendations:
1. Bioactive materials can be used for remineralization and
pulp capping.
2. Further research examining the basic properties and
long-term effect of bioactive materials and comparing
bioactive materials to other restorative materials is needed.
Preformed metal crowns
Preformed metal crowns (PMC), also known as SSC, are pre-
fabricated crown forms that are adapted to individual teeth and
cemented with a biocompatible luting agent. PMC have been
indicated for the restoration of primary and permanent teeth
with extensive caries, cervical decalcification, or developmental
defects (e.g., hypoplasia, hypocalcification), when failure of
other available restorative materials is likely (e.g., interproximal
caries extending beyond line angles, patients with bruxism),
following pulpotomy or pulpectomy, for restoring a primary
tooth that is to be used as an abutment for a space maintainer,
for the intermediate restoration of fractured teeth, and for
definitive restorative treatment for high caries-risk children.120
They are used more frequently in patients who exhibit high
caries risk and whose treatment is performed under sedation
or general anesthesia.121-123
Very few prospective RCTs compare outcomes for PMC
to intracoronal restorations. 124,125 A Cochrane review and
additional studies, including two systematic reviews, concluded
that the majority of clinical evidence for the use of PMC has
come from nonrandomized and retrospective studies.17,121-123
However, this evidence suggests that PMC showed greater
longevity than amalgam restorations,17 despite possible study
bias of placing SSCs on teeth more damaged by caries.122,123,126
Five studies which retrospectively compared Class II amalgams
to PMC showed an average five-year failure rate of 26 percent
for amalgam and seven percent for PMC.122 SSC were shown
in a recent retrospective study to have a higher survival rate
compared to multisurface restorations and may be considered
when treating multisurface caries in children younger than
four years old in order to avoid possible retreatment.127
A two-year RCT regarding restoration of primary teeth that
had undergone a pulpotomy procedure found a nonsignificant
difference in survival rate for teeth restored with PMC (95
percent) versus RMGIC/composite restoration (92.5 per-
cent).124 A one-year RCT comparing primary molars treated
with mineral trioxide aggregate (MTA) pulpotomies and
restored with either multisurface composite restorations or
PMC showed no difference in radiographic success over a
12-month follow-up period. 125 However, the pulpotomized
teeth with multisurface composite restorations had more
marginal change and required more maintenance than those
with PMC, and a majority turned gray up to 12 months
 BEST PRACTICES: RESTORATIVE DENTISTRY

later even with the use of white MTA. 125 A systematic
review on the use of SSC determined that the reported out-
comes of primary teeth with pulpal therapy are best in teeth
treated with SSC.120
With regards to gingival health adjacent to PMC, a one-
year RCT showed no difference in gingival inflammation
between PMC and composite restorations after pulpotomy.123
Yet, a two-year randomized clinical study showed more gingival
bleeding for PMC versus composite/glass ionomer restora-
tions. 124 Inadequately contoured crown and residues of set
cement remaining in contact with the gingival sulcus have
been suggested as reasons for gingivitis associated with PMC,
and a preventive regime including oral hygiene instruction
has been recommended for incorporation into the treatment
plan.122
The one RCT on PMC versus cast crowns placed on
permanent teeth 128 found no difference between the two
restoration types for quality and longevity after 24 months.
A recent retrospective cohort study that focused on long-
term clinical outcomes of SSCs compared to amalgam and
composite restorations in permanent teeth on special needs
populations concluded that posterior permanent teeth restored
with SSCs can be expected to last for 10 years and represent
a viable treatment option for severely carious or fractured
posterior permanent teeth.129 The remaining evidence is case
reports and expert opinion concerning indications for use of

Table 1. EVIDENCE OF EFFICACY OF VARIOUS DENTAL MATERIALS/TECHNIQUES IN PRIMARY 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 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
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.

RMGIC = resin modified glass ionomer cement. SSC = stainless steel crown. N/A = not available.
_ 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
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.

RMGIC = resin modified glass ionomer cement. SSC = stainless steel crown. N/A = not available.
_ 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 407

BEST PRACTICES: RESTORATIVE DENTISTRY
PMC on permanent molars. The indications include teeth
with severe genetic/developmental defects, grossly carious
teeth, and traumatized teeth, along with tooth developmental
stage or financial considerations that require semi-permanent
restoration instead of a permanent cast restoration. 121,126,128
The main reasons for PMC failure reportedly are crown
loss17,130,131 and perforation131.
A recent method of providing PMC is known as the
Hall technique (HT). 132 The HT calls for cementation of
an SSC over a caries-affected primary molar without local
anesthetic, caries removal, or tooth preparation. A less invasive
management procedure for treating carious primary teeth,
HT involves caries control by managing the activity of the
biofilm. 133 In essence, bacteria sealed into the tooth and
denied of substrate will die rather than result in caries pro-
gression, and the best way of producing an effective marginal
seal is with a crown.134
Using HT may reduce discomfort from local anesthetic
and caries removal at the time of treatment compared to fill-
ings, 132 but it may add the discomfort of placement of
separator bands prior to the SSC, as well as the pain from
biting the crown into place.135 In a randomized split mouth
clinical trial with general dentists as providers, sealing in caries
by using HT significantly outperformed the general dentists’
standard restorations to restore caries interproximally and was
more effective in the long term.136 HT may be considered a
treatment modality for carious primary molars when tradi-
tional SSC technique is not feasible due to limitations such
as poor cooperation or barriers to care.102 Additional studies
that compare this technique to traditionally-placed PMC
using long-term follow-ups, radiographic assessment, and
caries removal are needed.102,137
SSC continue to offer the advantage of full coverage to
combat recurrent caries and provide strength as well as long-
term durability with minimal maintenance, which are
desirable outcomes for caries management for high-risk
children.120
Recommendations:
1. Retrospective studies reported greater longevity of PMC
restorations compared to amalgam or resin-based res-
torations for the treatment of caries lesions in primary
teeth. Therefore, use of SSC is indicated for high-risk
children with large or multi-surface cavitated or non-
cavitated lesions on primary molars, especially when
children require advanced behavioral guidance tech-
niques138 including general anesthesia for the provision
of restorative dental care.
2. PMC may be indicated in permanent teeth as a semi-
permanent restoration for the treatment of severe enamel
defects or grossly carious teeth.
3. Further research comparing HT to traditionally-placed
PMC is needed.
Posterior esthetic crowns in primary teeth
The interest by clinicians and patients in esthetic options
408 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
for full coverage restoration of primary posterior teeth is
increasing.139,140 Scientific studies that evaluate esthetic options
for restoring posterior primary teeth with large caries lesions
are not widely reported in the literature. While opened-faced
SSC or preveneered SSC are not ideal based on minimum
evidence, zirconia crowns are an option that has been used
by pediatric dentists. Several preformed pediatric zirconia
crowns are available on the market, and brands differ in
material composition, fabrication, surface treatment, retentive
feature, and cementation method.141 More circumferential
tooth reduction is needed for proper fit and placement of
zirconia crowns compared to SSC142 and, for proper retention,
the minimum abutment height is two millimeters143. The indi-
cations for the preformed esthetic crowns are generally the
same as those of the preformed SSCs but with consideration
of esthetics.144 Clinical parameters between zirconia crowns
and SSC are similar except for retention and gingival health;
SSC have comparatively better retention and zirconia crowns
have relatively better gingival health.144,145
Recommendation:
1. Evidence is limited on the use of zirconia crowns as
esthetic crowns for primary posterior teeth. When SSC
would otherwise be indicated, zirconia crowns may be
considered in lieu of SSC to due to esthetic considerations.
Anterior esthetic restorations in primary teeth
With increasing demand for esthetic considerations for
children by their parents, treatment of dental caries of primary
anterior teeth remains one of the biggest challenges in pedi-
atric dentistry.146 Esthetic restoration of primary anterior teeth
can be especially challenging due to: the small size of the
teeth; close proximity of the pulp to the tooth surface;
relatively thin enamel; lack of surface area for bonding; and
issues related to child behavior.147
Most evidence for the clinical techniques utilized to restore
primary anterior teeth is regarded as expert opinion. While a
lack of strong clinical data does not preclude the use of these
techniques, it points out the strong need for well-designed,
prospective clinical studies to validate their use.147
Class III (interproximal) restorations of primary incisors
can be prepared with labial or lingual dovetails to incorporate
a large surface area for bonding to enhance retention.147 Resin-
based restorations are appropriate for anterior teeth that can
be adequately isolated from saliva and blood. RMGIC have
been suggested for this category, especially when adequate
isolation is not possible. 76,148,149 Patients considered at high
risk for caries may be better served with placement of full
tooth coverage restorations.147,149
Class V (cervical) cavity preparations for primary incisors
are similar to those in permanent teeth. Due to the young age
of children treated and associated cooperation difficulty, it is
sometimes impossible to isolate teeth for the placement of
composite restorations. In these cases, GIC or RMGIC is
suggested.148,149

Full coronal restoration of carious primary incisors may
be indicated when: (1) caries is present on multiple surfaces,
(2) the incisal edge is involved, (3) cervical decalcification is
extensive, (4) pulpal therapy is indicated, (5) caries may be
minor, but oral hygiene is very poor, or (6) the child’s behavior
makes moisture control very difficult.147 Currently, full coronal
restorations of primary teeth are bonded to existing tooth
structure or cemented in place. 147 Resin strip crowns are
bonded to the tooth, and two retrospective studies show that
80 percent are retained after three years. 150,151 Resin strip
crowns are esthetic, and parental satisfaction is high. They are
technique sensitive and require sufficient tooth structure to
provide surface area for bonding. Hemorrhage or saliva can
interfere with bonding of the materials, and hemorrhage
can affect the color of the crown.141,147
Preveneered SSC also are among the options of restoring
primary anterior teeth with full coronal coverage. Three retro-
spective studies report excellent clinical retention of this type
of crowns, yet a high incidence of partial or complete loss of
the resin facings.152,153 The crimping of preveneered SSC on
the metal side does not affect the fracture resistance.154 Pre-
veneered SSC have the concerns of color stability and surface
roughness changes,155 so long-term clinical studies are required
to establish their comparative effectiveness. Preformed
SSC and opened-faced SSC are still options for treatment
on primary anterior teeth, but published studies reporting
their effectiveness and use are sparse156 given the availability
of more esthetic and easier-to-use alternatives.
Preformed zirconia crowns have been available in pediatric
dentistry since 2010.147 Zirconia crowns are strong, esthetic,
and biocompatable.147,157 Zirconia crowns placed in a university
clinic displayed survival probability at 12, 24 and 36 months
of 93, 85, and 76 percent respectively. 158 Parental esthetic
satisfaction has been shown to be higher for zirconia crowns
than resin strip crowns or preveneered SSC.157 Disadvantages
of zirconia crowns include a steep learning curve for dentists
and, since the crowns cannot be adjusted, the tooth must
be reduced in order to fit the crown. The amount of tooth
reduction is greater than that required for an SSC and reduc-
tion of 1.5 to two millimeters with a feather margin is
required to passively seat the zirconia crown.142
Recommendations:
1. Resin-based composites may be used as a treatment
option for Class III and Class V restorations in the
primary and permanent dentition.
2. Expert opinion finds the use of RMGIC as a treatment
option for Class III and Class V restorations for pri-
mary teeth, particularly in circumstances where adequate
isolation of the tooth to be restored is difficult.
3. Expert opinion suggests that strip crowns, preveneered
SSC, preformed SSC, opened-faced SSC, and zirconia
crowns are treatment options for full coronal coverage
restorations in primary anterior teeth.
BEST PRACTICES: RESTORATIVE DENTISTRY
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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
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:415-23.

Abstract
This best practice supports clinicians in the diagnosis of pulp health or pathosis and provides evidence for various therapeutic interventions
for pulp therapy in both primary and immature permanent teeth. The health status of pulp tissue determines which form of pulp therapy
is indicated. Vital pulp therapies for primary teeth with normal pulp or reversible pulpitis include protective liner, indirect pulp treatment,
direct pulp cap, and pulpotomy. Nonvital pulp treatment for primary teeth with irreversible pulpitis or necrotic pulp include pulpectomy
and lesion stabilization/tissue repair. Vital pulp therapy for immature permanent teeth with a normal pulp or pulpitis include protective
liners, apexogenesis, indirect pulp treatment, direct pulp cap, partial pulpotomy, and complete pulpotomy. Nonvital pulp treatment for
permanent teeth includes conventional root canal treatment, apexification, and regenerative endodontics. Clinicians should familiarize them-
selves with these pulp therapies and consider the value of each tooth in question, restorability of the tooth, and potential alternative treatment.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and guidance on pulp therapy for primary and immature permanent teeth.
KEYWORDS: DENTAL PULP, ROOT CANAL THERAPY, ROOT CANAL PREPARATION, PULP CAPPING, APEXIFICATION

Purpose
The American Academy of Pediatric Dentistry (AAPD) intends
these recommendations to aid in the diagnosis of pulp health
versus pathosis and to set forth the indications, objectives,
and therapeutic interventions for pulp therapy in primary and
immature permanent teeth.
Methods
Recommendations on pulp therapy for primary and immature
permanent teeth were developed by the Clinical Affairs
Committee – Pulp Therapy Subcommittee and adopted in
1991.1 This document by the Council on Clinical Affairs is
a revision of the previous version, last revised in 2014.2 This
revision included a new search of the PubMed /MEDLINE
database using the terms: pulpotomy, pulpectomy, pulpec-
® as: normal pulp (symptom free and normally responsive to
tomy primary teeth, indirect pulp treatment (IPT), stepwise
excavation, pulp therapy, pulp capping, pulp exposure, bases,
liners, calcium hydroxide, formocresol, ferric sulfate, glass
ionomer, mineral trioxide aggregate (MTA), bacterial
microleakage under restorations, lesion sterilization tissue
repair (LSTR), dentin bonding agents, resin modified glass
ionomers, and endodontic irrigants; fields: all. Papers for
review were chosen from the resultant lists and from hand
searches. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/
or consensus opinion including those from the 2007 joint
symposium of the AAPD and the American Association of
Endodontists (AAE) titled Emerging Science in Pulp Therapy:
New Insights into Dilemmas and Controversies (Chicago, Ill.)
Background
The primary goal of pulp therapy is to maintain the integrity
and health of the teeth and their supporting tissues while
maintaining the vitality of the pulp of a tooth affected by
caries, traumatic injury, or other causes. Especially in young
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
dentinal walls that are thick enough to withstand normal
function. Therefore, pulp preservation is a primary goal for
treatment of the young permanent dentition.
The indications, objectives, and type of pulp therapy are
based on the health status of the pulp tissue which is classified
vitality testing), reversible pulpitis (pulp is capable of healing),
symptomatic or asymptomatic irreversible pulpitis (vital
inflamed pulp is incapable of healing), or necrotic pulp. 3 The
clinical diagnosis derived from:4-7
1. a comprehensive medical history.
2. a review of past and present dental history and
treatment, including current symptoms and chief
complaint.
ABBREVIATIONS
AAE: American Association of Endodontists. AAPD: American
Academy of Pediatric Dentistry. DPC: Direct pulp cap. IPT: Indirect
pulp therapy. ITR: Interim therapeutic restoration. LSTR: Lesion
sterilization/tissue repair. MTA: Mineral trioxide aggregate. ZOE:
Zinc oxide eugenol.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 415

BEST PRACTICES: PULP THERAPY
3. a subjective evaluation of the area associated with
the current symptoms/chief complaint by question-
ing the patient/parent on the location, intensity,
duration, stimulus, relief, and spontaneity.
4. an objective extraoral examination as well as examina-
tion of the intraoral soft and hard tissues.
5. if obtainable, radiograph(s) to diagnose periapical or
periradicular changes.
6. clinical tests such as palpation, percussion, and
mobility; however, electric pulp and thermal tests are
unreliable in immature permanent and primary teeth.
Teeth exhibiting provoked pain of short duration relieved
with over-the-counter analgesics, by brushing, or upon the
removal of the stimulus and without signs or symptoms of
irreversible pulpitis have a clinical diagnosis of reversible pulp-
itis and are candidates for vital pulp therapy. Teeth diagnosed
with a normal pulp requiring pulp therapy or with reversible
pulpitis should be treated with vital pulp therapy.8-11
Teeth exhibiting signs or symptoms such as a history of
spontaneous unprovoked pain, a sinus tract, soft tissue inflam-
mation not resulting from gingivitis or periodontitis, excessive
mobility not associated with trauma or exfoliation, furcation/
apical radiolucency, or radiographic evidence of internal/
external resorption have a clinical diagnosis of irreversible
pulpitis or necrosis and are candidates for nonvital pulp treat-
ment.12 Regenerative endodontics may be considered for im-
mature permanent teeth with apical periodontitis, a necrotic
pulp, and immature apex.13
Recommendations
All relevant diagnostic information, treatment, and treatment
follow-up shall be documented in the patient’s record.
Any planned treatment should include consideration of:
1. the patient’s medical history;
2. the value of each involved tooth in relation to the
child’s overall development;
3. alternatives to pulp treatment; and
4. restorability of the tooth.
When the infectious process cannot be arrested by the
treatment methods included in this section, bony support
cannot be regained, inadequate tooth structure remains for
a restoration, or excessive pathologic root resorption exists,
extraction should be considered.4,12
This document is intended to recommend the best available
clinical care for pulp treatment, but the AAPD encourages
additional research for consistently successful and predictable
techniques using biologically-compatible medicaments for
vital and non-vital primary and immature permanent teeth.
Pulp therapy requires periodic clinical and radiographic assess-
ment of the treated tooth and the supporting structures.14
Postoperative clinical assessment generally should be performed
every six months and could occur as part of a patient’s periodic
comprehensive oral examination. Patients treated for an acute
416 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
dental infection initially may require more frequent clinical
reevaluation. A radiograph of a primary tooth pulpectomy
should be obtained immediately following the procedure.5 This
can document the quality of the fill and help determine the
tooth’s prognosis. This image also would serve as a comparative
baseline for future films (the type and frequency of which are
at the clinician’s discretion). Radiographic evaluation of primary
tooth pulpotomies should occur at least annually because the
success rate of pulpotomies diminishes over time.15 Bitewing
radiographs obtained as part of the patient’s periodic compre-
hensive examinations may suffice. If a bitewing radiograph
does not display the interradicular area, a periapical image is
indicated. Immature permanent teeth treated with pulp therapy
also should have close clinical and radiographic follow-up to
confirm that pulp pathology is not developing.16 Isolation is
necessary to minimize bacterial contamination and to protect
soft and hard tissues. Use of rubber dam isolation is considered
a gold standard17 for pulp treatment. When unable to use a
rubber dam, other effective isolation may be considered.
When a pulp exposure occurs and pulp therapy is indicated,
irrigants for pulp therapy should not come from dental
unit water lines. The Centers for Disease Control and
Prevention states “conventional dental units cannot reliably
deliver sterile water even when equipped with independent
water reservoirs containing sterile water because the water-
bearing pathway cannot be reliably sterilized.”18 A single-use
disposable syringe should be used to dispense irrigants for
pulp therapy.
Primary teeth
Vital pulp therapy for primary teeth diagnosed with a normal
pulp or reversible pulpitis
Protective liner. A protective liner is a thinly-applied material
placed on the dentin in proximity to the underlying pulpal
surface of a deep cavity preparation, covering exposed dentin
tubules to act as a protective barrier between the restorative
material or cement and the pulp. Placement of a thin protec-
tive liner such as MTA, trisilicate cements, calcium hydroxide,
or other biocompatible material is at the discretion of the
clinician.19,20
• Indications: In a tooth with a normal pulp when all caries
is removed for a restoration, a protective liner may be
placed in the deep areas of the preparation to minimize
injury to the pulp, promote pulp tissue healing, and/or
minimize postoperative sensitivity.21,22
• Objectives: The placement of a liner in a deep area of the
preparation is utilized to preserve the tooth’s vitality, pro-
mote pulp tissue healing and tertiary dentin formation, and
minimize bacterial microleakage.23 Adverse posttreatment
clinical signs or symptoms such as sensitivity, pain, or
swelling should not occur.
Indirect pulp treatment. IPT is a procedure performed in a
tooth with a deep caries lesion approximating the pulp but
without evidence of radicular pathology. “Indirect pulp

treatment is a procedure that leaves the deepest caries adjacent
to the pulp undisturbed in an effort to avoid a pulp exposure.
This caries-affected dentin is covered with a biocompatible
material to produce a biological seal.”17 A radiopaque liner such
as a dentin bonding agent,24,25 resin modified glass ionomer,4
calcium hydroxide,25 or MTA (or any other biocompatible
material)26 is placed over the remaining carious dentin to
stimulate healing and repair. The liner that is placed over the
dentin (calcium hydroxide, glass ionomer, or bonding agents)
does not affect the IPT success.27 The tooth then is restored
with a material that seals the tooth from microleakage.
Interim therapeutic restorations (ITR) with glass ionomer
cements may be used for caries control in teeth with caries
lesions that exhibit signs of reversible pulpitis. The ITR can
be removed once the pulp’s vitality is determined and, if
the pulp is vital, an indirect pulp cap can be performed.15,28
Current literature indicates there is no conclusive evidence
that it is necessary to reenter the tooth to remove the residual
caries.29,30 As long as the tooth remains sealed from bacterial
contamination, the prognosis is good for caries to arrest and
reparative dentin to form to protect the pulp. 29-34 Indirect
pulp treatment has been shown to have a higher success rate
than direct pulp cap (DPC) and pulpotomy in long term
studies.8,10,15,25,27,35-40 IPT also allows for a normal exfoliation
time. Therefore, IPT can be chosen instead of DPC or
pulpotomy when the pulp is normal or has a diagnosis of
reversible pulpitis and there is no pulp exposure.
• Indications: IPT is indicated in a primary tooth with deep
caries that exhibits no pulpitis or with reversible pulpitis
when the deepest carious dentin is not removed to avoid
a pulp exposure.9,27 The pulp is judged by clinical and
radiographic criteria to be vital and able to heal from the
carious insult.17,27
• Objectives: The restorative material should seal completely
the involved dentin from the oral environment. The tooth’s
vitality should be preserved. No posttreatment signs or
symptoms such as sensitivity, pain, or swelling should be
evident. There should be no radiographic evidence of
pathologic external or internal root resorption or other patho-
logic changes. There should be no harm to the succedaneous
tooth.
Direct pulp cap. When a pinpoint exposure (one millimeter
or less)17 of the pulp is encountered during cavity preparation
or following a traumatic injury, a biocompatible radiopaque
base such as MTA26,41-43 or calcium hydroxide44 may be placed
in contact with the exposed pulp tissue. The tooth is restored
with a material that seals the tooth from microleakage.8
• Indications: This procedure is indicated in a primary tooth
with a normal pulp following a small (one millimeter or
less) pulp exposure of when conditions for a favorable
response are optimal.26,41-43
• Objectives: The tooth’s vitality should be maintained. No
posttreatment signs or symptoms such as sensitivity, pain,
or swelling should be evident. Pulp healing and repara-
BEST PRACTICES: PULP THERAPY
tive dentin formation should result. There should be no
radiographic signs of pathologic external or progressive
internal root resorption or furcation/apical radiolucency.
There should be no harm to the succedaneous tooth.
Pulpotomy. A pulpotomy is performed in a primary tooth
when caries removal results in a pulp exposure in a tooth with
a normal pulp or reversible pulpitis or after a traumatic pulp
exposure12 and there is no radiographic sign of infection or
pathologic resorption. The coronal pulp is amputated, pulpal
hemorrhage is controlled, and the remaining vital radicular pulp
tissue surface is treated with a long-term clinically-successful
medicament. Only MTA and formocresol are recommended
as the medicament of choice for teeth expected to be retained
for 24 months or more.17 Other materials or techniques such
as ferric sulfate, lasers, sodium hypochlorite, and tricalcium
silicate have conditional recommendations.17 The AAPD’s Use
of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions
recommended against the use of calcium hydroxide for pulpo-
tomy.17 After the coronal pulp chamber is filled with a suitable
base, the tooth is restored with a restoration that seals the
tooth from microleakage. If there is sufficient supporting
enamel remaining, amalgam or composite resin can provide a
functional alternative when the primary tooth has a life span
of two years or less.45-47 However, for multisurface lesions, a
stainless steel crown is the restoration of choice.17
• Indications: The pulpotomy procedure is indicated when
caries removal results in pulp exposure in a primary tooth
with a normal pulp or reversible pulpitis or after a traumatic
pulp exposure,7 and when there are no radiographic signs of
infection or pathologic resorption. When the coronal tissue
is amputated, the remaining radicular tissue must be judged
to be vital without suppuration, purulence, necrosis, or
excessive hemorrhage that cannot be controlled by a cotton
pellet after several minutes.4
• Objectives: The radicular pulp should remain asymptom-
atic without adverse clinical signs or symptoms such as sensi-
tivity, pain, or swelling. There should be no postoperative
radiographic evidence of pathologic external root resorption.
Internal root resorption may be self-limiting and stable. The
clinician should monitor the internal resorption, removing
the affected tooth if perforation causes loss of supportive
bone and/or clinical signs of infection and inflammation.48-51
There should be no harm to the succedaneous tooth.
Nonvital pulp treatment for primary teeth diagnosed with irre-
versible pulpitis or necrotic pulp
Pulpectomy. Pulpectomy is a root canal procedure for pulp
tissue that is irreversibly inflamed or necrotic due to caries or
trauma. The root canals are debrided and shaped with hand
or rotary files52 and then irrigated. A recent systematic review
showed no difference in success when irrigating with chlor-
hexidine or one- to five-percent sodium hypochlorite or sterile
water/saline.53,54 Because it is a potent tissue irritant, sodium
hypochlorite must not be extruded beyond the apex.55 After the
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 417
BEST PRACTICES: PULP THERAPY
canals are dried, a resorbable material such as non-reinforced
zinc/oxide eugenol (ZOE),56,57 iodoform-based paste4, or a
combination paste of iodoform and calcium hydroxide58,59 is
used to fill the canals. A recent systematic review reports that
ZOE performed better long term than iodoform-based pastes.53
The tooth then is restored with a restoration that seals the
tooth from microleakage. Clinicians should evaluate non-vital
pulp treatments for success and adverse events clinically and
radiographically at least every 12 months.53,54
• Indications: A pulpectomy is indicated in a primary tooth
with irreversible pulpitis or necrosis or a tooth treatment
planned for pulpotomy in which the radicular pulp exhibits
clinical signs of irreversible pulpitis or pulp necrosis (e.g.,
suppuration, purulence) The roots should exhibit minimal
or no resorption. When there is no root resorption present,
pulpectomy is recommended over LSTR.53,54
• Objectives: Following treatment, the radiographic infectious
process should resolve in six months as evidenced by bone
deposition in the pretreatment radiolucent areas, and pre-
treatment clinical signs and symptoms should resolve within
a few weeks. There should be radiographic evidence of suc-
cessful filling without gross overextension or underfilling.57-59
The treatment should permit resorption of the primary
tooth root and filling material to permit normal eruption of
the succedaneous tooth. There should be no pathologic root
resorption or furcation/apical radiolucency.
Lesion sterilization/tissue repair. LSTR is a procedure that
usually has no instrumentation of the root canals but, instead,
an antibiotic mixture is placed in the pulp chamber which is
intended to disinfect the root canals.53,54 After opening the
pulp chamber of a necrotic tooth, the canal orifices are
enlarged using a large round bur to create medication
receptacles. The walls of the chamber are cleaned with
phosphoric acid and then rinsed and dried.60 A three antibi-
otic mixture of clindamycin, metronidazole, and ciprofloxacin
is combined with a liquid vector of polyethylene glycol and
macrogol to form a paste placed directly into the medication
receptables and over the pulpal floor.60 It then is covered
with a glass-ionomer cement and restored with a stainless steel
crown.60 Previous studies have used minocycline in place of
clindamycin61, but there are concerns about staining when a
tetracycline-like drug is used.62 Although similar success rates
have been reported whether minocycline or clindamycin is
used62, a more recent systematic review concluded statistically
significant less success using a tetracycline mix versus a mix
without tetracycline53. Therefore, the AAPD’s Use of Non-Vital
Pulp Therapies in Primary Teeth recommends antibiotic
mixtures used in LSTR should not include tetracycline.54
• Indications: LSTR is indicated for a primary tooth with
irreversible pulpitis or necrosis or a tooth treatment planned
for pulpotomy in which the radicular pulp exhibits clinical
signs of irreversible pulpitis or pulp necrosis (e.g., suppura-
tion, purulence). Root resorption and strategic tooth position
in the arch should be considered prior to treatment. When
418 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
a tooth is to be maintained for less than twelve months and
exhibits root resorption, LSTR is preferred to pulpectomy.53,54
• Objectives: Following treatment, the radiographic infectious
process should resolve as evidenced by bone deposition in
the pretreatment radiolucent areas and pretreatment clinical
signs and symptoms should resolve.
Immature permanent teeth
Vital pulp therapy for teeth diagnosed with a normal pulp or
reversible pulpitis
Protective liner. A protective liner is a thinly-applied material
placed on the pulpal surface of a deep cavity preparation,
covering exposed dentin tubules, to act as a protective barrier
between the restorative material or cement and the pulp. Place-
ment of a thin protective liner such as MTA, trisilicate
cements, calcium hydroxide, or other biocompatible material
is at the discretion of the clinician.19 The liner must be followed
by a well-sealed restoration to minimize bacterial leakage from
the restoration-dentin interface.23
• Indications: In a tooth with a normal pulp, when caries is
removed for a restoration, a protective liner may be placed
in the deep areas of the preparation to minimize pulp injury,
promote pulp tissue healing, and/or minimize postoperative
sensitivity.
• Objectives: The placement of a liner in a deep area of the
preparation is utilized to preserve the tooth’s vitality, promote
pulp tissue healing, and facilitate tertiary dentin formation.
This liner must be followed by a well-sealed restoration
to minimize bacterial leakage from the restoration-dentin
interface.23 Adverse posttreatment signs or symptoms such
as sensitivity, pain, or swelling should not occur.
Apexogenesis (root formation). Apexogenesis is a histological
term used to describe the continued physiologic development
and formation of the root’s apex. Formation of the apex in
vital young permanent teeth can be accomplished by im-
plementing the appropriate vital pulp therapy described in
this section (i.e., indirect pulp treatment, direct pulp capping,
partial pulpotomy for carious exposures and traumatic
exposures).
Indirect pulp treatment. IPT is a procedure performed in a
tooth with a diagnosis of reversible pulpitis and deep caries
that might otherwise need endodontic therapy if the decay was
completely removed.12 In recent years, rather than completing
the caries removal in two appointments, the focus has been to
excavate as close as possible to the pulp, place a protective liner,
and restore the tooth without a subsequent reentry to remove
any remaining affected dentin.63,64 The risk of this approach is
either an unintentional pulp exposure or irreversible pulpitis.64
When there is concern for pulp exposure, the step-wise excava-
tion of deep caries may be considered.16 This approach involves
a two-step process. The first step is the removal of carious
dentin along the dentin-enamel junction and excavation of
only the outermost infected dentin, leaving a carious mass

over the pulp. The objective is to change the cariogenic
environment in order to decrease the number of bacteria,
close the remaining caries from the biofilm of the oral cavity,
and slow or arrest the caries development.65-67 This interim
restoration should be able to be maintained for up to 12
months.16 The second step is the removal of the remaining
caries and placement of a final restoration. Critical to both
steps of excavation is the placement of a well-sealed
restoration.23 A recent meta-analysis has shown that long term
success rates are equivalent for partial caries removal or step-
wise caries removal with greater than 96 percent of teeth
treated remaining vital after two years.68
• Indications: IPT is indicated in a permanent tooth with
deep caries that exhibits no pulpitis or has been diagnosed
as reversible pulpitis when the deepest carious dentin is not
removed to avoid a pulp exposure. The pulp is judged by
clinical and radiographic criteria to be vital and able to heal
from the carious insult.
• Objectives: The intermediate and/or final restoration should
seal completely the involved dentin from the oral environ-
ment. The vitality of the tooth should be preserved. No
posttreatment signs or symptoms such as sensitivity, pain,
or swelling should be evident. There should be no radio-
graphic evidence of internal or external root resorption or
other pathologic changes. Teeth with immature roots should
show continued root development and apexogenesis.
Direct pulp cap. When a small exposure of the pulp is
encountered during cavity preparation and after hemorrhage
control is obtained, the exposed pulp is capped with a
material such as calcium hydroxide44,69 or MTA69 prior to
placing a restoration that seals the tooth from microleakage.23
• Indications: Direct pulp capping is indicated for a perma-
nent tooth that has a small carious or mechanical exposure
in a tooth with a normal pulp.
• Objectives: The tooth’s vitality should be maintained. No
posttreatment clinical signs or symptoms of sensitivity,
pain, or swelling should be evident. Pulp healing and
reparative dentin formation should occur. There should
be no radiographic evidence of internal or external root re-
sorption, periapical radiolucency, abnormal calcification, or
other pathologic changes. Teeth with immature roots should
show continued root development and apexogenesis.
Partial pulpotomy for carious exposures. The partial pulpotomy
for carious exposures is a procedure in which the inflamed
pulp tissue beneath an exposure is removed to a depth of
one to three millimeters or deeper to reach healthy pulp
tissue. Pulp bleeding must be controlled by irrigation with
a bacteriocidal agent such as sodium hypochlorite or
chlorhexidine51,70,71 before the site is covered with calcium
hydroxide12 or MTA.72-74 While calcium hydroxide has been
demonstrated to have long-term success, MTA results in
more predictable dentin bridging and pulp health.75 MTA (at
least 1.5 millimeters thick) should cover the exposure and
BEST PRACTICES: PULP THERAPY
surrounding dentin followed by a layer of light-cured resin-
modified glass ionomer.69 A restoration that seals the tooth
from microleakage is placed.
• Indications: A partial pulpotomy is indicated in a young
permanent tooth for a carious pulp exposure in which the
pulp bleeding is controlled within several minutes. The
tooth must be vital, with a diagnosis of normal pulp or
reversible pulpitis.
• Objectives: The remaining pulp should continue to be vital
after partial pulpotomy. There should be no adverse clini-
cal signs or symptoms such as sensitivity, pain, or swelling.
There should be no radiographic sign of internal or external
resorption, abnormal canal calcification, or periapical radio-
lucency postoperatively. Teeth having immature roots should
continue normal root development and apexogenesis.
Partial pulpotomy for traumatic exposures (Cvek pulpotomy).
The partial pulpotomy for traumatic exposures is a procedure
in which the inflamed pulp tissue beneath an exposure that
is four millimeters or less in size76 is removed to a depth of
one to three millimeters or more to reach the deeper healthy
tissue. While literature indicates that a Cvek pulpotomy may
be completed up to nine days after an exposure, there is no
evidence on tooth outcomes with longer periods of waiting
time.76 Pulp bleeding is controlled using irrigants such as
sodium hypochlorite or chlorhexidine,70,71 and the site then
is covered with calcium hydroxide77,78 or MTA12,79. MTA may
cause tooth discoloration.80,81 The two versions (light and
gray) have been shown to have similar properties.82,83 While
calcium hydroxide has been demonstrated to have long-term
success, MTA results in more predictable dentin bridging
and pulp health.75 MTA (at least 1.5 millimeters thick)
should cover the exposure and surrounding dentin, followed
by a layer of light-cured resin-modified glass ionomer.79 A
restoration that seals the tooth from microleakage is placed.
• Indications: This pulpotomy is indicated for a vital,
traumatically-exposed, young permanent tooth, especially
one with an incompletely formed apex
• Objectives: The remaining pulp should continue to be vital
after partial pulpotomy. There should be no adverse clinical
signs or symptoms of sensitivity, pain, or swelling. There
should be no radiographic signs of internal or external re-
sorption, abnormal canal calcification, or periapical radio-
lucency postoperatively. Teeth with immature roots should
show continued normal root development and apexogenesis.
Complete pulpotomy. A complete or traditional pulpotomy
involves complete surgical removal of the coronal vital pulp
tissue followed by placement of a biologically acceptable ma-
terial in the pulp chamber and restoration of the tooth.6
Compared to the traditionally-used calcium hydroxide,
MTA and tricalcium silicate exhibit superior long-term seal
and reparative dentin formation leading to a higher success
rate.84-86
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 419
BEST PRACTICES: PULP THERAPY
• Indications: A full pulpotomy is indicated in immature
permanent teeth with cariously exposed pulp as an interim
procedure to allow continued root development (apexogen-
esis). It also may be performed as an emergency procedure
for temporary relief of symptoms until a definitive root
canal treatment can be accomplished.6
• Objectives: Full pulpotomy procedure in a vital permanent
tooth aims to preserve the vitality of remaining radicular
pulp.3 The objective is to prevent adverse clinical signs and
symptoms, obtain radiographic evidence of sufficient root
development for endodontic treatment, prevent breakdown
of periradicular tissues, and to prevent resorptive defects
or accelerated canal calcification as determined by periodic
radiographic evaluation.6
Nonvital pulp treatment
Pulpectomy (conventional root canal treatment). Pulpectomy
in apexified permanent teeth is conventional root canal
(endodontic) treatment for exposed, infected, and/or necrotic
teeth to eliminate pulp and periradicular infection. In all
cases, the entire roof of the pulp chamber is removed to gain
access to the canals and eliminate all coronal pulp tissue.
Following cleaning, disinfection, and shaping of the root canal
system, obturation of the entire root canal is accomplished
with a biologically-acceptable semi-solid or solid filling
material.6
• Indications: Pulpectomy or conventional root canal treat-
ment is indicated for a restorable permanent tooth with a
closed apex that exhibits irreversible pulpitis or a necrotic
pulp. For root canal-treated teeth with unresolved peri-
radicular lesions, root canals that are not accessible from the
conventional coronal approach, or calcification of the root
canal space, endodontic treatment of a more specialized
nature may be indicated.
• Objectives: There should be evidence of a successful filling
without gross overextension or underfilling in the presence
of a patent canal. There should be no adverse posttreatment
signs or symptoms such as prolonged sensitivity, pain, or
swelling, and there should be evidence of resolution of
pretreatment pathology with no further breakdown of peri-
radicular supporting tissues clinically or radiographically.
Apexification (root end closure). Apexification is a method of
inducing root end closure of an incompletely formed non-vital
permanent tooth by removing the coronal and non-vital
radicular tissue just short of the root end and placing a bio-
compatible agent such as calcium hydroxide in the canals for
two weeks to one month to disinfect the canal space.16 Root
end closure is accomplished with an apical barrier such as
MTA.6 In instances when complete closure cannot be accom-
plished by MTA, an absorbable collagen wound dressing87 can
be placed at the root end to allow MTA to be packed within
the confines of the canal space. Gutta percha is used to fill
the remaining canal space. If the canal walls are thin, the
420 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
canal space can be filled with MTA or composite resin instead
of gutta percha to strengthen the tooth against fracture.6
• Indications: This procedure is indicated for non-vital
permanent teeth with incompletely formed roots.
• Objectives: This procedure should induce root end closure
(apexification) at the apices of immature roots or result in
an apical barrier as confirmed by clinical and radiographic
evaluation. Adverse posttreatment clinical signs or symptoms
of sensitivity, pain, or swelling should not be evident. There
should be no radiographic evidence of external root resorp-
tion, lateral root pathosis, root fracture, or breakdown of
periradicular supporting tissues during or following therapy.
The tooth should continue to erupt, and the alveolus should
continue to grow in conjunction with the adjacent teeth.
Regenerative endodontics. Regenerative endodontics is defined
as biologically-based procedures designed to physiologically
replace damaged tooth structure, including dentin and root
structures, as well as the pulp-dentin complex.88 The goals of
the regenerative procedure are elimination of clinical symptoms/
signs and resolution of apical periodontitis in teeth with a
necrotic pulp and immature apex.89 Thickening of the canal
walls and/or continued root maturation is an additional goal.89
The difference between regenerative endodontic therapy and
nonsurgical conventional root canal therapy is that the disin-
fected root canal space in the former therapy is filled with the
host’s own vital tissue and the canal space in the latter therapy
is filled with biocompatible foreign materials.
• Indications: This procedure is indicated for nonvital perma-
nent teeth with incompletely formed roots.
• Objectives: This procedure should result in increased width
of the root walls and may lead to increase in root length,
both confirmed by radiographic evaluation. Adverse post-
treatment clinical signs or symptoms of sensitivity, pain,
or swelling should not be evident. There should be no
radiographic evidence of external root resorption, lateral
root pathosis, root fracture, or breakdown of periradicular
supporting tissues during or following therapy. The tooth
should continue to erupt, and the alveolus should continue
to grow in conjunction with the adjacent teeth.
References
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41. Agamy HA, Bakry NS, Mounir MM, Avery DR. Com-
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151-4.
43. Caicedo R, Abbott PV, Alongi DJ, Alarcon MY. Clinical,
radiographic and histological analysis of the effects of
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44. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp
capping of carious exposures: Treatment outcome after
5 and 10 years–A retrospective study. J Endod 2000;26
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45. Guelmann M, Fair J, Bimstein E. Permanent versus tem-
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46. Holan G, Fuks AB, Keltz N. Success rate of formocresol
pulpotomy in primary molars restored with stainless steel
crown vs amalgam. Pediatr Dent 2002;24(3):212-6.
47. Guelmann M, McIlwain MF, Primosch RE. Radiographic
assessment of primary molar pulpotomies restored with
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48. Huth KC, Paschos E, Hajek-Al-Khatar N, et al. Effective-
ness of 4 pulpotomy techniques – Randomized controlled
trial. J Dent Res 2005;84(12):1144-8.
49. Thompson KS, Seale NS, Nunn ME, Huff G. Alternative
method of hemorrhage control in full strength formo-
cresol pulpotomy. Pediatr Dent 2001;23(3):217-22.
50. Strange DM, Seale NS, Nunn ME, Strange M. Outcome
of formocresol/ZOE sub-base pulpotomies utilizing
alternative radiographic success criteria. Pediatr Dent
2001;23(3):331-6.
51. Siqueira JF Jr, Rôças IN, Paiva SS, Guimarães-Pinto T,
Magalhaes KM, Lima KC. Bacteriologic investigation of
the effectiveness of sodium hypochlorite and chlorhexidine
during the endodontic treatment of teeth with apical
periodontitis. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;104(1):122-30.
52. Lo EC, Holmgren CJ, Hu D, Van Palenstein Helderman
W. Six-year follow up of atraumatic restorative treat-
ment restorations placed in Chinese school children.
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53. Coll JA, Vargas K, Marghalani AA, et al. A systematic
review and meta-analysis of nonvital pulp therapy for
primary teeth. Pediatr Dent 2020;42(4):256-72.E11-E199.
54. Coll JA, Dhar V, Vargas K, et al. Use of non-vital pulp
therapies in primary teeth. Pediatr Dent 2020;42(5):
337-49.
55. Mehdipour O, Kleier DJ, Averbach RE. Anatomy of
sodium hypochlorite accidents. Compend Contin Educ
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56. Coll JA, Sadrian R. Predicting pulpectomy success and its
relationship to exfoliation and succedaneous dentition.
Pediatr Dent 1996;18(1):57-63.
57. Casas MJ, Kenny DJ, Johnston DH, Judd PL. Long-term
outcomes of primary molar ferric sulfate pulpotomy and
root canal therapy. Pediatr Dent 2004;26(1):44-8.
58. Ozalp N, Saroğlu I, Sönmez H. Evaluation of various root
canal filling materials in primary molar pulpectomies:
An in vivo study. Am J Dent 2005;18(6):347-50.
59. Primosch RE, Ahmadi A, Setzer B, Guelmann M. A retro-
spective assessment of zinc oxide-eugenol pulpectomies
in vital maxillary primary incisors successfully restored
with composite resin crowns. Pediatr Dent 2005;27(6):
470-7.
60. Burrus D, Barbeau L, Hodgson B. Treatment of abscessed
primary molars utilizing lesion sterilization and tissue
repair: Literature review and report of three cases. Pediatr
Dent 2014;36(3):240-4.
61. Takushige T, Cruz EV, Asgor Moral A, Hoshino E. Endo-
dontic treatment of primary teeth using a combination of
antibacterial drugs. Int Endod J 2004;37(2):132-8.

62. Raslan N, Mansour O, Assfoura L. Evaluation of anti-
biotic mix in non-instrumentation endodontic treatment
of necrotic primary molars. Eur J Paediatr Dent 2017;18
(4):285-290.
63. Oen KT, Thompson VP, Vena D, et al. Attitudes and ex-
pectations of treating deep caries: A PEARL Network
survey. Gen Dent 2007;55(3):197-203.
64. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clini-
cal, microbiologic, and radiographic study of deep caries
lesions after incomplete caries removal. Quintessence Int
2002;33(2):151-9.
65. Bjørndal L, Larsen T, Thylstrup A. A clinical and micro-
biological study of deep carious lesions during stepwise
excavation using long treatment intervals. Caries Res
1997;31(6):411-7.
66. Bjørndal L, Larsen T. Changes in the cultivable flora in
deep carious lesions following a stepwise excavation
procedure. Caries Res 2000;34(6):502-8.
67. Bjørndal L, Mjör IA. Pulp-dentin biology in restorative
dentistry. Part 4: Dental caries-characteristics of lesions
and pulpal reactions. Quintessence Int 2001;32(9):
717-36.
68. Hoefler V, Nagaoka H, Miller CS. Long-term survival
and vitality outcomes of permanent teeth following deep
caries treatment with step-wise and partial-caries-removal:
A systematic review. J Dent 2016;54:25-32.
69. Bogen G, Kim JS, Bakland LK. Direct pulp capping with
mineral trioxide aggregate: An observational study. J Am
Dent Assoc 2008;139(3):305-15.
70. Ercan E, Ozekinci T, Atakul F, Gül K. Antibacterial
activity of 2% chlorhexidine gluconate and 5.25%
sodium hypochlorite in infected root canal: In vivo study.
J Endod 2004;30(2):84-7.
71. Zehnder M. Root canal irrigants. J Endod 2006;32(5):
389-98.
72. El-Meligy OAS, Avery DR. Comparison of mineral tri-
oxide aggregate and calcium hydroxide as pulpotomy
agents in young permanent teeth (apexogenesis). Pediatr
Dent 2006;28(5):399-404.
73. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium
hydroxide vs mineral trioxide aggregates for partial
pulpotomy of permanent molars with deep caries. Eur
Arch Paediatr Dent 2007;8(2):99-104.
74. Witherspoon DE, Small JC, Harris GZ. Mineral trioxide
aggregate pulpotomies: A series outcomes assessment. J
Am Dent Assoc 2006;137(9):610-8.
75. Chacko V, Kurikose S. Human pulpal response to mineral
trioxide aggregate (MTA): A histological study. J Clin
Pediatr Dent 2006;30(3):203-10.
76. Bimstein E, Rotstein I. Cvek pulpotomy – revisited.
Dental Traumatol 2016;32(6):438-42.
77. Blanco L, Cohen S. Treatment of crown fractures with
exposed pulps. J Calif Dent Assoc 2002;30(6):419-25.
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78. Cvek M. Endodontic management and the use of calcium
hydroxide in traumatized permanent teeth. In: Andreasen
JO, Andreasen FM, Andersson L, eds. Textbook and
Color Atlas of Traumatic Injuries to the Teeth. 4th ed.
Ames, Iowa: Blackwell Munksgaard; 2007:598-657.
79. Bakland LK. New endodontic procedures using mineral
trioxide aggregate (MTA) for teeth with traumatic injuries.
In: Andreasen JO, Andreasen FM, Andersson L, eds.
Textbook and Color Atlas of Traumatic Injuries to the
Teeth. 4th ed. Ames, Iowa: Blackwell Munksgaard; 2007:
658-68.
80. Belobrov I, Parashos P. Treatment of tooth discoloration
after the use of white mineral trioxide aggregate. J Endod
2011;37(7):1017-20.
81. Subay RK, Ilhan B, Ulukapi H. Mineral trioxide aggregate
as a pulpotomy agent in immature teeth: Long term case
report. Eur J Dent 2013;7(1):133-8.
82. Ferris DM, Baumgartner JC. Perforation repair comparing
two types of mineral trioxide aggregate. J Endod 2004;
30(6):422-4.
83. Menezes R, Bramante CM, Letra A, Carvalho VG, Garcia
RB. Histologic evaluation of pulpotomies in dog using
two types of mineral trioxide aggregate and regular and
white Portland cements as wound dressings. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2004;98(3):
376-9.
84. Witherspoon DE. Vital pulp therapy with new materials:
New directions and treatment perspectives–Permanent
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85. Aguilar PA, Linsuwanont P. Vital pulp therapy in vital
permanent teeth with cariously exposed pulp: A systematic
review. J Endod 2011;37(5):581-7.
86. Taha NA, Abdulkhader SZ. Full pulpotomy with Bio-
dentine in symptomatic young permanent teeth with
carious exposure. J Endod 2018;44(6):932-7. Epub 2018
Apr 19.
87. Patino MG, Neiders ME, Andreana S, Noble B, Cohen
RE. Collagen as an implantable material in medicine and
dentistry. J Oral Implantol 2002;28(5):220-5.
88. American Association of Endodontists Special Committee
on the Scope of Endodontics. AAE Position Statement:
Scope of Endodontics: Regenerative Endodontics. 2013.
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Accessed August 3, 2020.
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Endodontics. Endodontics Colleagues for Excellence,
Spring 2013. Available at: “https://f3f142zs0k2w1kg84k-
5p9i1o-wpengine.netdna-ssl.com/specialty/wp-content/
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August 3, 2020.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 423
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

Management of the Developing Dentition and

Occlusion in Pediatric Dentistry
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Management
2021 * of the developing dentition and occlusion in pediatric dentistry.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:424-41.

Abstract
This best practice asserts that the management of developing dentition and occlusion is an essential part of comprehensive oral health care
and that early diagnosis and treatment of abnormalities can aid patients in achieving the goal of a stable, functional, and esthetic occlusion.
The document outlines the components of the clinical examination and necessary diagnostic records and emphasizes the importance of the
diagnostic summary for determining treatment priorities and timing. Considerations for management according to each stage of dentition
(primary, mixed, adolescent, adult) are presented along with treatment objectives and recommendations for relevant dental concerns,
including oral habits, congenitally-missing or supernumerary teeth, ectopic eruption, and ankylosis or primary failure of eruption. Lastly,
the document provides discussion of arch length discrepancy, space maintenance, space regaining, crossbites, and Class II and Class III
malocclusions. Providers may use this document as a resource for gathering crucial diagnostic information and making informed decisions
regarding the timing, sequence, and appropriateness of interventions.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and recommendations regarding management of developing dentition and occlusion.
KEYWORDS: MALOCCLUSION, SPACE MAINTENANCE, CROSSBITE, ANKYLOSIS, TOOTH ERUPTION, ORAL HABITS, SUPERNUMERARY TEETH

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the importance of managing the developing denti-
tion and occlusion and its effect on the well-being of infants,
children, and adolescents. Management includes the recog-
nition, diagnosis, and appropriate treatment of dentofacial
abnormalities. These recommendations are intended to set
forth objectives for management of the developing dentition
and occlusion in pediatric dentistry.
Methods
Recommendations on management of the developing dentition
and occlusion were developed by the Developing Dentition
Subcommittee of the Clinical Affairs Committee and adopted
in 1990.1 This document by the Council on Clinical Affairs is
a limited modification of the previous revision, last revised in
2019.2 This revision is based upon a new PubMed /MEDLINE
search using the terms: tooth ankylosis, Class II malocclusion,
® term benefits while achieving the goals of occlusal harmony
Class III malocclusion, interceptive orthodontic treatment,
evidence-based, dental crowding, ectopic eruption, dental im-
paction, obstructive sleep apnea syndrome (OSAS), occlusal
development, craniofacial development, craniofacial growth,
airway, facial growth, oligodontia, oral habits, occlusal wear
and dental erosion, anterior crossbite, posterior crossbite, space
maintenance, third molar development, and tooth size/arch
* The 2021 revision was limited to the section on ankylosis.
length discrepancy; fields: all; limits: within the last 10 years,
humans, English, and birth through age 18. Papers for review
were chosen from these searches and from references within
selected articles. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/
or consensus opinion by experienced researchers and clinicians.
Background
Guidance of eruption and development of the primary, mixed,
and permanent dentitions is an integral component of com-
prehensive oral health care for all pediatric dental patients.
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
development. Early diagnosis and successful treatment of
developing malocclusions can have both short-term and long-
and function and dentofacial esthetics.3-5 Dentists have the
responsibility to recognize, diagnose, and manage or refer
abnormalities in the developing dentition as dictated by the
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. AP: Anteroposterior.
CBCT: Cone-beam computed tomography. EE: Ectopic eruption.
OSAS: Obstructive sleep apnea syndrome. PFE: Primary failure of
eruption. TMD: Temporomandibular joint dysfunction.

424 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


complexity of the problem and the individual clinician’s
training, knowledge, and experience.6
Many factors can affect the management of the developing
dental arches and minimize the overall success of any treatment.
The variables associated with the treatment of the developing
dentition that will affect the degree to which treatment is
successful include, but are not limited to:
1. chronological/mental/emotional age of the patient
and the patient’s ability to understand and cooperate
in the treatment.
2. intensity, frequency, and duration of an oral habit.
3. parental support for the treatment.
4. compliance with clinician’s instructions.
5. craniofacial configuration.
6. craniofacial growth.
7. concomitant systemic disease or condition.
8. accuracy of diagnosis.
9. appropriateness of treatment.
10. timing of treatment.
A thorough clinical examination, appropriate pretreatment
records, differential diagnosis, sequential treatment plan,
and progress records are necessary to manage any condition
affecting the developing dentition.
Clinical examination should include:
1. facial analysis to:
a. identify adverse transverse growth patterns includ-
ing asymmetries (maxillary and mandibular);
b. identify adverse vertical growth patterns;
c. identify adverse sagittal (anteroposterior [AP])
growth patterns and dental AP occlusal dishar-
monies; and
d. assess esthetics and identify orthopedic and ortho-
dontic interventions that may improve esthetics
and resultant self-image and emotional
development.
2. intraoral examination to:
a. assess overall oral health status; and
b. determine the functional status of the patient’s
occlusion.
3. functional analysis to:
a. determine functional factors associated with the
malocclusion;
b. detect deleterious habits; and
c. detect temporomandibular joint dysfunction
(TMD), which may require additional diagnostic
procedures.
Diagnostic records may be needed to assist in the evaluation
of the patient’s condition and for documentation purposes.
Prudent judgment is exercised to decide the appropriate
records required for diagnosis of the clinical condition.7
Diagnostic orthodontic evaluations fall into three major
categories: (1) health of the teeth and oral structures, (2)
alignment and occlusal relationships of the teeth, and (3)
facial and jaw proportions.7
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
Diagnostic records may include:
1. extraoral and intraoral photographs to:
a. supplement clinical findings with oriented facial
and intraoral photographs; and
b. establish a database for documenting facial
changes during treatment.
2. diagnostic dental casts to:
a. assess the occlusal relationship;
b. determine arch length requirements for intraarch
tooth size relationships;
c. determine arch length requirements for interarch
tooth size relationships; and
d. determine location and extent of arch asymmetry.
3. intraoral and panoramic radiographs to:
a. establish dental age;
b. assess eruption problems;
c. estimate the size and presence of unerupted teeth;
and
d. identify dental anomalies/pathology.
4. lateral and AP cephalograms to:
a. produce a comprehensive cephalometric analysis
of the relative dental and skeletal components in
the AP, vertical, and transverse dimensions;
b. establish a baseline growth record for longitudinal
assessment of growth and displacement of the
jaws; and
c. determine dental maturity relative to skeletal
maturity and chronological age.
5. other diagnostic views (e.g., magnetic resonance
imaging, cone-beam computed tomography [CBCT])
for hard and soft tissue imaging as indicated by
history and clinical examination.
A differential diagnosis and diagnostic summary are
completed to:
1. establish the relative contributions of the soft tissue
and dental and skeletal structures to the patient’s
malocclusion;
2. prioritize problems in terms of relative severity;
3. detect favorable and unfavorable interactions that may
result from treatment options for each problem area;
4. establish short-term and long-term objectives; and
5. summarize the prognosis of treatment for achieving
stability, function, and esthetics.
A sequential treatment plan will:
1. establish timing priorities for each phase of therapy;
2. establish proper sequence of treatments to achieve
short-term and long-term objectives; and
3. assess treatment progress and update the biomechan-
ical protocol accordingly on a regular basis.
Stages of development of occlusion
General considerations and principles of management: The
stages of occlusal development include:
1. primary dentition: beginning in infancy with the
eruption of the first tooth, usually about six months
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 425
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
of age, and complete from approximately three to
six years of age when all primary teeth are erupted.
2. mixed dentition: from approximately age six to 13,
primary and permanent teeth are present in the
mouth. This stage can be divided further into early
mixed and late mixed dentition.
3. adolescent dentition: all succedaneous teeth have
erupted, second permanent molars may be erupted
or erupting, and third molars have not erupted.
4. adult dentition: all permanent teeth are present.7,8
Historically, orthodontic treatment was provided mainly for
adolescents. Interest continues to be expressed in the concept
of interceptive (early) treatment as well as in adult treatment.
Treatment and timing options for the growing patient have
increased and continue to be evaluated by the research com-
munity.9,10 Many clinicians seek to modify skeletal, muscular,
and dentoalveolar abnormalities before the eruption of the
full permanent dentition.
A thorough knowledge of craniofacial growth and develop-
ment of the dentition, as well as orthodontic treatment, must
be used in diagnosing and reviewing possible interceptive
treatment options before recommendations are made to
parents. Treatment is beneficial for many children but may not
be indicated for every patient with a developing malocclusion.
Treatment considerations: The developing dentition should
be monitored throughout eruption. This monitoring at regular
clinical examinations should include, but not be limited to,
diagnosis of missing, supernumerary, developmentally de-
fective, and fused or geminated teeth; ectopic eruption; space
and tooth loss secondary to caries; and periodontal and pulpal
health of the teeth.
Radiographic examination, when necessary11 and feasible,
should accompany clinical examination. Diagnosis of anomalies
of primary or permanent tooth development and eruption
should be made to inform the patient’s parent and to plan
and recommend appropriate intervention. This evaluation is
ongoing throughout the developing dentition, at all stages.7,8
1. Primary dentition stage: Anomalies of primary teeth
and eruption may not be evident/diagnosable prior
to eruption, due to the child’s not presenting for
dental examination or to a radiographic examination
not being possible in a child due to age or behavior.
Evaluation, however, should be accomplished when
feasible. The objectives of evaluation include identi-
fication of:
a. all anomalies of tooth number and size (as
previously noted);
b. anterior and posterior crossbites;
c. presence of habits along with their dental and
skeletal sequelae;
d. openbite; and
e. airway problems.
426 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Radiographs are taken with appropriate clinical
indicators or based upon risk assessment/history.
2. Early mixed dentition stage: The objectives of evalu-
ation continue as noted for the primary dentition
stage. Palpation for unerupted teeth should be part
of every examination. Panoramic, occlusal, and peria-
pical radiographs, as indicated at the time of eruption
of the lower incisors and first permanent molars,
provide diagnostic information concerning:
a. unerupted teeth;
b. missing, supernumerary, fused, and geminated teeth;
c. tooth size and shape (e.g., peg or small lateral
incisors);
d. positions (e.g., ectopic first permanent molars);
e. developing skeletal discrepancies; and
f. periodontal health.
Space analysis can be used to evaluate arch length at
the time of incisor eruption.
3. Late mixed dentition stage: The objectives of the
evaluations remain consistent with the prior stages,
with an emphasis on evaluation for ectopic tooth
positions, especially canines, premolars, and second
permanent molars.
4. Adolescent dentition stage: If not instituted earlier,
orthodontic diagnosis and treatment should be
planned for Class I crowded, Class II, and Class III
malocclusions as well as posterior and anterior
crossbites. Third molars should be monitored as to
position and space, and parents should be informed
of the dentist’s observations.
5. Early adult dentition stage: Third molars should be
evaluated. If orthodontic diagnosis has not been
accomplished, recommendations should be made as
necessary.
Treatment objectives: At each stage, the objectives of
intervention/treatment include managing adverse growth,
correcting dental and skeletal disharmonies, improving esthe-
tics of the smile and the accompanying positive effects on
self-image, and improving the occlusion.
1. Primary dentition stage: Habits and crossbites should
be diagnosed and, if predicted not likely to be self-
correcting, they should be addressed as early as feasible
to facilitate normal occlusal relationships. Parents
should be informed about findings of adverse
growth and developing malocclusions. Interventions/
treatment can be recommended if diagnosis can be
made, treatment is appropriate and possible, and
parents are supportive and desire to have treatment
done.
2. Early mixed dentition stage: Treatment consideration
should address:
a. habits;
b. arch length shortage;
c. intervention for crowded incisors;

d. intervention for ectopic teeth;
e. holding of leeway space;
f. crossbites;
g. openbite;
h. surgical needs; and
i. adverse skeletal growth.
Intervention for ectopic teeth may include extrac-
tions of primary teeth and space maintenance/
regaining to aid erupting teeth and reduce the risk
of need for permanent tooth extraction or surgical
bracket placement for orthodontic traction. Treat-
ment should take advantage of the child’s growth
and should be aimed at prevention of adverse dental
relationships and skeletal growth.
3. Late mixed dentition stage: Intervention for treat-
ment of skeletal disharmonies and crowding may be
instituted at this stage.
4. Adolescent dentition stage: In full permanent denti-
tion, orthodontic diagnosis and treatment can provide
the most functional, stable, and esthetic occlusion.
5. Early adult dentition stage: Third molar position or
space can be evaluated and, if indicated, the tooth/
teeth removed. Full orthodontic treatment should be
recommended if needed.
Recommendations
Oral habits
General considerations and principles of management:
The habits of nonnutritive sucking, bruxing, tongue thrust
swallow and abnormal tongue position, self-injurious/
self-mutilating behavior, and OSAS are discussed in these
recommendations.
Oral habits may apply negative forces to the teeth and
dentoalveolar structures. The relationship between oral habits
and unfavorable dental and facial development is associational
rather than cause and effect.12,13 Habits of sufficient frequency,
duration, and intensity may be associated with dentoalveolar
or skeletal deformations such as increased overjet, reduced
overbite, openbite, posterior crossbite, or increased facial
height. The duration of force is more important than its
magnitude14; the resting pressure from the lips, cheeks, and
tongue has the greatest impact on tooth position as these
forces are maintained most of the time.15,16
Nonnutritive sucking behaviors are considered normal in
infants and young children. Long-term nonnutritive sucking
habits (e.g., pacifier use, thumb/finger sucking) have been
associated with anterior open bite and posterior crossbite.12,15-19
Some evidence indicates that changes resulting from sucking
habits persist past the cessation of the habit; therefore, it has
been suggested that early dental visits provide parents with
anticipatory guidance to help their children stop sucking habits
by age 36 months or younger.12,15,16
Bruxism, defined as the habitual nonfunctional and force-
ful contact between occlusal surfaces, can occur while awake
or asleep. The etiology is multifactorial and has been reported
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
to include central factors (e.g., emotional stress,20 parasomnias,21
traumatic brain injury,22 neurologic disabilities23) and mor-
phologic factors (e.g., malocclusion24, muscle recruitment25).
The occlusal wear that may result from bruxism is important
to differentiate from other forms of occlusal loss of enamel
(e.g., erosion caused by diet or gastroesophageal reflux).26
Reported complications of bruxism include dental attrition,
headaches, TMD, and soreness of the masticatory muscles.20
Evidence indicates that juvenile bruxism is self-limiting and
does not persist in adults.27 The spectrum of bruxism man-
agement ranges from patient/parent education, occlusal splints,
and psychological techniques to medications.21,22,28,29
Tongue thrusting, an abnormal tongue position and
deviation from the normal swallowing pattern, may be asso-
ciated with anterior open bite, abnormal speech, and anterior
protrusion of the maxillary incisors.30 There is no evidence
that intermittent short-duration pressures, created when
the tongue and lips contact the teeth during swallowing or
chewing, have significant impact on tooth position.15,30 If the
resting tongue posture is forward of the normal position,
incisor displacement is likely, but if resting tongue posture is
normal, a tongue thrust swallow has no clinical significance.15
Self-injurious or self-mutilating behavior (i.e., repetitive
acts that result in physical injury to the individual) is ex-
tremely rare in the normal child. Such behavior, however, is
a chronic condition more frequently seen in special needs
populations, having been associated with developmental delay
or disabilities, psychiatric disorders, traumatic brain injuries,
and some syndromes.31,32 The spectrum of treatment options
for developmentally disabled individuals includes pharmaco-
logic management, behavior modification, and physical
restraint.33 Dental treatment modalities include, among others,
lip-bumper and occlusal bite appliances, protective padding,
and extractions. Some habits, such as lip-licking and lip-
pulling, are relatively benign in relation to an effect on the
dentition. Severe lip- and tongue-biting habits may be
associated with profound neurodisability due to severe brain
damage.33 Management options include monitoring the lesion,
odontoplasty, providing a bite-opening appliance, or extracting
the teeth.33
Research on the relationship between malocclusion and
mouth breathing suggests that impaired nasal respiration
may contribute to the development of increased facial height,
anterior open bite, increased overjet, and narrow palate, but it
is not the sole or even the major cause of these conditions.34
OSAS may be associated with narrow maxilla, crossbite,
low tongue position, vertical growth, increased overjet, and
openbite. 35-37 History associated with OSAS may include
snoring, observed apnea, restless sleep, daytime neurobehavioral
abnormalities or sleepiness, and bedwetting. Physical findings
may include growth abnormalities, signs of nasal obstruction,
adenoidal facies, and enlarged tonsils.34,38,39
The identification of an abnormal habit and the assessment
of its potential immediate and long-term effects on the cra-
niofacial complex and dentition should be made as early as
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 427
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
possible. The dentist should evaluate habit frequency, duration,
and intensity in all patients with habits. Intervention to
terminate the habit should be initiated if indicated, and
parents should be provided with information regarding con-
sequences of a habit as well as tools to help in elimination of
the habit.12,13
Treatment considerations: Management of an oral habit is
indicated whenever the habit is associated with unfavorable
dentofacial development or adverse effects on child health or
when there is a reasonable indication that the oral habit will
result in unfavorable sequelae in the developing permanent
dentition. Any treatment must be appropriate for the child’s
development, comprehension, and ability to cooperate. Habit
treatment modalities include patient/parent counseling, be-
havior modification techniques, myofunctional therapy,
appliance therapy (extraoral and intraoral), or referral to
other providers including, but not limited to, orthodontists,
psychologists, myofunctional therapists, or otolaryngologists.
The child’s desire to stop the habit is beneficial for managing
oral habits.13
Treatment objectives: Treatment is directed toward decreasing
or eliminating the habit and minimizing potential deleterious
effects on the dentofacial complex.
Disturbances in number
Congenitally missing teeth
General considerations and principles of management: Hypo-
dontia, the congenital absence of one or more permanent
teeth, has a prevalence of 3.5 to 6.5 percent.40 Excluding third
molars, the most frequently missing permanent tooth is the
mandibular second premolar followed by the maxillary lateral
incisor.40 In the primary dentition, hypodontia occurs less fre-
quently (0.1 to 0.9 percent prevalence) and almost always
affects the maxillary incisors and first primary molars.41 The
chance of familial occurrence of one or two congenitally missing
teeth is to be differentiated from missing lateral incisors in
cleft lip/palate42 and multiple missing teeth (six or more) due
to ectodermal dysplasia or other syndromes43 as the treatment
usually differs. A congenitally missing tooth should be sus-
pected in patients with cleft lip/palate, certain syndromes, and
a familial pattern of missing teeth. In addition, patients with
asymmetric eruption sequence, over-retained primary teeth, or
ankylosis of a primary mandibular second molar may have a
congenitally missing tooth.42,44,45
Treatment considerations: With congenitally missing perma-
nent maxillary incisor(s) or mandibular second premolar(s),
the decision to extract the primary tooth and close the space
orthodontically versus opening the space orthodontically and
placing a prosthesis or implant depends on many factors. For
maxillary laterals, the dentist may move the maxillary canine
mesially and use the canine as a lateral incisor or create space
for a future lateral prosthesis or implant.13,46
428 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Factors that influence the decision are: (1) patient age; (2)
canine size and shape; (3) canine position; (4) child’s occlu-
sion and amount of crowding; (5) bite depth; (6) profile;
(7) smile line; and (8) quality and quantity of bone in the
edentulous area.46,47 Early extraction of the primary canine and/
or lateral may be needed.46 Opening space for a prosthesis or
implant requires less tooth movement, but the space needs to
be maintained with an interim prosthesis, especially if an
implant is planned. 43,46 Moving the canine into the lateral
position produces little facial change, but the resultant tooth
size discrepancy often does not allow a canine guided occlu-
sion.45,46 Patients generally prefer space closure over implants.47
For a congenitally missing premolar, the primary molar
may either be maintained or extracted with placement of a
prosthesis, autotransplantation, or orthodontic space closure.48-54
Maintaining the primary second molar may cause occlusal
problems due to its larger mesiodistal diameter, compared
to the second premolar.46 Reducing the width of the second
primary molar is a consideration, but root resorption and
subsequent exfoliation may occur.13,46 In crowded arches or
with multiple missing premolars, extraction of the primary
molar(s) can be considered, especially in mild Class III
cases. 13,46,50 For a single missing premolar, if maintaining
the primary molar is not possible, placement of a prosthesis,
autotransplantation, or implant should be considered.13,47,50
Preserving the primary tooth may be indicated in certain
cases. However, maintaining a submerged/ankylosed tooth
may increase the likelihood of an alveolar defect which can
compromise later implant success. 50,51 Consideration for
extraction and space maintenance may be indicated.50,51 Con-
sultation with an orthodontist and/or prosthodontist may be
considered.
Treatment objectives: Treatment is directed toward an esthe-
tically pleasing occlusion that functions well for the patient.
Supernumerary teeth (primary, permanent, and mesiodens)
General considerations and principles of management: Super-
numerary teeth, or hyperdontia, can occur in the primary or
permanent dentition but are five times more common in the
permanent.44 Prevalence is reported in the primary dentition
from 0.3-0.8 percent and the mixed dentition from 0.52 to
two percent.52-55 Between 80 and 90 percent of all super-
numeraries occur in the maxilla, with half in the anterior
area and almost all in the palatal position.52 A supernumerary
primary tooth is followed by a supernumerary permanent
tooth in one-third of the cases.56 Supernumerary teeth are
classified according to their form and location.52,57
During the early mixed dentition, 79 to 91 percent of
anterior permanent supernumerary teeth are unerupted.45,53
While more erupt with age, only 25 percent of all mesiodens
(a permanent supernumerary incisor located at the midline)
erupt spontaneously.52 Mesiodens can prevent or cause ectopic
eruption of a central incisor. Less frequently, a mesiodens can
cause dilaceration or resorption of the permanent incisor’s

root. Dentigerous cyst formation involving the mesiodens, in
addition to eruption into the nasal cavity, has been reported.52
If there is an asymmetric eruption pattern of the maxillary
incisors, delayed eruption, an overretained primary incisor, or
ectopic eruption of an incisor, a supernumerary tooth can be
suspected.41,42,53 Panoramic, occlusal, and periapical radiographs
all can reveal a supernumerary tooth. To determine the super-
numerary tooth’s position, either a cone beam radiograph or
two periapical or occlusal films reviewed by the parallax rule
is recommended.52,54
Treatment considerations: Management and treatment of
hyperdontia differ if the tooth is primary or permanent. Pri-
mary supernumerary teeth normally are accommodated into
the arch and usually erupt and exfoliate without complications.56
Surgical extraction of unerupted anterior supernumerary teeth
during the primary dentition can displace or damage the per-
manent incisor.52 Removal of an erupted mesiodens or other
permanent supernumerary incisor results in eruption of the
permanent adjacent normal incisor in 75 percent of the cases.52
Extraction of an unerupted supernumerary during the early
mixed dentition (i.e., at age six to seven years when the
permanent crown has formed completely and the root length
is less than the crown height) allows for a normal eruptive
force and eruption of the adjacent normal permanent in-
cisor.52-54,58 Later removal of the mesiodens reduces the likeli-
hood that the adjacent normal permanent incisor will erupt
on its own, especially if the apex is completed.52 Inverted conical
supernumerary teeth can be harder to remove if removal is
delayed, as they can migrate deeper into the jaw.53 After
removal of the supernumerary tooth, clinical and radiographic
follow-up is indicated in six months to determine if the
normal incisor is rupting. If there is no eruption after six to
12 months and sufficient space exists, surgical exposure and
orthodontic extrusion may be needed.52,59,60
Treatment objectives: Removal of supernumerary teeth should
facilitate eruption of permanent teeth and encourage normal
alignment. In cases where normal alignment or spontaneous
eruption does not occur, further orthodontic treatment is
indicated.
Localized disturbances in eruption
Ectopic eruption
General considerations and principles of management:
Ectopic eruption (EE) of permanent first molars occurs due to
the molar’s abnormal mesioangular eruption path, resulting in
an impaction at the distal prominence of the primary second
molar’s crown.61,62 EE can be suspected if asymmetric eruption
is observed or if the mesial marginal ridge is noted to be
under the distal prominence of the second primary molar.61,62
EE of permanent molars can be diagnosed from bitewing
or panoramic radiographs in the early mixed dentition.61,62
This condition occurs in up to three percent of the popula-
tion.61 EE of first permanent molars has been associated with
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
transverse and sagittal crowding and is more common in the
maxillary arch and in children with cleft lip and palate. 62-64
EE of second permanent molars occurs infrequently.65 EE of
permanent molars is classified into two types. There are those
that self-correct and others that remain impacted. Previous
data suggested that 66 percent of EE permanent molars
self-correct by age seven;45,62 however, a recent cohort study
demonstrated that 71 percent self-correct by age nine.66 In
some cases, definitive treatment is indicated to manage and/
or avoid early loss of the primary second molar and space
loss. 61,62 Increased magnitude of impaction, increased
resorption of the primary tooth, and bilateral occurrence were
positively associated with irreversible ectopic eruption and
may indicate the need for early intervention.66
The maxillary canine appears in an impacted position in
1.5–2 percent of the population.67 Maxillary canine impaction
should be suspected when the canine bulge is not palpable,
asymmetric canine eruption is evident, or peg shaped lateral
incisors are present.67-71 Panoramic radiographs may demon-
strate that the canine has an abnormal inclination and/or over-
laps the lateral incisor root. Additional potential radiographic
signs of maxillary canine impaction include enlarged follicular
sac, lack of root resorption of primary canines, and presence
of premolar impaction.69,70,72
Maxillary incisors can erupt ectopically or be impacted from
supernumerary teeth in up to two percent of the population.57
Incisors also can have altered eruption due to pulp necrosis
(following trauma or caries) or pulpal treatment of the primary
incisor. 73 EE of permanent incisors can be suspected after
trauma to primary incisors, with pulpally-treated primary
incisors, with asymmetric eruption, or if a supernumerary
incisor is diagnosed.67,71
Treatment considerations: Treatment for ectopic molars
depends on how severe the impaction appears clinically and
radiographically. For mildly impacted first permanent molars,
where little of the tooth is impacted under the primary second
molar, elastic or metal orthodontic separators can be placed
to wedge the permanent first molar distally.61 For more severe
impactions, distal tipping of the permanent molar is re-
quired.61 Tipping action can be accomplished with brass
wires, removable appliances using springs, fixed appliances
such as sectional wires with open coil springs,74 sling shot-type
appliances,75 or a Halterman appliance.76
Early diagnosis and treatment of impacted maxillary canines
can lessen the severity of the impaction and may stimulate
eruption of the canine. Extraction of the primary canine is
indicated when the canine bulge cannot be palpated in the
alveolar process and there is radiographic overlapping of the
canine with the formed root of the lateral during the mixed
dentition.67,77,78 The use of rapid maxillary expansion alone79,80
or with cervical pull headgear81 in the early mixed dentition
has been shown to increase the potential for eruption of
palatally-displaced maxillary canines. When the impacted ca-
nine is diagnosed at a later age (11 to 16 years), if the canine
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BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
is not horizontal, extraction of the primary canine lessens the
severity of the permanent canine impaction and 75 percent
will erupt. 82 Extraction of the first primary molar also has
been reported to allow eruption of first premolars and to assist
in the eruption of the canines.83 This need can be determined
from a panoramic radiograph,84,85 although CBCT will provide
greater localization of the impacted canine.86 Bonded ortho-
dontic treatment normally is required to create space or
align the canine. Long-term periodontal health of impacted
canines after orthodontic treatment is similar to nonimpacted
canines, and there is insufficient data to conclude the best
type of surgical technique.87,88
Treatment of ectopically erupting incisors depends on the
etiology. Extraction of necrotic or over-retained pulpally-
treated primary incisors is indicated in the early mixed
dentition.73 Removal of supernumerary incisors in the early
mixed dentition will lessen ectopic eruption of an adjacent
permanent incisor. 52 After incisor eruption, orthodontic
treatment involving removable or banded therapy may be
needed.
Treatment objectives: Management of ectopically erupting
molars, canines, and incisors should result in improved
eruptive positioning of the tooth. In cases where normal
alignment does not occur, subsequent comprehensive ortho-
dontic treatment may be necessary to achieve appropriate arch
form and intercuspation.
Ankylosis
General considerations and principles of management:
Ankylosis is a condition in which the cementum of a tooth’s
root fuses directly to the surrounding bone.89 The periodontal
ligament is replaced with osseous tissue, rendering the tooth
immobile to eruptive change.89 An ankylosed tooth stays at
the same vertical level, yet in a growing child appears to
submerge as the other teeth continue to erupt. Ankylosis can
occur in the primary and permanent dentitions, with the most
common incidence involving primary molars. The incidence
is reported to be between seven and 14 percent in the primary
dentition.90 In the permanent dentition, ankylosis occurs
most frequently following luxation injuries.91
Ankylosis is common in anterior teeth following trauma
(e.g., avulsion) or injury to periodontal ligament cells and is
the process of pathological fusion of the external root surface
of the tooth to the surrounding alveolar bone.92 The degree
of replacement resorption and infraocclusion contribute to
the severity of ankylosis. Over time, normal bony activity
may result in the replacement of root structure with osseous
tissue.90,91 Ankylosis can occur rapidly or gradually, in some
cases as long as five years post trauma. It also may be transient
if only a small bony bridge forms then is resorbed with sub-
sequent osteoclastic activity.92,93
Ankylosis can be verified by clinical and radiographic
means. Submergence of the tooth, or infraocclusion, is the
primary recognizable sign, but the diagnosis also can be made
430 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
through percussion and palpation.94 Lack of physiologic mo-
bility and the presence of a dull tone (in comparison to adjacent
teeth) upon percussion with a metal instrument such as a
dental mirror handle are indicative of ankylosis. Intraoral
radiographic examination, while limited in its two-dimensional
view, may show the loss of the periodontal ligament, external
resorption, and alveolar replacement.89
Treatment considerations: Management of an ankylosed
primary molar with a successor consists of maintaining it until
an interference with eruption or tipping/drifting of adjacent
teeth occurs. If associated problems occur, the practitioner
should extract the ankylosed primary molar and place a
lingual arch or other fixed appliance if needed. Management
of ankylosed primary molars without successors should take
into consideration the patient’s age, specific tooth condition,
comprehensive orthodontic treatment plan including future
prosthodontic considerations, and parental preferences. If
severe infraocclusion is anticipated, ankylosed primary molars
without a permanent successor should either undergo extrac-
tion before a large vertical occlusal discrepancy develops or
decoronation to maintain alveolar width and prevent further
loss of vertical height.95,96 Decoronation is the removal of the
clinical crown and root structure below the soft tissue level
and necessitates removal of the remaining vital pulp tissue. It
reduces the chance of ridge resorption and the need for bone
grafting95-97 following a surgical extraction. Decoronation helps
preserve bone until an implant can be placed.98 Extraction of
ankylosed primary molars without a succedaneous tooth can
assist in resolving crowded arches in complex orthodontic
cases.96,99 Consultation with other dental specialists (e.g.,
orthodontists, prosthodontists) may assist clinicians in their
treatment decision making.
Surgical luxation of ankylosed permanent teeth with forced
orthodontic eruption has been described as an alternative to
premature extraction.100 Management of ankylosed permanent
anterior teeth can include build-up of minor infraocclusion,
intentional repositioning (surgical or orthodontic) with splint-
ing, autotransplantation, decoronation91,101,102, or extraction
with prosthetic rehabilitation. In permanent incisor decoro-
nation, the tooth undergoes endodontic treatment and then
removal of the clinical crown and the cervical portion of the
root to a level two millimeters below marginal bone height,
followed by reflecting, repositioning, and suturing a muco-
periosteal flap over the root.103 Additional research on man-
agement of ankylosed permanent anterior teeth is needed.92
Treatment objectives: Treatment of ankylosis should result in
the continuing normal development of the permanent denti-
tion. In the case of replacement resorption of a permanent
tooth, appropriate prosthetic replacement should be planned.
Primary failure of eruption
General considerations and principles of management: Primary
failure of eruption (PFE) is an eruption disorder characterized

by partial or complete non-eruption of permanent teeth in the
absence of any mechanical obstruction or syndrome.104 Failure
in eruptive mechanisms prevent permanent successors from
following the eruption path after the exfoliation of deciduous
teeth.105 Posterior teeth are most commonly affected and one
or all four quadrants may be involved.106 Although typically
associated with permanent teeth, examples in the primary
dentition have been noted.107 Two main phenotypes of PFE
have been identified: (1) All teeth distal to the most mesial
non-erupted tooth are affected, or (2) unerupted teeth do not
follow the pattern that all teeth distal to the most mesial in-
volved tooth are also affected.108 Hallmark features of PFE
include posterior open bite in the presence of normal vertical
growth, infraocclusion of affected teeth, and the inability to
move affected teeth orthodontically.109
The reported incidence of PFE is between 0.01 and 0.06
percent;110,111 however, some data suggests PFE may be mis-
diagnosed as infraocclusion or ankylosis.112,113 PFE differs from
ankylosis in that eruption fails to occur due to an imbalance
in resorptive and appositional factors related to tooth erup-
tion.114,115 Teeth with PFE are not initially ankylosed but may
become ankylosed when orthodontic forces are applied.116 A
systematic review demonstrated 85 percent of patients with
PFE have another family member with the condition.116 PFE
has variable expression and has been associated with mutations
in the autosomal dominant parathyroid hormone receptor
(PTH1R) gene.116-119 A sample of blood or saliva deoxyribo-
nucleic acid (DNA) can be used to test for mutations in
PTH1R.119,120
Treatment considerations: Diagnosis of PFE should be based
on a combination of clinical, radiographic, and genetic infor-
mation.115,116 A positive family history also supports a diagnosis
of PFE.108 Other than a few anecdotal reports, PFE is strongly
associated with the failure of orthodontically assisted eruption
or tooth movement.108,109 To that point, early orthodontic inter-
vention of the affected teeth should be avoided.109,114,115,120 To
date there are no established mechanotherapeutic methods of
modifying dentoalveolar growth for these patients.109,114,115,120
Space maintenance, uprighting adjacent teeth that have tipped
into the sites, prevention of supraeruption in opposing arch,
or modification of lateral tongue thrust habits may be addi-
tional considerations.109,120 Once growth is complete, multidis-
ciplinary treatment options such as single tooth or segmental
osteotomies with immediate traction, or selective extractions
followed by implants can be considered to create a functioning
occlusion.115 Early extraction of first molars allowing the
second molars to drift forward has also been suggested.109
Treatment objectives: Since best available evidence does not
support early orthodontic intervention, treatment objectives
of PFE should involve reassurance and education about the
eruption disorder and preparation for future prosthetic rehabil-
itation.109 In some cases, early extraction can improve normal
development of the alveolus and permanent dentition.109
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
Objectives include space and intraarch maintenance in
preparation for future implants, prosthetic rehabilitation, or
corticotomy-assisted tooth movement.109
Tooth size/arch length discrepancy and crowding
General considerations and principles of management:
Arch length discrepancies include inadequate arch length and
crowding of the dental arches, excess arch length and spacing,
and tooth size discrepancy, often referred to as a Bolton dis-
crepancy.121 These arch length discrepancies may be found in
conjunction with complicating and other etiological factors
including missing teeth, supernumerary teeth, and fused or
geminated teeth. Inadequate arch length with resulting incisor
crowding is a common occurrence with various negative
sequelae and is particularly common in the early mixed denti-
tion.120-125 Studies of arch length in today’s children compared
to their parents and grandparents of 50 years ago indicate less
arch length, more frequent incisor crowding, and stable tooth
sizes.126-128 This implies that the problem of incisor crowding
and ultimate arch length discrepancies may be increasing in
numbers of patients and in amount of arch length shortage.127-129
Arch length and especially crowding must be considered in
the context of the esthetic, dental, skeletal, and soft tissue
relationships. Mandibular incisors have a high relapse rate in
rotations and crowding.122,123 Growth of the aging skeleton
causes further crowding and incisor rotations.130 Functional
contacts are diminished where rotations of incisors, canines,
and premolars exist.131 Occlusal harmony and temporoman-
dibular joint health are impacted negatively by less functional
contacts.131
Initial assessment may be done in early mixed dentition,
when mandibular incisors begin to erupt.122 Evaluation of avail-
able space and consideration of making space for permanent
incisors to erupt may be done initially utilizing appropriate
radiographs to ascertain the presence of permanent successors.
Comprehensive diagnostic analysis is suggested, with evaluation
of maxillary and mandibular skeletal relationships, direction
and pattern of growth, facial profile, facial width, muscle
balance, and dental and occlusal findings including tooth
positions, arch length analysis, and leeway space.
Derotation of teeth just after emergence in the mouth implies
correction before the transseptal fiber arrangement has been
established.122,131 It has been shown that the transseptal fibers
do not develop until the cementoenamel junction of erupting
teeth pass the bony border of the alveolar process.131 Therefore,
long-term stability of aligned incisors may be increased.132
Treatment considerations: Treatment considerations may
include, but are not limited to:
1. gaining space for permanent incisors to erupt and
become straight naturally through primary canine
extraction and space/arch length maintenance with
holding arches. Extraction of primary or permanent
teeth with the aim of alleviating crowding should
not be undertaken without a comprehensive space
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BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
analysis and a short- and long-term orthodontic
treatment plan.
2. orthodontic alignment of permanent teeth as soon
as erupted and feasible, expansion and correction of
arch length as early as feasible.
3. utilizing holding arches in the mixed dentition until
all premolars and permanent canines have erupted.
4. maintaining patient’s original arch form.131
5. interproximal stripping of the enamel of mandibular
primary canines to allow alignment of crowded lower
permanent lateral incisors.133
Additional treatment modalities may include, but are not
limited to: (1) interproximal reduction; (2) restorative bond-
ing; (3) veneers; (4) crowns; (5) implants; and (6) orthognathic
surgery.
Treatment objectives: Well-timed intervention can:
1. prevent crowded incisors.
2. increase long-term stability of incisor positions.
3. decrease ectopic eruption and impaction of perma-
nent canines.
4. reduce orthodontic treatment time and sequelae.
5. improve gingival health and overall dental
health.122,134,135
Space maintenance
General considerations and principles of management: The
premature loss of primary teeth due to caries, infection, trauma,
ectopic eruption, or crowding deviates from the normal exfolia-
tion pattern and may lead to loss of arch length. Arch length
deficiency can produce or increase the severity of malocclusions
with crowding, rotations, ectopic eruption, crossbite, excessive
overjet, excessive overbite, and unfavorable molar relation-
ships.136 Whenever possible, restoration of carious primary
teeth should be attempted to avoid malocclusions that could
result from their extraction.137 The use of space maintainers to
reduce the prevalence and severity of malocclusion following
premature loss of primary teeth should be considered.13,138,139
Adverse effects associated with space maintainers include:
(1) dislodged, broken, and lost appliances; (2) plaque accumu-
lation; (3) increase in microorganisms and increase in perio-
dontal index scores; (4) caries; (5) damage or interference with
successor eruption; (6) undesirable tooth movement; (7)
inhibition of alveolar growth; (8) soft tissue impingement; and
(9) pain.136,140-146 Premature loss of a primary tooth, especially
in crowded dentitions, has the potential to cause loss of space
available for the succeeding permanent tooth, but there is a
lack of consensus or evidence regarding the effectiveness of
space maintainers in preventing or reducing the severity of
malocclusion.136
Treatment considerations: It is prudent to consider space
maintenance when primary teeth are lost prematurely. Factors
to consider include: (1) specific tooth lost; (2) time elapsed since
432 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
tooth loss; (3) occlusion and space assessment; (4) dental age;
(5) presence and root development of permanent successor;
(6) amount of alveolar bone covering permanent successor;
(7) patient’s health history and medical status; (8) patient’s
cooperative ability; (9) active oral habits; and (10) oral
hygiene.13,136,137
The literature pertaining to the use of space maintainers
specific to the loss of a particular primary tooth type include
expert opinion, case reports, and details of appliance design.13,
138,139
Space maintainers can be designed as fixed unilateral
(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).157
Variations of these appliances have been described. Unilateral
space maintainer kits as well as direct bonded techniques
eliminate laboratory involvement and allow for single visit
delivery; however, the literature describes mixed results on the
longevity of these options compared to success rates of custom
appliances.158-161
The placement and retention of space maintaining appli-
ances requires ongoing compliant patient behavior. Follow-up
of patients with space maintainers is necessary to assess inte-
grity of cement and to evaluate and clean the abutment
teeth.141 The appliance should function until the succedaneous
teeth have erupted into the arch. However, adjustment or new
appliances may be necessary with continued development and
changes in the dentition.
Treatment objectives: The goal of space maintenance is to
prevent loss of arch length, width, and perimeter by main-
taining the relative position of the existing dentition.13,138
The AAPD recognizes the need for controlled randomized
clinical trials to determine efficacy of space maintainers as
well as analysis of costs and side effects of treatment.
Space regaining
General considerations and principles of management: Some
of the more common causes of space loss within an arch are
(1) primary teeth with interproximal caries; (2) ectopically
erupting teeth; (3) alteration in the sequence of eruption; (4)
ankylosis of a primary molar; (5) dental impaction; (6) trans-
position of teeth; (7) loss of primary molars without proper
space management; (8) congenitally missing teeth; (9) abnor-
mal resorption of primary molar roots; (10) premature and
delayed eruption of permanent teeth; and (11) abnormal
dental morphology.13,136,139,162,163 Therefore, loss of space in the
dental arch that interferes with the desired eruption of the
permanent teeth may require evaluation.
The degree to which space is affected varies according to
the arch, site in the arch, and time elapsed since tooth loss.164
The quantity and incidence of space loss are dependent upon
which adjacent teeth are present in the dental arch and their
status.13,136 The amount of crowding or spacing in the dental
arch will determine the consequence of space loss.163

Treatment considerations: Space can be maintained or regained
with removable or fixed appliances.136,138 Some examples of
fixed space regaining appliances are active holding arches, pen-
dulum appliances, Halterman-type appliances, and Jones jig.
Examples of removable space regaining appliances are Hawley
appliance with springs, lip bumper, and headgear.138 If space
regaining is planned, a comprehensive analysis should be
completed prior to any treatment decisions. Some factors
that should be considered in the analysis include: dentofacial
development, age at time of tooth loss, tooth that has been
lost, space available, and space needed.136,138
Treatment objectives: The goal of space regaining intervention
is the recovery of lost arch width and perimeter and/or im-
proved eruptive position of succedaneous teeth. Space regained
should be maintained until adjacent permanent teeth have
erupted completely and/or until a subsequent comprehensive
orthodontic treatment plan is initiated.
Crossbites (dental, functional, and skeletal)
General considerations and principles of management: Cross-
bites are defined as any abnormal buccal-lingual relation
between opposing incisors, molars, or premolars in centric
relation.165-167 If the midlines undergo a compensatory or
habitual shift when the teeth occlude in crossbite, this is
termed a functional shift.163 A crossbite can be of dental or
skeletal origin, or a combination of both.163
A simple anterior crossbite is of dental origin if the molar
occlusion is Class I and the malocclusion is the result of an
abnormal axial inclination of maxillary and/or mandibular
anterior teeth. This condition should be differentiated from a
Class III skeletal malocclusion where the crossbite is the result
of the basal bone position.165 Posterior crossbites may be the
result of bilateral or unilateral lingual position of the maxillary
teeth relative to the mandibular posterior teeth due to tipping
or alveolar discrepancy, or a combination. Most often, uni-
lateral posterior crossbites are the manifestation of a bilateral
crossbite with a functional mandibular shift.167 Dental
crossbites may be the result of tipping or rotation of a tooth
or teeth. In this case, the condition is localized and does not
involve the basal bone. In contrast, skeletal crossbites
involve disharmony of the craniofacial skeleton.167,168
Aberrations in bony growth may give rise to crossbites in two
ways:
1. adverse transverse growth of the maxilla and
mandible, and
2. disharmonious or adverse growth in the sagittal (AP)
length of the maxilla and mandible.166,169
Such growth aberrations can be due to inherited growth
patterns, trauma, or functional disturbances that alter normal
growth.167-169
Treatment considerations: Crossbites should be considered
in the context of the patient’s total treatment needs. Anterior
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
crossbite correction can: (1) reduce dental attrition; (2) improve
dental esthetics; (3) redirect skeletal growth; (4) improve the
tooth-to-alveolus relationship; (5) increase arch perimeter, (6)
help avoid periodontal damage, and (7) prevent the potential
for TMD.168,170 If enough space is available, a simple anterior
crossbite can be aligned as soon as the condition is noted.
Treatment options include acrylic incline planes, acrylic re-
tainers with lingual springs, or fixed appliances with springs.
If space is needed, an expansion appliance also is an option.166
Posterior crossbite correction can accomplish the same objec-
tives and can improve the eruptive position of the succedaneous
teeth. Early correction of posterior crossbites with a mandibular
functional shift has been shown to improve functional condi-
tions significantly and largely eliminate morphological and
positional asymmetries of the mandible.30,171,172 Contemporary
evidence indicates a need for long-term studies to assess the
possibility for spontaneous crossbite correction, as current
proof is conflicting.173 Functional shifts should be eliminated
as soon as possible with early correction169 to avoid TMD
and/or asymmetric growth.167,173 Treatment can be completed
with:
1. equilibration.
2. appliance therapy (fixed or removable).
3. extractions.
4. a combination of these treatment modalities to
correct the alveolar constriction.173
Skeletal expansion with fixed or removable palatal expand-
ers can be utilized until midline suture fusion occurs.163,165
Treatment decisions depend on the:
1. amount and type of movement (tipping versus bodily
movement, rotation, or dental versus orthopedic
movement);
2. space available;
3. AP, transverse, and vertical skeletal relationships;
4. growth status; and
5. patients cooperation.
Patients with crossbites and concomitant Class III skeletal
patterns and/or skeletal asymmetry should receive compre-
hensive treatment as covered in the Class III malocclusion
section.
Treatment objectives: Treatment of a crossbite should result
in improved intramaxillary alignment and an acceptable
interarch occlusion and function.171
Class II malocclusion
General considerations and principles of management: Class
II malocclusion (distocclusion) may be unilateral or bilateral
and involves a distal relationship of the mandible to the
maxilla or the mandibular teeth to maxillary teeth. This rela-
tionship may result from dental (malposition of the teeth in
the arches), skeletal (mandibular retrusion and/or maxillary
protrusion), or a combination of dental and skeletal factors.6
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 433
BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
Results of randomized clinical trials indicate that Class II
malocclusion can be corrected effectively with either a single
or two-phase regimen.174-177 Growth-modifying effects in some
studies did not show an influence on the Class II skeletal
pattern,177-179 while other studies dispute these findings.180,181
There is substantial variation in treatment response to growth
modification treatments (headgear or functional appliance),
and no reliable predictors for favorable growth response have
been found.168,174 Some reports state interceptive treatment
does not reduce the need for either premolar extractions or
orthognathic surgery,176,177 while others disagree with these
findings.182 Two-phase treatment results in significantly longer
treatment time169,176,183 although the time spent in full bonded
appliance therapy in the permanent dentition can be signifi-
cantly less.184
Clinicians may decide to provide interceptive treatment
based on other factors.176,180 Evidence suggests that, for some
children, interceptive Class II treatment may improve self-
esteem and decreases negative social experiences, although the
improvement may not be different longterm.180,185 Early Class
II correction may improve facial convexity and/or reduce
incidence of maxillary anterior tooth trauma.186,191 An overjet
in excess of three millimeters is associated with an increased
risk of incisor injury, with large overjets (greater than eight
millimeters) resulting in trauma in more than 40 percent of
children.192,193
Treatment considerations: Factors to consider when planning
orthodontic intervention for Class II malocclusion are: (1)
facial growth pattern; (2) amount of AP discrepancy; (3) patient
age; (4) projected patient compliance; (5) space analysis; (6)
anchorage requirements; and (7) patient and parent desires.
Treatment modalities include: (1) extraoral appliances head-
gear; (2) functional appliances; (3) fixed appliances; (4) tooth
extraction and interarch elastics; and (5) orthodontics with
orthognathic surgery.163
Treatment objectives: Treatment of a developing Class II mal-
occlusion should result in an improved overbite, overjet, and
intercuspation of posterior teeth and an esthetic appearance
and profile compatible with the patient’s skeletal morphology.
Class III malocclusion
General considerations and principles of management: Class
III malocclusion (mesio-occlusion) involves a mesial relation-
ship of the mandible to the maxilla or mandibular teeth to
maxillary teeth. This relationship may result from dental factors
(malposition of the teeth in the arches), skeletal factors
(asymmetry, mandibular prognathism, and/or maxillary retro-
gnathism), anterior functional shift of the mandible, or a
combination of these factors.194
The etiology of Class III malocclusions can be hereditary,
environmental, or both. Hereditary factors can include clefts
of the alveolus and palate as well as other craniofacial ano-
malies that are part of a genetic syndrome.195,196 Some
434 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
environmental factors are trauma, oral/digital habits, caries,
and early childhood OSAS.197
Treatment considerations: Treatment of Class III malocclu-
sions is indicated to provide psychosocial benefits for the
child patient by reducing or eliminating facial disfigurement
and to reduce the severity of malocclusion by promoting
compensating growth.198 Interceptive Class III treatment has
been proposed for years and has been advocated as a necessary
tool in contemporary orthodontics, with initiation in the
primary-early mixed dentition recommended.199-208 Factors to
consider when planning orthodontic intervention for Class
III malocclusion are: (1) facial growth pattern; (2) amount of
AP discrepancy; (3) patient age; (4) projected patient compli-
ance; and (5) space analysis.
Treatment objectives: Interceptive Class III treatment may
provide a more favorable environment for growth and may
improve occlusion, function, and esthetics.109 Although inter-
ceptive treatment can minimize the malocclusion and poten-
tially eliminate future orthognathic surgery, this is not always
possible. Typically, Class III patients tend to grow longer and
more unpredictably and, therefore, surgery combined with
orthodontics may be the best alternative to achieve a satisfac-
tory result for some patients, especially if they exhibit facial
characteristics as follow: mandible forward to cranial base,
increase mandibular length, short ramal length, or obtuse
gonial angle.59,210-212
Treatment of a Class III malocclusion can be achieved
using several modalities including protraction therapy with or
without rapid palatal expansion, functional appliances, inter-
maxillary elastics with modified miniplates, or chin cup
therapy.199-202,210,213-218 These interventions in a growing patient
should result in improved overbite, overjet, and intercuspa-
tion of posterior teeth and an esthetic appearance and profile
compatible with the patient’s skeletal morphology.
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term stability of rapid maxillary expansion combined
with chin cup protraction followed by fixed appliances.
Angle Orthod 2015;85(2):270-7.
217. Wendl B, Kamenica A, Droshci H. Retrospective 25
year follow up of treatment outcomes in angle Class III
patients: Early vs late treatment. J Orofac Orthop 2017;
78(3):201-10.
218. Proffit WR, Fields HW, Jr. Treatment of skeletal transverse
and class III problems. In: Proffit WR, Fields HW, Jr.,
Larson BE, Sarver DM, eds. Contemporary Orthodontics.
6th ed. Philadelphia, Pa.: Elsevier; 2019:440-53.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 441
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.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:442-50.

Abstract
This best practice assists dental practitioners in recognizing and diagnosing temporomandibular disorders and identifying evidence-based
treatment options. Temporomandibular disorders are a group of musculoskeletal and neuromuscular conditions that include clinical signs and
symptoms involving the muscles of mastication, the temporomandibular joint, and associated structures and occasionally occur in infants,
children, and adolescents. Temporomandibular disorders generally are classified into two broad categories: temporomandibular joint disorders
and masticatory muscle disorders. Diagnosing temporomandibular disorders should be based on a screening history, clinical examination,
and/or craniocervical and temporomandibular joint imaging. Temporomandibular disorder treatment goals include restoring function,
reducing pain, reducing risk factors, and improving quality of life. The two main treatment approaches are reversible and irreversible therapies.
Common reversible approaches include patient instruction, physical therapy, behavioral therapy, prescription medication, and occlusal splints.
Meanwhile, with limited evidence for effectiveness of irreversible therapies (e.g., occlusal adjustments, orthodontic treatment, surgery), such
approaches should be avoided in children.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance on acquired temporomandibular disorders in infants, children, and adolescents.
KEYWORDS: TEMPOROMANDIBULAR JOINT, TEMPOROMANDIBULAR JOINT DISORDERS, EVIDENCE-BASED DENTISTRY, PEDIATRIC DENTISTRY

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that disorders of the temporomandibular joint
(TMJ), masticatory muscles, and associated structures occa-
sionally occur in infants, children, and adolescents. These
recommendations are intended to assist the practitioner in
the recognition and diagnosis of temporomandibular disorder
(TMD) and to identify possible treatment options. It is
beyond the scope of this document to recommend the use
of specific treatment modalities.
Background
Definition of TMD
TMD is a collective term for a group of musculoskeletal and
neuromuscular conditions which includes several clinical signs
and symptoms involving the muscles of mastication, the TMJ,
and associated structures.3 While TMD has been defined as
“functional disturbances of the masticatory system”,4 some
researchers and clinicians include masticatory muscle dis-
orders,5 degenerative and inflammatory TMJ disorders,6 and
TMJ disk displacements5 under the umbrella of TMD.

Methods Prevalence of TMD in children and adolescents

Recommendations on acquired temporomandibular disorders
in infants, children, and adolescents were developed by the
Clinical Affairs Committee—Temporomandibular Joint
Problems in Children Subcommittee and adopted in 1990.1
This document by the Council on Clinical Affairs is a revision
of the previous version, last revised in 2015.2 The update
included an electronic search using the terms: temporo-
mandibular disorder, TMJ dysfunction, TMD AND adoles-
cents, TMD AND gender differences, TMD AND occlusion,
TMD AND treatment; fields: all fields; limits: within the
last 15 years, humans, English, clinical trials. The reviewers
agreed upon the inclusion of 104 references to support these
recommendations. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/
or consensus opinion by experienced researchers and clinicians.
TMDs have been identified as a major cause of nonodonto-
genic pain in the orofacial region.8 The reported prevalence of
TMD in infants, children, and adolescents varies widely in the
literature.9-14 This variation may be due to differences in pop-
ulations studied, diagnostic criteria, examination methods, and
inter- and/or intrarater variations of examining practitioners.15,16
The Diagnostic Criteria (DC) TMD examination protocol is
used in research settings to decrease variability in diagnosis;
however, few pediatric studies use this methodology.17,18 One
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CBCT: Cone-beam
computed tomography. DC: Diagnostic Criteria. TMD: Temporo-
mandibular disorder. TMJ: Temporomandibular joint.

442 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


study using the criteria from the DC/TMD demonstrated an
11.9 percent prevalence of TMD in adolescents.18 Most data
suggests the prevalence of signs and symptoms of TMD
increases with age.14,18,19 One investigation noted that TMD-
related symptoms were rare in three- and five-year-olds whereas
five to nine percent of 10- and 15-year-olds reported more
severe symptoms.19 Another study found4.2 percent of adoles-
cents aged 12-19 years reported TMD pain.16 A study of
children in the primary dentition found that 34 percent of
patients have signs and/or symptoms of TMD.20 This could
be due, in part, to inclusion of muscular signs such as
tenderness to palpation which can be difficult to assess in young
children.13,20 A systematic review and meta-analysis of intra-
articular TMD in children and adolescents found a 16 per-
cent prevalence of clinical signs and a 14 percent prevalence
of TMJ sounds.13 Although TMD pain in children increases
with age in both boys and girls, recent surveys have indicated
a significantly higher prevalence of symptoms and greater need
for treatment in girls than boys.14,21 The development of symp-
tomatic TMD has been correlated with the onset of puberty
in girls.22 For ages 16-19 years, 32.5 percent of girls compared
to 9.7 percent of boys reported school absences and analgesic
consumption due to TMD-related pain.21 Headaches appear
to be independently and highly associated with TMD in
adolescents, with most occurring before the onset of jaw pain.23
Etiology of TMD
Temporomandibular disorders have multiple etiological
factors.24 There is insufficient evidence to reliably predict
which patients will or will not develop TMD.25 Predisposing
(risk) factors, precipitating (initiating) factors, and perpetuat-
ing (or sustaining) factors contribute to the development of
TMDs.25 The available evidence base suggests a poor correla-
tion between any single etiological factor and resulting signs
(i.e., findings identified by the dentist during the examination)
and symptoms (i.e., findings reported by the child or parent).26
Alterations in any one or a combination of teeth, periodontal
ligament, the TMJ, or the muscles of mastication may lead to
TMD.26 Furthermore, systemic and psychosocial factors may
reduce the adaptive capacity of the masticatory system and
contribute to TMD.27
Etiologic factors suggested as contributing to the develop-
ment of TMD are:
1. macrotrauma: a common occurrence in childhood
because of falling, chin trauma is reported to be a factor
in the development of TMD in pediatric patients. 28-31
Additional macrotraumatic injuries occur due to motor
vehicle accidents, sports, physical abuse, forceful intuba-
tion, and third molar extraction. 31,32 Unilateral and bi-
lateral intracapsular or subcondylar fractures are the
most common mandibular fractures in children.33 Closed
reduction and prolonged immobilization can result in
ankylosis.34,35 Improperly treated fractures may result in
facial asymmetry.34,35 Traumatic brain injury may accom-
pany mandibular fracture and other types of jaw injuries.31
BEST PRACTICES: TEMPOROMANDIBULAR DISORDERS
Indirect trauma such as flexion-extension (whiplash)
injuries may alter pain processing and lead to TMD
symptoms; however, a direct relationship between TMD
and indirect trauma has yet to be established.27
2. microtrauma from parafunctional habits: bruxism,
clenching, hyperextension, and other repetitive habitual
behaviors are thought to contribute to the development
of TMD by joint overloading that leads to cartilage
breakdown, synovial fluid alterations, and other changes
within the joint.36 Bruxism may occur while the patient
is asleep or awake; sleep bruxism is a different entity from
daytime bruxism. Sleep bruxism has been classified as a
sleep-related movement disorder.37 A study of 854 patients
younger than 17 years old found the prevalence of
bruxism to be 38 percent,38 but studies generally do not
distinguish between sleep or daytime bruxism. The liter-
ature on the association between parafunction and TMD
in pediatric patients is contradictory.39-41 However, child-
hood parafunction was found to be a predictor of the
same parafunction 20 years later.42 Other studies found
a significant association between reported bruxism and
TMD.34,44 Children who grind their teeth were found to
complain more often of pain and muscle tenderness when
eating.45 Other examples of microtrauma include repeti-
tive strain such as playing a wind instrument, fingernail
biting,25 or another activity in which the mouth is held
open outside of rest position.
3. anatomical factors (skeletal and occlusal) and orthodontic
treatment: The association of skeletal and occlusal factors
and the development of TMD is relatively weak. 27,46-48
Furthermore, the available data does not support that the
development of TMD is caused or improved by ortho-
dontic treatment,49-53 regardless of whether premolars were
extracted. 32 Changes in freeway dimension of the rest
position (normally two to four millimeters) may be impinged
by occlusal changes, disease, muscle spasms, nervous
tension, and/or restorative prosthetics.4 While most chil-
dren and adolescents may be able to compensate without
problem, in others, failure of the masticatory system to
adapt may lead to greater risk of dysfunction. Although
there is little evidence to implicate skeletal or occlusal
factors with TMD, the following have some association
across studies:
a. skeletal anterior open bite.54,55
b. steep articular eminence of the temporal bone.27
c. overjet greater than six to seven millimeters.54-57
d. skeletal Class II profile58
e. Class III malocclusion.16
f. unilateral posterior crossbite.46-55
g. posterior crossbite.46
Craniocervical posture has been suggested to be asso-
ciated with occlusion and with dysfunction of the TMJ,
including abnormalities of the mandibular fossa, condyle,
ramus, and disc.59 Cervical pain and dysfunction can be
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 443
BEST PRACTICES: TEMPOROMANDIBULAR DISORDERS
a result of poor posture. 60 Cervical pain is frequently
referred to orofacial structures and can be misinterpreted
as TMD.61
4. psychosocial factors: psychosocial factors may play a part
in the etiology of TMD.61,62 Behavioral factors such as
somatization, anxiety, obsessive-compulsive feelings, and
psychologic stress were predictors of TMD onset.61 Emo-
tional stress predisposes to clenching and bruxism which
in turn contribute to orofacial pain.63 Results from a case-
control study indicate that management of stress and
anxiety can mitigate the signs and symptoms of TMD.64
Depression, anxiety, post-traumatic stress disorder, psy-
chologic distress, and sleep dysfunction may influence
TMD prognosis and symptoms.64 Higher pain intensity
in the orofacial region correlated with greater impact on
quality of life including difficulty with prolonged jaw
opening, eating hard/soft foods, and sleeping.64
5. systemic and pathologic factors: systemic factors con-
tributing to TMD include connective tissue diseases such
as rheumatoid arthritis, systemic lupus erythematosus,
juvenile idiopathic arthritis, and psoriatic arthritis.25,65,66
These systemic diseases occur as a result of imbalance of
pro-inflammatory cytokines which causes oxidative stress,
free radical formation, and ultimately joint damage.67
Other systemic factors may include joint hypermobility,
genetic susceptibility, and hormonal fluctuations. Gener-
alized joint laxity or hypermobility (e.g., Ehler Danlos
syndrome) has been cited but has a weak association
with TMD. 68,69 Pathologic hyperplasia and condylar
tumors represent a unique category of TMDs.66
6. genetic and hormonal factors: there is little research
regarding genetic susceptibility for development of
TMD. Recently, study of catechol-O-methyl-transferase
haplotypes found that the presence of one low pain
sensitivity haplotype decreased the risk of developing
TMD.61 The role of hormones in the etiology of TMD
is debatable. Randomized controlled trials indicate that
estrogen does not play a role in the etiology of TMD,
whereas cohort and case-controlled studies show the
opposite. 27 Although the biological basis for gender-
based disparity in TMD is unclear, the time course of
symptoms is of note in females. Additional studies have
shown that TMJ pain and other symptoms vary in
relation to phases of the menstrual cycle.70 The suggestion
of a hormonal influence in development of TMD is
supported clinically by a study of 3,428 patients who
sought treatment for TMD. This study revealed that
85.4 percent of patients seeking treatment were female
and the peak age for treatment seeking was 33.8 years.70
In a similar study of adolescents,71 15.1 percent of all
patients evaluated for TMD were less than 20 years of
age, and girls accounted for 89.9 percent of patients
aged 15-19 seeking care and 75.5 percent of patient
six-14 years of age.
444 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Diagnosing TMD
All comprehensive dental examinations should include a
screening evaluation of the TMJ and surrounding area.72,73
Diagnosis of TMD is based upon a combination of historical
information, clinical examination, and/or craniocervical and
TMJ imaging.27 The findings are classified as symptoms and
signs.72 These symptoms may include pain, headache, TMJ
sounds, TMJ locking, and ear pain.24 Certain medical condi-
tions are reported to occasionally mimic TMD. Among these
differential diagnoses are trigeminal neuralgia, central nervous
system lesions, odontogenic pain, sinus pain, otological pain,
developmental abnormalities, neoplasias, parotid diseases,
vascular diseases, myofascial pain, cervical muscle dysfunction,
and Eagle’s syndrome.8 Other common medical conditions
(e.g., otitis media, allergies, airway congestion, rheumatoid
arthritis) can cause symptoms similar to TMD.24
Clinical and physical assessment of the patient may include
history and determination of joint sounds, evaluation of
mandibular range of motion, appraisal of pain, evaluation for
signs of inflammation, and select radiographic examination.24
A screening history, as part of the health history, may include
questions such as:25,27
• do you have difficulty opening your mouth?
• do you hear noises within your jaw joint?
• do you have pain in or around your ears or your cheeks?
• do you have pain when chewing, talking, or using your
jaws?
• do you have pain when opening your mouth wide or
when yawning?
• has your bite felt uncomfortable or unusual?
• does your jaw ever lock or go out?
• have you ever had an injury to your jaw, head, or neck?
If so, when? How was it treated?
• have you previously been treated for a temporomandi-
bular disorder? If so, when? How was it treated?
Physical assessment should include the following:24,25,27
1. palpation of the muscles of mastication and cervical
muscles for tenderness, pain, or pain referral patterns;
2. palpation of the lateral capsule of the TMJs;
3. mandibular function and provocation tests;
4. palpation and auscultation for TMJ sounds; and
5. mandibular range of motion.
Evaluation of jaw movements including assessment of
mandibular range of motion using a millimeter ruler (i.e.,
maximum unassisted opening, maximum assisted opening,
maximum lateral excursion, maximum protrusive excursion)
and mandibular opening pattern (i.e., symmetrical vs.
asymmetrical) may be helpful in the diagnosis of TMD. In
addition, both limited and excessive mandibular range of
motion may be seen in TMD.25,27
TMJ imaging is recommended when there is a recent
history of trauma or developing facial asymmetry, or when
hard-tissue grinding or crepitus is detected.74 Imaging also
should be considered in patients who have failed to respond

to conservative TMD treatment.36 TMJ imaging assessment
may include:
• panoramic radiograph;
• mandible radiographs including oblique views;
• conventional computed tomography (CT) or cone-beam
computed tomography (CBCT);
• magnetic resonance imaging (both open and closed
mouth to view disc position); and
• ultrasound.
TMJ arthography is not recommended as a routine diag-
nostic procedure.75-77 The readily available panoramic radio-
graph is reliable for evaluating condylar head morphology
and angulation but does not permit evaluation of the joint
space, soft tissues, or condylar motion.25 The panoramic ra-
diograph may indicate osseous changes, but negative findings
do not rule out TMJ pathology.78 CBCT can be used to detect
boney abnormalities and fractures and to assess asymmetry,76-78
but it generates a much higher radiation burden than the
panoramic image. Magnetic resonance imaging provides
visualization of soft tissues, specifically the position and contours
of the TMJ disc, and can be used to detect inflammation.25,74,77
Ultrasound is a noninvasive imaging method for viewing
superficial lateral aspects of the TMJ.79
TMD has been divided into two broad categories, TMJ
disorders and masticatory muscles disorders,77 which are listed
below.
1. TMJ disorders:
a. joint pain:
(1) arthralgia.
(2) arthritis.
b. joint disorders:
(1) disc-condyle complex disorders (disc displace-
ment with reduction, disc displacement with
reduction with intermittent locking, disc dis-
placement without reduction with limited
opening, disc displacement without reduction
without limited opening).
(2) hypomobility disorders (ankylosis, bony
ankylosis, fibrous adhesions).
(3) hypermobility disorders (subluxation, luxation).
c. joint diseases:
(1) osteoarthritis (degenerative joint disease, condy-
lysis/idiopathic condylar resorption, osteo-
chondritis dissecans, osteonecrosis).
(2) systemic arthritides such as rheumatoid arthritis,
idiopathic juvenile arthritis, spondyloarthro-
pathies, psoriatic arthritis, infections arthritis,
Reiter syndrome, and crystal induced disease.
(3) neoplasms.
(4) fractures (open and closed condylar and sub-
condylar).
2. Masticatory muscle disorders:
a. muscle pain limited to orofacial region (myalgia,
myofascial pain with spreading, myofascial pain with
referral, tendonitis, myositis, spasm).
BEST PRACTICES: TEMPOROMANDIBULAR DISORDERS
b. muscle pain due to systemic/central disorders
(centrally mediated myalgia, fibromyalgia).
c. movement disorders (dyskinesia, dystonia).
d. other muscle disorders (contracture, hypertrophy,
neoplasm).
Treatment of TMD
The goals of TMD treatment include restoration of function,
decreased pain, decreased aggravating or contributing factors,
and improved quality of life.80,81 Few studies document success
or failure of specific treatment modalities for TMD in infants,
children, and adolescents on a long-term basis. It has been sug-
gested that simple, conservative, and reversible types of therapy
are effective in reducing most TMD symptoms in children.81,82
The focus of treatment should be to find a balance between
active and passive treatment modalities. Active modalities
include participation of the patient whereas passive modalities
may include wearing a stabilization splint. In a randomized trial,
adolescents undergoing occlusal appliance therapy combined
with information attained a clinically significant improvement
on the pain index.83 Combined approaches may be more suc-
cessful in treating TMD than single treatment modalities.81
Treatment of TMD can be divided into reversible and irre-
versible treatment. Reversible therapies may include:
• patient education (e.g., explanation in clear and simple
terms describing the nature of the disorder, the signifi-
cance of predisposing, precipitating, and perpetuating
factors, anatomy of the TMJ, management options, and
goals of therapy).27,81
• physical therapy (e.g., jaw exercises or transcutaneous
electrical nerve stimulation [TENS], ultrasound, ionto-
phoresis, massage, TMJ distraction and mobilization,
thermotherapy, coolant therapy).27,36,81,84-86
• behavioral therapy (e.g., biofeedback, relaxation train-
ing, cognitive behavioral therapy [CBT] for developing
behavior-coping strategies and modifying perceptions
about TMD, habit reversal and awareness of daytime
clenching and bruxing, avoiding excessive chewing of hard
foods or gum, voluntary avoidance of stressors, treatment
of co-morbid behavioral health conditions, obtaining ade-
quate, uninterrupted sleep).36,81,86
• prescription medication (e.g., nonsteroidal anti-
inflammatory drugs, anxiolytic agents, muscle relaxers).
While antidepressants have proved to be beneficial, they
should be prescribed by a practitioner familiar with pain
management.27,36,81,87
• occlusal splints. The goal of an occlusal appliance is to
provide orthopedic stability to the TMJ. These alter the
patient’s occlusion temporarily and may be used to de-
crease parafunctional activity and pain. 83,88-90 Occlusal
splints may be made of hard or soft acrylic. The stabilization
type of splint covers all teeth on either the maxillary or
mandibular arch and is balanced so that all teeth are
in occlusion when the patient is closed and the jaw is in
a musculoskeletally stable position.8,36
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 445
BEST PRACTICES: TEMPOROMANDIBULAR DISORDERS
Additional reversible therapies may include TMJ arthro-
centesis, TMJ injections, nerve blocks, acupuncture, trigger point
injections, and off-label use of botulinum toxin A injections.91-95
Irreversible therapies can include:
• occlusal adjustment (i.e., permanently altering the occlu-
sion or mandibular position by selective grinding or full
mouth restorative dentistry).96 A systematic review and
meta-analysis demonstrated that occlusal alteration seems
to have no effect on TMD.97
• orthodontics. This may include mandibular positioning
devices designed to alter the growth or permanently
reposition the mandible (e.g., headgear, functional appli-
ances). There is little evidence that orthodontic treatment
can prevent or relieve TMD.27,98,99
• surgery. Surgical interventional includes orthognathic
surgery, open joint TMJ surgery to removed diseased
synovium, and TMJ reconstruction.66 Data suggests sur-
gery is limited in most situations to cases of severe joint
degeneration or destruction following trauma or tumor
resection.66,81,100
Controversy surrounds the significance of signs and symp-
toms in children and adolescents, the value of certain diagnostic
procedures, and what constitutes appropriate therapy.58,101,102 It
is not clear whether these signs and symptoms constitute
normal variation, preclinical features, or manifestations of a
disease state.103 Whether these signs and symptoms warrant
treatment as predictors of TMD in adulthood is questionable.42,103
Recommendations
Every comprehensive dental history and examination should
include a TMJ history and assessment.73 The history should
include questions concerning the presence of head and neck
pain and mandibular dysfunction, previous orofacial trauma,
and history of present illness with an account of current symp-
toms.102 In the presence of a positive history and/or signs and
symptoms of TMD, a more comprehensive examination (e.g.,
palpation of masticatory and associated muscles and the TMJ’s,
documentation of joint sounds, occlusal analysis, and assess-
ment of range of mandibular movements including maximum
opening, protrusion, and lateral excursions) should be per-
formed. 102 Joint imaging may be recommended in some
cases. 74 Referral should be made to other health care pro-
viders, including those with expertise in TMD, oral surgery,
or pain management, when the diagnostic and/or treatment
needs are beyond the treating dentist’s scope of practice.27
Reversible therapies should be considered for children and
adolescents with signs and symptoms of TMD. 83,104 Because
of inadequate data regarding their effectiveness, irreversible
therapies should be avoided.83,96,99 Referral to a medical spe-
cialist may be indicated when primary headaches, otitis media,
allergies, abnormal posture, airway congestion, rheumatoid
arthritis, connective tissue disease, psychiatric disorders, or
other medical conditions are suspected.
446 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
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 BEST PRACTICES: PERIODONTAL DISEASES

Classification of Periodontal Diseases in Infants,

Children, Adolescents, and Individuals with Special
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; 2022:451-65.

Abstract
This best practice familiarizes clinicians with new classifications of periodontal and peri-implant diseases/conditions to improve their diagnoses.
Three major determinants of periodontal health include microbiological determinants (e.g., plaque and biofilm), host determinants, and
environmental determinants (e.g., smoking, medications, stress, and nutrition). Gingival diseases are categorized as dental plaque biofilm-
induced gingivitis or non-dental-plaque-induced gingival diseases. Periodontal disease can be grouped as periodontitis, necrotizing periodon-
titis, and periodontitis as a manifestation of systemic conditions. An assessment of the periodontal status of pediatric patients should be part
of a routine dental visit and oral examination. Bleeding on probing remains the best parameter to monitor gingival health or inflammation
longitudinally, and the practice of probing should be initiated once permanent first molars are fully erupted and the child is cooperative.
While destructive periodontal disease may be uncommon among children and adolescents, nearly half of all children will experience gingivitis
in their later preschool years, and nearly all will by puberty.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance regarding the classification of periodontal diseases in infants, children, adolescents,
and individuals with special health care needs.
KEYWORDS: PERIODONTAL DISEASES, GINGIVAL DISEASES, PERIODONTITIS, ORAL DIAGNOSES, BLEEDING ON PROBING, GINGIVAL.

Purpose Peri-implant Diseases and Conditions. The objective of the

The American Academy of Pediatric Dentistry (AAPD) recog-
nizes that although the prevalence of destructive forms of
periodontal disease is low among children and adolescents, this
population can develop several forms of periodontal diseases
and conditions most frequently associated with an underlying
systemic or immunologic disorder.1-4 In addition, current and
early studies show that gingivitis occurs in half of the pop-
ulation by age of four or five years and peaks nearly to 100
percent at puberty.3 The prevalence of gingivitis can be similar
to or greater than dental caries during childhood.1 Neverthe-
less, when compared to dental caries, gingivitis in children has
received much less attention in understanding the long-term
impact that chronic inflammation of the periodontal tissues
in childhood may have on overall health of the periodontium
throughout life.1 Therefore, it is critical that pediatric dental
patients receive a periodontal assessment as part of their routine
dental visits. Early diagnosis ensures the greatest opportunity
for successful treatment, primarily by reducing etiological
factors, establishing appropriate therapeutic measures, and
developing an effective periodic maintenance protocol.2
In 2017, the American Academy of Periodontology and
the European Federation of Periodontology co-sponsored the
World Workshop on the Classification of Periodontal and
workshop was to update the previous disease classification
established at the 1999 International Workshop for Classifi-
cation of Periodontal Diseases and Conditions. 5 One of the
major highlights included the recategorization of three forms
of periodontitis, the development of a multidimensional
staging and grading system for periodontitis, and the new
classification for peri-implant diseases and conditions.6
The intent of this best practices document is to present an
abbreviated overview of the new classification of periodontal
and peri-implant diseases and conditions, including gingivitis.
In addition, this document aims to emphasize the key role
dentists have in diagnosing, treating and/or referring pediatric
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. ADA: American
Dental Association. BoP: Bleeding on probing. CAL: Clinical attach-
ment loss. EPL: Endodontic-periodontal lesions. FDA: Food and Drug
Administration. GH: Gingival health. ICD: International Statistical
Classif ication of Diseases and Related Health Problems. HIV/AIDS:
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.

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BEST PRACTICES: PERIODONTAL DISEASES

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 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”.

452 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: PERIODONTAL DISEASES

patients and those medically compromised or with special
health care needs affected by periodontal problems. A com-
prehensive review of the 2017 World Workshop on the
Classification of Periodontal and Peri-implant Diseases and
Conditions including the rationale, criteria, and implementa-
tion of the new classifications, is available in the June 2018
Journal of Periodontology (Table 1).6-28
Methods
This document presents an abbreviated overview of the new
classification of periodontal and peri-implant diseases and
conditions.6-28 In addition to reviewing the proceeding papers
from the 2017 World Workshop, an electronic search was
®
conducted using PubMed /MEDLINE using the terms:
periodontal health AND children, periodontal health AND
adolescents, gingival disease AND children, gingival disease
AND adolescents, periodontal disease AND children, perio-
dontal disease AND adolescents, gingivitis AND prevalence,
periodontitis AND prevalence, gingival disease AND prevalence,
periodontal disease AND prevalence, dental plaque AND
children, dental plaque AND adolescents; fields: all; limits:
within the last 10 years, humans, English, and clinical trials.
From this search, 1588 articles matched these criteria and
were evaluated by title and/or abstract. Information from
61 papers for review was chosen from this list and from
references within selected articles. When data did not appear
sufficient or were inconclusive, recommendations were based
upon expert and/or consensus opinion by experienced re-
searchers and clinicians.
Background
Periodontal health, gingival diseases and conditions
Periodontal health
The World Health Organization (WHO) defines health as
“a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”. 29 Fol-
lowing this framework, periodontal health is defined as the
absence of clinical inflammation associated with gingivitis,

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
periodontium
2. Clinical gingival health on
a reduced periodontium
a. Stable periodontitis patient
b. Non-periodontitis patient
Plaque-induced plaque-induced
1. Associated with biofilm alone 1. Genetic/developmental disorders (e.g.,
2. Mediated by systemic or local risk hereditary gingival fibromatosis)
factors 2. Specific infections
a. Systemic risk factors (modifying a. Bacterial origin
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

© 2018 American Academy of Periodontol and European Federation of Periodontology. J Periodontol 2018;89(Supp 1):S74-S84.
John Wiley and Sons. Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.17-0719”.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 453

BEST PRACTICES: PERIODONTAL DISEASES
periodontitis, or any other periodontal conditions, and may
include patients who have had a history of successfully treated
gingivitis or periodontitis, or other periodontal conditions,
and who have been and are able to maintain their dentition
without signs of clinical gingival inflammation.11 According to
the WHO health framework,29 the absence of inflammatory
periodontal disease allows an individual to function normally
and avoid the consequences (mental or physical) associated to
present or past disease.11
Assessing periodontal health is important to establish a
common reference point for diagnosing disease and determining
therapy outcomes by practitioners. 11,21 Four levels of perio-
dontal health have been proposed, depending on whether (1)
the periodontium (attachment and bone level) is structurally
and clinically sound or reduced, (2) the ability to control local
and systemic modifying factors, as well as (3) the relative
treatment outcomes. These levels are: (1) pristine periodontal
health, characterized by total absence of clinical inflammation,
and physiological immune surveillance on a periodontium
with normal support; (2) clinical periodontal health, charac-
terized by an absence or minimal levels of clinical inflamma-
tion in a periodontium with normal support; (3) periodontal
disease stability, characterized as a state in which the
periodontitis has been successfully treated and clinical signs
of the disease do not appear to worsen in extent or severity
despite the presence of a reduced periodontium; and (4)
periodontal disease remission/control, characterized as a period
in the course of disease when symptoms become less severe
but may not be fully resolved with a reduced periodontium
(Table 2). 6,21 It should be noted that “pristine periodontal
health” characterized by no attachment loss, no bleeding on
probing (BoP), no sulcular probing greater than three milli-
meters (mm) in the permanent dentition and no redness,
clinical swelling/edema or pus is a rare entity, especially
among adults.21 Therefore, minimal levels of clinical inflam-
mation observed in “clinical periodontal health” is com-
patible with a patient classified as periodontally healthy.
Monitoring gingival health or inflammation is best docu-
mented by the parameter of BoP since it is considered the
primary parameter to set thresholds for gingivitis and the most
reliable for monitoring patients longitudinally in clinical
practice.6,21 Clinicians are encouraged to start probing regularly
when the first permanent molars are fully erupted and the
child is able to cooperate for this procedure in order to establish
a baseline, detect early signs of periodontal disease, and prevent
its progression. Probing prior to the eruption of the first
permanent molars is encouraged in the presence or suspicion
of any clinical and/or radiographic signs of periodontal disease.
While probing, clinicians should rule out the presence of
pseudopockets associated, for example, with tooth exfoliation
or partially erupted teeth. For patients with special health
care needs receiving dental treatment under sedation and/or
general anesthesia, clinicians are encouraged to take this op-
portunity and perform the periodontal probing. The probing
force should not exceed 0.25 Newton (light probing) in
454 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
order to rule out the confounding issue of BoP induced by too
much pressure, as well as unnecessary bleeding resulting from
trauma.21 When probing positioning and pressure into the
sulcus/pocket are performed correctly, the patient should not
feel discomfort. With regards to periodontal probing depth
(PPD), there is strong evidence that deep pockets are not
necessarily consistent with disease. Deep pockets may remain
stable and uninflamed, especially in cases where patients receive
long term careful supportive periodontal care and are referred
to as “healthy pockets”. PPD or probing attachment levels
alone should not be used as evidence of gingival health or
disease; rather, they should be considered in conjunction with
other important clinical parameters such as BoP, as well as
modifying and predisposing factors. Radiographic assessment
is a critical component of clinical assessment of the periodontal
tissues. Radiographically, a normal, anatomically-intact perio-
dontium would present an intact lamina dura, no evidence
of bone loss in furcation areas, and a two mm distance (on
average, varying between 1.0 and 3.0 mm) from the most
coronal portion of the alveolar bone crest to the cemento-
enamel junction. While analyzing dental radiographs of
children, it is important that clinicians not follow only on
diagnosing interproximal caries lesions, but also evaluate the
periodontal status, especially as the child grows older. Tooth
mobility is not recommended as a clinical parameter of either
periodontal health or disease status.21
Important differences between periodontal disease stability
and periodontal disease remission/control are the ability to
control for modifying factors and the therapeutic response.
Stability is characterized by minimal inflammation (less than
10 percent in BoP sites), optimal therapeutic response (no
probing depths greater than four mm), and lack of progressive
periodontaldestruction while controlling for risk factors.
Remission/control is characterized by a significant decrease in
inflammation, some improvement in other clinical parameters,
and stabilization of disease progression. Stability is the major
treatment goal for periodontitis; however, remission/control
may be the more realistically achievable therapeutic goal when
it is not possible to fully control for modifying factors.11,19,22,28
There are three major determinants of clinical periodontal
health. These include:
1. microbiological determinants
a. supragingival plaque; and
b. subgingival biofilm compositions.
2. host determinants
a. local predisposing factors
i. periodontal pockets;
ii. dental restorations;
iii. root anatomy;
iv. tooth position; and
v. crowding.
b. systemic modifying factors
i. host immune function;
ii. systemic health; and
iii. genetics.
 BEST PRACTICES: PERIODONTAL DISEASES

3. environment determinants of gingival disease and conditions: dental plaque biofilm-

a. smoking; induced gingivitis and non-dental-plaque-induced gingival
b. medications; disease.
c. stress; and
d. nutrition. Dental plaque biofilm-induced gingivitis
During the 2017 World Workshop on the Classification of
In order to attain or maintain clinical periodontal health, Periodontal and Peri-implant Diseases and Conditions,
clinicians should not underestimate predisposing and modify- revisions of the 1999 classification system5 for dental plaque-
ing factors for each patient and should recognize when these induced gingival diseases included four components: (1) des-
factors can be fully controlled or not. Predisposing factors are cription of the extent and severity of the gingival inflammation;
any agent or condition that contributes to the accumulation of (2) description of the extent and severity of gingival enlarge-
dental plaque (e.g., tooth anatomy, tooth position, restorations), ments; (3) a reduction in gingival disease taxonomy; and (4)
while modifying factors are any agent or condition that alters discussion of whether mild localized gingivitis should be
the way in which an individual responds to subgingival plaque considered a disease or variant of health.22 These four components
accumulation (e.g., smoking, systemic conditions, medications). are addressed in this review.
Many factors are determined controllable (e.g., removal of Dental plaque biofilm-induced gingivitis usually is regarded
overhangs, smoking cessation, good diabetes control) while as a localized inflammation initiated by microbial biofilm
others are not (e.g., genetics, immune status, use of critical accumulation on teeth and considered one of the most com-
medications).21 mon human inflammatory diseases (Table 2).6,19 When dental
plaque is not removed, gingivitis may initiate as a result of loss
Gingival health of symbiosis between the biofilm and the host’s immune-
Gingival health (GH) is usually associated with an inflammatory inflammatory response. The common features of plaque-induced
infiltrate and host response in relatively stable equilibrium.21
GH in a patient with intact periodontium is diagnosed by (1)
no probing attachment loss, (2) no radiographic bone loss Table 3. DIAGNOSTIC LOOK-UP TABLE FOR GINGIVAL HEALTH
(RBL), (3) less than three mm of PPD, and (4) less than 10 per- OR DENTAL PLAQUE-INDUCED GINGIVITIS IN
cent BoP. 11 GH can be restored following treatment of CLINICAL PRACTICE ( Adapted from Chapple et al. 11 )
gingivitis and periodontitis. The diagnostic criteria for GH in a
Intact periodontium Health Gingivitis
patient followingtreatment of gingivitis are the same as those
just mentioned. These same clinical features also are observed Probing attachment loss No No
on a reduced periodontium following successful treatment Probing pocket depths
≤ 3 mm ≤ 3 mm
of periodontitis. A patient with a current GH status who has (assuming no pseudopockets)
a history of successfully treated and stable periodontitis Bleeding on probing < 10% Yes (≥ 10%)
remains at an increased risk of recurrent periodontitis; there- Radiological bone loss No No
fore, the patient should be monitored closely to ensure optimal Health Gingivitis
Reduced periodontium
disease management. Non-periodontitis patient
Probing attachment loss Yes Yes
Gingival diseases and conditions
Probing pocket depths (all sites
Gingivitis is a reversible disease characterized by an inflamma- ≤ 3 mm ≤ 3 mm
& assuming no pseudopockets)
tion of the gingiva that does not result in clinical attachment Bleeding on probing < 10% Yes (≥ 10%)
loss (CAL).30 Gingivitis is highly prevalent among children
Radiological bone loss Possible Possible
and adolescents11,21 and a necessary prerequisite for the de-
velopment of periodontitis and progressive connective tissue Successfully treated stable Health Gingivitis in a
attachment and bone loss.6,22,28 Controlling gingival inflam- periodontitis patient patient with
a history of
mation is considered the primary preventive strategy for
periodontitis
periodontitis, as well as the secondary preventive strategy for
recurrence of periodontitis. Even though there is a predilection Probing attachment loss Yes Yes
of attachment loss to occur at inflamed sites of the gingiva, Probing pocket depths (all sites
≤ 4 mm
not all affected areas are destined to progress to periodontitis. (no site ≥ 4 mm ≤ 3 mm
& assuming no pseudopockets)
with BoP)
This is because the interrelationship between health, gingivitis,
Bleeding on probing < 10% Yes (≥ 10%)
and periodontitis is highly dependent on the host’s susceptibility
and immune-inflammatory response. Nevertheless, clinicians Radiological bone loss Yes Yes
must understand their crucial role in ongoing management of
© 2018 American Academy of Periodontol and European Federation of Periodontology.
gingivitis for their patients of all ages with and/or without a J Periodontol 2018;89(Supp 1):S74-S84. John Wiley and Sons.
history of periodontal disease. There are broadly two categories Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.17-0719”.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 455

BEST PRACTICES: PERIODONTAL DISEASES
gingivitis include (1) clinical signs and symptoms of inflamma-
tion confined to the free and attached gingiva that do not
extend to the periodontal attachment (cementum, periodontal
ligament and alveolar bone); (2) reversibility of the inflam-
mation achieved by biofilm removal at and apical to the
gingiva margin; (3) presence of a high bacterial plaque burden
needed to initiate the inflammation; and (4) stable attachment
levels on a periodontium, which may or may not have experi-
enced a loss of attachment or alveolar bone (Table 3).11,22,28 The
diagnostic criteria for gingivitis is based on clinical features.
Radiographs and probing attachment level analysis should not
be used to diagnose gingivitis since they usually do not indicate
loss of supporting structures. Clinical signs of inflammation
include erythema, edema, heat, and loss of function. Clinical
signs of gingivitis include swelling (loss of knife-edged gingival
margin and blunting of papillae), redness, and bleeding and
discomfort on gentle probing. Patient symptoms may include
bleeding gums, metallic/altered taste, pain/soreness, halitosis,
difficulty eating, appearance of swollen red gums, and reduced
oral health-related quality of life. 11Although there are no
objective clinical criteria for defining gingivitis severity, the
extent of gingivitis (referred as mild, moderate, and severe)
can be used as a patient communication tool. The definitions
of mild, moderate, and severe gingivitis continue to be a
matter of professional opinion. Practitioners may define gin-
givitis as percentages of BoP sites (e.g., mild = < 10 percent,
moderate = 10-30 percent, severe = > 30 percent sites) or based
on grading (e.g., Grade 1 to 5 in 20 percent quintiles for
percent sites BoP).10 The gingival index by Löe31 also can be
used to describe intensity of gingival inflammation as mild
(area with a minor change in color and little change in the
texture of the tissue), moderate (area with glazing, redness,
edema, enlargement, and bleeding upon probing), and severe
(area of overt redness and edema with a tendency toward
bleeding when touched rather than probed). Lastly, the extent
or the number of gingival sites exhibiting gingival inflam-
mation can be described as either localized (< 30 percent of
the teeth are affected) or generalized (≥ 30 percent of the teeth
are affected).22
As mentioned above, one revision from the 1999 classification
system 5 was the proposal to introduce the term incipient
gingivitis “where, by definition, only a few sites are affected by
mild inflammation, expressed as mild redness and/or a delayed
and broken line of bleeding rather than edema or an imme-
diate unbroken line of bleeding on probing. Incipient gingivitis
may be regarded as a condition that is part of a spectrum of
‘clinical health,’ but may rapidly become localized gingivitis
if untreated.”22
The severity, extent, and progression of plaque-induced
gingivitis at specific sites or at the entire mouth vary between
individuals and can be influenced by local (predisposing) and
systemic (modifying) factors. Local oral factors that exacer-
bate plaque-induced gingivitis are those that can influence the
initiation or progression of gingival inflammation by facilitating
accumulation of bacterial plaque at a specific site, inhibiting
456 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
daily mechanical plaque removal, and/or creating a biological
niche that encourages increased plaque accumulation. Examples
of plaque-induced gingivitis exacerbated by plaque biofilm
retention are prominent subgingival restoration margins and
certain tooth anatomies that contribute with plaque accu-
mulation increasing the risk for gingivitis and, consequently,
compromising the gingival health. Oral dryness is a clinical
condition frequently associated with xerostomia, which in turn
is a symptom caused by a decrease in the salivary flow (hypo-
salivation). Hyposalivation interferes with plaque removal,
thereby increasing the risk of caries, halitosis, and gingival
inflammation among other oral conditions. Xerostomia may
occur as a side effect of medications such as antidepressants,
antihistamines, decongestants, and antihypertensive medica-
tions. In addition, health diseases/conditions such as Sjögren’s
syndrome, anxiety, and poorly controlled diabetes may cause
xerostomia due to hyposalivation.11,22
Systemic risk factors can modify the host immune inflam-
matory response in the presence of dental plaque biofilm
resulting in exaggerated inflammatory response. Examples
of systemic conditions include: (1) sex steroid hormones
(e.g., puberty, pregnancy, menstrual cycle, oral contraceptives);
(2) hyperglycemia; (3) leukemia; (4) malnutrition; and (5)
smoking.11,22
Elevations in sex steroid hormones, especially, during
puberty and pregnancy may modify the gingival inflammatory
response and result in an exaggerated gingival inflammation
in the presence of even relatively small amounts of plaque.
Other factors that predispose to gingivitis in both male and
female adolescents are dental caries, mouth breathing, dental
crowding, and eruption of teeth. As for the use of oral contra-
ceptives, exaggerated gingival inflammatory response to
plaque is not reported in current, lower-dosage formulations as
previously was observed with first generation high-dose oral
contraceptives.32-34 Although modest gingival inflammation
changes have been reported during ovulation,35-37 most women
with gingival inflammation associated with menstrual cycles will
present with nondetectable clinical signs of the condition.38-40
Hyperglycemia, hematologic malignancies (e.g., leukemia),
and nutritional deficiencies also are significant systemic condi-
tions that can negatively affect the gingival tissues. Increased
incidence of chronic gingivitis and risk of periodontitis among
children with poorly controlled Type 1 diabetes mellitus have
been reported.41-43 The severity of gingival inflammation may
be more associated with the level of glycemic control rather
than the quality of plaque control.36-40 Hyperglycemia can alter
the immune system and have a negative direct effect on perio-
dontal cells and neutrophil activity, as well as have an indirect
adverse effect by stimulating immune system cells to release
inflammatory cytokines.44,45 Early diagnosis of periodontal prob-
lems among children and adolescents with poorly controlled
diabetes through periodic periodontal screenings, as well as
prevention of periodontal diseases among this population, is
of fundamental importance. It is worth mentioning that, in
addition to gingivitis and periodontitis, xerostomia and candida

infections also are associated with diabetes.45 Certain hemato-
logic malignancies (e.g., leukemia) are associated with signs of
excess gingival inflammation inconsistent with levels of dental
plaque biofilm accumulation. Oral manifestations include
gingival enlargement/bleeding, petechiae, oral ulcerations/
infections, and cervical lymphadenopathy. Signs of gingival
inflammation include swollen, glazed, and spongy tissues that
are red to deep purple in appearance.11,22,46,47 These oral mani-
festations may be either the result of direct gingiva infiltration
of leukemic cells or thrombocytopenia and/or clotting-factor
deficiencies. Both gingival bleeding and hyperplasia have been
reported as initial oral signs and symptoms of patients with acute
and chronic leukemias.22,46,47 Through periodic clinical examina-
tions, dentists have an opportunity for early diagnosis of such
malignant diseases, as well as timely referral and, subsequently,
increased chances for improved patient treatment outcomes.
The literature lacks information regarding the exact role of
nutrition in the initiation and/or progression of periodontal
diseases. However, the role of vitamin C (ascorbic acid) in
supporting periodontal tissues due to its essential function in
collagen synthesis is well-documented.10,19 Vitamin C deficiency,
or scurvy, compromises antioxidant micronutrient defenses
to oxidative stress and collagen synthesis leading to weakened
capillary blood vessels, consequently increasing the predis-
position to gingival bleeding.48 Nevertheless, gingival inflam-
mation due to vitamin C deficiency may be difficult to detect
clinically and indistinguishable from plaque-induced gingivitis.22
Scurvy may occur in certain populations of pediatric interest
such as infants and children from low socioeconomic families.22
One major change in the 2017 classification of dental
plaque-induced gingival diseases was to simplify the system for
the clinician and condense the catalog to include only condi-
tions affecting the gingiva that could be clinically identified.
Therefore, terms previously used such as menstrual cycle-
associated gingivitis, oral contraceptive–associated gingivitis,
and ascorbic acid-associated gingivitis were eliminated from
the classification system because signs of these conditions were
not clinically evident to the dentist.11
Smoking is a major lifestyle and behavioral risk factor for
periodontitis mostly attributed to alterations in the microflora
and/or host response. 11,22 Increased pocket depth measure-
ments, attachment loss, and alveolar bone loss are more pre-
valent in smokers than nonsmokers.49 Tobacco use is no longer
classified as a habit but as a dependence to nicotine and a
chronic relapsing medical disorder.50 Smoking and smokeless
tobacco use almost always are initiated and established in
adolescence. 51-57 The most common tobacco products used
by middle school and high school students are reported to
be e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs,
pipe tobacco, and bidis (unfiltered cigarettes from India). 52
However, the exposure to cannabis (marijuana) among chil-
dren and adolescents has increased in the United States due
to its legalization in many states.55 Frequent cannabis use has
been associated with deeper probing depths, more CAL, and
increased risk of severe periodontitis.55 Periodontitis, visible
BEST PRACTICES: PERIODONTAL DISEASES
plaque, and gingival bleeding also have been reported among
crack cocaine users. 56 Clinical signs associated with smoke-
less tobacco may include increased gingival recession and
attachment loss, particularly at the sites adjacent to mucosal
lesion associated with the habit. 55 Health professionals who
treat adolescents and young adults should be aware of the
signs of tobacco use and be able to provide counseling (or
referral to an appropriate provider) regarding the serious
health consequences of tobacco and drug use, as well as use
brief interventions for encouragement, support, and positive
reinforcement for cessation when the habit is identified.
Drug-influenced gingival enlargements occur as a side effect
in patients treated with anticonvulsant drugs (e.g., phenytoin,
sodium valproate), certain calcium channel–blocking drugs
(e.g., nifedipine, verapamil, diltiazem, amlodipine, felodipine),
immune-regulating drugs (e.g., cyclosporine), and high-dose
oral contraceptives.11,57 For drug-influenced gingival conditions
to occur, the presence of plaque bacteria is needed. The onset
of this condition may occur within three months of the drug
use, 11 but not all individuals taking these medications are
susceptible and will develop gingival overgrowth. Reports show
that approximately half of the people who take phenytoin,
nifedipine, or cyclosporin are affected with this condition.57 A
major consideration during the 2017 workshop was to select
an easy and appropriate clinical assessment to define the
extent and severity of the drug-influenced overgrowth. The
extent of gingival enlargements was defined as either localized
(enlargement limited to the gingiva in relation to a single tooth
or group of teeth) or generalized (enlargement involves the
gingiva throughout the mouth).22 Mild gingival enlargement
involves enlargement of the gingival papilla; moderate gingival
enlargement involves enlargement of the gingival papilla and
marginal gingiva; and severe gingival enlargement involves
enlargement of the gingival papilla, gingival margin, and
attached gingiva.22 Drug-influenced gingival enlargement is
not associated with attachment loss or tooth mortality.
Non-dental-plaque-induced gingival diseases
The gingiva and oral tissues may demonstrate a variety of
gingival lesions that are not caused by plaque and usually do
not resolve after plaque removal (Table 2). 6 However, the
severity of the clinical manifestations of these lesions often
is dependent upon plaque accumulation and subsequent gin-
gival inflammation. These lesions may be manifestations of
a systemic condition or medical disorder. They also may re-
present pathologic changes confined to the gingiva. Because
oral health and systemic health are strongly interrelated, it is
important that dentists and other health care providers col-
laborate to adequately diagnose, educate the patient about his
condition, treatment plan, treat, or refer to a specialist for
treatment. The current classification of non-dental-plaque-
induced gingival conditions is based on the etiology of the
lesions. These include: genetic/developmental disorders
(e.g., hereditary gingival fibromatosis); specific infections of
bacterial (e.g., necrotizing periodtal diseases, Streptococcal
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 457
BEST PRACTICES: PERIODONTAL DISEASES
gingivitis), viral (e.g., hand-foot-and-mouth disease, primary
herpetic gingivostomatitis), and fungal (e.g., candidiasis)
origins; inflammatory and immune conditions and lesions
(e.g., hypersensitivity reactions, autoimmune disease of skin
and mucous membranes); reactive processes (e.g., epulides);
premalignant neoplasms (e.g., leukoplakia); malignant neo-
plasms (e.g., leukemia, lymphoma); traumatic lesions (e.g.,
physical, chemical, thermal insults); endocrine, nutritional,
and metabolic diseases (e.g., vitamin deficiencies); and gingival
pigmentation (e.g., amalgam tattoo). The major difference
between the 1999 and 2017 classifications is the development
of a more comprehensive nomenclature of non-plaque induced
gingival diseases and conditions based on the primary etiology,
as well as the inclusion of the International Statistical Classi-
fication of Diseases and Related Health Problems (ICD)–10
diagnostic codes (e.g., ICD–10 code for primary herpetic
gingivostomatitis is B00.2).6,11,19 Several of these conditions
may occur in pediatric patients, as well as in those with special
health care needs; therefore, they are of great interest to
pediatric dentists. For a comprehensive review on this topic,
the reader is encouraged to review the position paper on
non-dental-plaque-induced gingival diseases by Holmstrup
et al.19 and the workshop consensus report by Chapple et al.11
Classification of periodontal diseases
The new classification of periodontal disease proposed in the
2017 workshop defines three distinct forms: (1) periodontitis
(single category grouping the two forms of the disease
formerly recognized as aggressive or chronic); (2) necrotizing
periodontitis; and (3) periodontitis as a manifestation of systemic
conditions. The new periodontitis classification was further
characterized based on a multi-dimensional staging and grading
framework system. The former indicates the disease severity
and complex management, while the latter estimates the rate
and likelihood of the disease progression and/or response to
standard periodontal therapy taking into consideration the
patient’s biological features.6,24,26 An individual case of perio-
dontitis should be further defined using a simple matrix that
describes the stage and grade of the disease24 as seen in Table 4.
Periodontitis
Currently, evidence is insufficient to support the notion that
chronic and aggressive periodontitis are two pathophysiologically
distinct diseases. Due to concerns from clinicians, researchers,
educators, and epidemiologists regarding their ability to prop-
erly distinguish between chronic and aggressive periodontitis,
the 2017 World Workshop members proposed grouping these
two previously forms of periodontitis into a single category
simply referred to as periodontitis.24,27 The clinical entity pre-
viously referred to as aggressive periodontitis due to its rapid
rate of progression is now categorized as Grade C periodontitis
and represents the extreme end of a continuum of disease rates.
Periodontitis is a multifactorial, microbially-associated, host-
mediated inflammatory disease characterized by progressive
destruction of the periodontal attachment apparatus. Loss
458 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
of periodontal tissue support is the primary feature of perio-
dontitis, which is detected as CAL by circumferential assess-
ment of erupted teeth using a standardized periodontal probe
with reference to the cemento-enamel junction. Clinically, a
patient is characterized as a periodontitis case if: (1) interdental
CAL is detectable at two or more nonadjacent teeth; or (2)
buccal or oral CAL three or more mm with pocketing greater
than three mm is detectable at two or more teeth. Further-
more, the CAL cannot be attributed to nonperiodontal
causes such as: (1) gingival recession of traumatic origin; (2)
dental caries extending in the cervical area of the tooth; (3) the
presence of CAL on the distal aspect of a second molar and
associated with malposition or extraction of a third molar; (4)
an endodontic lesion draining through the marginal perio-
dontium; and (5) the occurrence of a vertical root fracture.24,27
In the context of the 2017 World Workshop, three clearly
different forms of periodontitis have been identified based on
pathophysiology. Differential diagnosis is based on the history
and the specific signs and symptoms of necrotizing periodon-
titis and the presence or absence of an uncommon systemic
disease that definitively modify the host immune response.6,24,27
Evidence supports necrotizing periodontitis as a separate
disease entity based on (1) distinct pathophysiology charac-
terized by prominent bacterial invasion and ulceration of
epithelium; (2) rapid and full thickness destruction of the
marginal soft tissue resulting in characteristic soft and hard
tissue defects; (3) obvious symptoms; and (4) faster resolution
in response to specific antimicrobial treatment.27 This painful
and infectious condition should be diagnosed primarily based
on its typical clinical features, which includes necrosis and
ulceration in the interdental papilla, gingival bleeding,
pseudomembrane formation, and halitosis.18,24 In severe cases,
bone sequestrum also may occur. 58 Pain and halitosis are
observed less often among children, while systemic conditions
such as fever, adenopathy, and sialorrhea (hypersalivation) are
observed more frequently.18,59 Necrotizing periodontal diseases
are strongly associated with impairment of the host immune
system. Predisposing factors include inadequate oral hygiene,
chronic gingivitis, human immunodeficiency virus and
acquired immune deficiency syndrome (HIV/AIDS), malnu-
trition, tobacco/alcohol consumption, psychological stress,
and insufficient sleep among others.24 Among children, higher
risk of necrotizing periodontitis is observed in those with se-
vere malnutrition, extreme living conditions (e.g., substandard
accommodations, limited access to potable water, poor sanitary
disposal system), and disease resultant from severe viral infec-
tions (e.g., HIV/AIDS, measles, chicken pox, malaria).18,24
Although the prevalence of necrotizing periodontitis is low, it
is a severe condition leading to very rapid tissue destruction
that can be life-threating among compromised children.18 For
a more in-depth review of necrotizing periodontitis, readers
are directed to the positional papers by Herrera et al. 18 and
Tonetti et al.,27 as well as to the consensus report by Papapanou
et al.24

Systemic disease is defined as a disease that affects multiple
organs and tissues or that affects the body as a whole.60 Several
systemic disorders and conditions can affect the course of
periodontal diseases or have a negative impact on the periodontal
attachment apparatus independently of dental biofilm-induced
inflammation.7,20 For some cases, the periodontal problems may
be among the first signs of the disease. These disorders or
conditions are grouped as periodontitis as a manifestation
of systemic disease, and classification should be based on
and follow the classification of the primary systemic disease
according to the respective ICD codes.6 Moreover, they can be
grouped into broad categories such as genetic disorders that
affect the host immune response (e.g., Down syndrome, Papil-
lon Lefèvre, histiocytosis) or affect the connective tissues (e.g.,
Ehlers-Danlos syndrome, systemic lupus erythematosus);
metabolic and endocrine disorders (e.g., hypophosphatasia,
hypophosphatemic rickets); inflammatory conditions (e.g.,
epidermolysis bullosa acquisita, inflammatory bowel disease);
as well as other systemic disorders (e.g., obesity, emotional stress
and depression, diabetes mellitus, Langerhans cell histiocytosis,
neoplasms). For a more comprehensive review of classifications,
case definitions and diagnostic considerations, the reader is
encouraged to read the positional paper and consensus report
by Albandar et al.7 and Jepsen et al.,20 respectively.
The remaining clinical cases of periodontitis that do not
present with the local characteristics of necrotizing perio-
dontitis or the systemic characteristics of a rare immune
disorder with a secondary manifestation of periodontitis should
be diagnosed as periodontitis and be further characterized
using the staging and grading system that describes clinical
presentation,6,7,18,20,24,27 (Table 4).
The concept of staging is adopted from the field of oncol-
ogy that classifies staging of tumors based on baseline clinical
observations of size or extent and whether it has metastasized
or not.61 Understanding the stage of the periodontal disease
helps the clinician communicate with the patient the current
severity and extent of the disease (localized or generalized),
assess the complexities of disease management, develop a
prognosis, and design an individualized treatment plan for the
patient. Staging is determined by a number of variables such
as PPD, CAL, amount and percentage of bone loss, presence
and extent of angular bony defects and furcation involvement,
tooth mobility, and tooth loss due to periodontitis.27 Staging
involves four categories: Stage I (initial periodontitis), Stage II
(moderate periodontitis), Stage III (severe periodontitis –
potential for tooth loss), and Stage IV (advanced periodontitis –
potential for loss of dentition). Grading assesses the future risk
of the periodontitis progression and anticipated treatment
outcomes but also estimates the positive or negative impact
that periodontitis and its treatment have on the overall health
status of the patient. Grading also allows the clinician to
incorporate the individual patient risk factors (e.g., smoking,
uncontrolled Type 2 diabetes) into the diagnosis, which may
influence the comprehensive case management. Grading
includes three levels: Grade A (low risk of progression), Grade
BEST PRACTICES: PERIODONTAL DISEASES
B (moderate risk of progression), and Grade C (high risk of
progression). Table 4 shows the framework for staging and
grading of periodontitis, as well as the criteria for periodontitis
stage and grade, respectively.27 Table 5 presents the three steps
to staging and grading a patient with periodontitis. 27 For a
more comprehensive description of staging and grading of
periodontitis, the reader is encouraged to review an outcome
workshop paper by Tonetti et al.27 and the workshop consensus
report by Papapanou et al.24
Other conditions affecting the periodontium
Peridontal abscesses and endodontic-periodontal lesions
Both periodontal abscesses (PA) and endodontic-periodontal
lesions (EPL) share similar characteristics that differentiate
them from other periodontal conditions. These include pain
and discomfort requiring immediate emergency treatment,
rapid onset and destruction of periodontal tissues, negative
effect on the prognosis of the affected tooth, and possible severe
systemic consequences.
PA are defined as acute lesions characterized by localized
accumulation of pus within the gingival wall of the perio-
dontal pocket, initiated by either bacterial invasion or foreign
body impaction.18,24 The most prominent sign associated with
PA is the presence of an ovoid elevation in the gingiva along
the lateral part of the root. Other signs and symptoms may
include pain, tenderness and swelling of the gingiva, bleeding
and suppuration on probing, deep periodontal pocket, bone
loss observed radiographically, and increased tooth mobility.18,24
Facial swelling, elevated body temperature, malaise, regional
lymphadenopathy, or increased blood leukocytes are less
commonly observed.18 Etiologic factors such as pulp necrosis,
periodontal infections, pericoronitis, trauma, surgery, or foreign
body impaction may explain the development of PA. PA can
develop in both periodontitis and nonperiodontitis patients.
Of interest to pediatric dentists, PA can occur in healthy
sites due to impaction of foreign bodies (e.g., dental floss,
orthodontic elastic, popcorn hulls), harmful habits (e.g., nail
biting, clenching), inadequate orthodontic forces, gingival en-
largement, and alterations of the root surface (e.g., invaginated
tooth, alterations, enamel pearls, iatrogenic perforations, vertical
root fracture, external root resorption).
EPL are pathological communications between the endo-
dontic and periodontal tissues at a given tooth that occur in
either an acute or a chronic form and are classified according
to the signs and symptoms that have direct impact on their
prognosis and treatment (e.g., presence or absence of fractures
and perforations, presence or absence of periodontitis, the
extent of periodontal destruction around the affected teeth).
The primary signs associated with EPL are deep periodontal
pockets reaching or close to the apex and/or negative or altered
response to pulp vitality tests. Other signs and symptoms may
include radiographic evidence of bone loss in the apical or
furcation region, spontaneous pain or pain on palpation and
percussion, purulent exudate or suppuration, tooth mobility,
sinus tract/fistula, and crown and/or gingival color alterations.18,24
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 459
BEST PRACTICES: PERIODONTAL DISEASES

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

© 2018 American Academy of Periodontol and European Federation of Periodontology. J Periodontol 2018;89(Supp 1):S159-S172.
John Wiley and Sons. Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.18-0006”.

460 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: PERIODONTAL DISEASES

Signs observed in EPL associated with traumatic and/or
iatrogenic factors may include root perforation, fracture/
cracking or external root resorption, commonly associated
with the presence of an abscess accompanied by pain. In
periodontitis patients, EPL usually presents low and chronic
progression without evident symptoms. For further review
on the classification, pathophysiology, microbiology, and histo-
pathology of both PA and EPL, readers are directed to the
positional paper by Herrera et al.18 and the consensus report
by Papapanou et al.24
hygiene, and requiring cervical restorative and/or orthodontic
treatment are at an increased risk for gingival recession.12,20
Monitoring specific gingival recession sites is considered
a proper approach in the absence of any pathosis. However,
mucogingival surgical interventions may be necessary in
the presence of esthetic concerns, dentin hypersensitivity,
cervical lesions, thin gingival biotypes and mucogingival
deformities.

Mucogingival deformities and conditions
Normal mucogingival condition is defined
as the absence of pathosis such as gingival
recession, gingivitis, and periodontitis. Muco-
gingival deformities, including gingival
recession, are a group of conditions that affect
a large number of patients, are observed more
frequently in adults, and have a tendency to
increase with age independent of the patient/s
oral hygiene status. Recession is defined as an
apical shift of the gingival margin caused by
different conditions and pathologies that is
associated with CAL in any surface (buccal/
lingual/interproximal) of the teeth.20 Although,
gingival thickness has been referenced in the
literature as gingival biotype, the 2017 World
Workshop group strongly suggested the adop-
tion of the term periodontal phenotype, which
is determined by gingival phenotype (gingival
thickness, keratinized tissue width) and bone
morphotype (thickness of the buccal bone
plate). Periodontal phenotype can be assessed
by measuring the gingival thickness through
the use of a periodontal probe. The phenotype
is classified as thin when a periodontal probe
inserted into the sulcus is visible through the
tissue, indicating the tissue is one mm or less
in thickness. If the probe is not visible
through the tissue, indicating the tissue is
greater than one mm thick, it is classified as
a thick phenotype. 20 The development and
progression of gingival recession is not asso-
ciated with increased tooth mortality. How-
ever, this condition often is associated with
patient esthetic concerns, dentinal hypersensi-
tivity and carious/noncarious cervical lesions
on the exposed root surface.12,20 While lack
of keratinized tissue is a predisposing factor
for gingival recession and inflammation, perio-
dontal health can be maintained despite the
lack of keratinized tissues in most patients
with optimal home care and professional
maintenance. Conversely, patients with thin
periodontal phenotypes, with inadequate oral
Table 5. THREE STEPS TO STAGING AND GRADING A PATIENT WITH PERIODONTITIS
( Adapted from Tonetti et al. 27 )
Screen:
• Full mouth probing
Step 1 • Full mouth radiographs
Initial Case • Missing teeth
Overview to Mild to moderate periodontitis will typically be either
Assess Disease Stage I or Stage II
Severe to very severe periodontitis will typically be
either Stage III or g IV
For mild to moderate periodontitis (typically Stage I
or Stage II):
• Confirm clinical attachment loss (CAL)
• Rule out non-periodontitis causes of CAL
(e.g., cervical restorations or caries, root fractures,
CAL due to traumatic causes)
• Determine maximum CAL or RBL
Step 2
• Conform RBL patterns
Establish Stage
For moderate to severe periodontitis (typically Stage III
or Stage IV):
• Determine maximum CAL or RBL
• Confirm RBL patterns
• Assess tooth loss due to periodontitis
• Evaluate case complexity factors (e.g., severe CAL
frequency, surgical challenges)
• Calculate RBL (% of root length x 100) divided
by age
• Assess risk factors (e.g., smoking, diabetes)
Step 3 • Measure response to scaling and root planning and
plaque control
Establish Grade
• Assess expected rate of bone loss
• Conduct detailed risk assessment
• Account for medical and systemic inflammatory
considerations
© 2018 American Academy of Periodontol and European Federation of Periodontology.
J Periodontol 2018;89(Supp 1):S159-S172. John Wiley and Sons.
Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.18-0006”.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 461

BEST PRACTICES: PERIODONTAL DISEASES
Traumatic occlusal forces and occlusal trauma
Traumatic occlusal force is defined as “any occlusal force that
causes an injury to the teeth and/or the periodontal attach-
ment apparatus.”20 It may be indicated by one or more of the
following: fremitus (visible tooth movement upon occlusal
force), tooth mobility, thermal sensitivity, excessive occlusal
wear, tooth migration, discomfort/pain on chewing, fractured
teeth, radiographically widened periodontal ligament space,
root resorption, and hypercementosis.20 Occlusal trauma is a
lesion in the periodontal ligament, cementum, and adjacent
bone caused by traumatic occlusal forces. It may be indicated
by one or more of the following: progressive tooth mobility,
fremitus, radiographically widened periodontal ligament space,
tooth migration, discomfort/pain on chewing, and root resorp-
tion.20 Traumatic occlusal forces and occlusal trauma can be
classified as: (1) primary occlusal trauma; (2) secondary occlusal
trauma; and (3) orthodontic forces. Primary and secondary
occlusal trauma have been defined as injuries resulting in
tissue changes from traumatic occlusal forces, the former when
applied to a tooth or teeth with normal periodontal support
and the latter when applied to a tooth or teeth with reduced
support.20
There is either little or no evidence that traumatic occlusal
forces can cause periodontal attachment loss, inflammation
of the periodontal ligament, noncarious cervical lesions,
abfraction, or gingival recession.14,20 Traumatic occlusal forces
lead to adaptive mobility in teeth with normal support and
are not progressive, while in teeth with reduced support,
they lead to progressive mobility usually requiring splinting.
Although, there is evidence that traumatic occlusal forces may
be associated periodontitis, there is no evidence that these forces
can accelerate the progression of periodontitis in humans.20
Moreover, there is insufficient clinical evidence regarding the
impact that elimination of traumatic occlusal forces may have
on the response to periodontal therapies. With regards to
orthodontic forces, observational studies suggest that ortho-
dontic treatment has minimal adverse effects to the periodontal
supporting apparatus, especially in patients with good plaque
control and healthy periodontium. 14,20 However, non-
controlled orthodontic forces can have adverse effects such as
pulpal disorders as well as root and alveolar bone resorptions.
Dental prostheses and tooth-related factors
Several conditions associated with the fabrication and presence
of dental restorations and fixed prostheses, placement of
orthodontic appliances, as well as tooth-related factors may
facilitate the development of gingivitis and periodontitis,
especially in individuals with poor compliance with home
care plaque control and attendance to periodic maintenance
visits.13,20
Tooth anatomic factors (e.g., cervical enamel projections,
enamel pearls, developmental grooves), root proximity, ab-
normalities and traumatic dental injuries potentially altering
the local anatomy of both hard and soft tissues, as well as
tooth relationships in the dental arch and with the opposing
dentition, are associated with dental plaque-biofilm induced
462 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
gingivitis and periodontitis. Placement of restoration margins
infringing within the junctional epithelium and supracrestal
connective tissue attachment (biological width) also can be
associated with gingival inflammation and, potentially,
recession. Tooth-supported and/or tooth-retained restorations
and their design, fabrication, delivery, and materials often have
been associated with plaque retention and loss of periodontal
supporting tissues. However, optimal restoration margins
located within the gingival sulcus do not cause gingivitis if
patients are compliant with self-performed plaque control and
periodic maintenance care.13,20
The available evidence does not support that optimal
removable and fixed dental prostheses are associated with
periodontitis when patients perform adequate plaque control
and attend maintenance appointments. However, there is
evidence to suggest that removable dental prostheses can serve
as plaque retentive factors and be associated with gingivitis/
periodontitis, increased mobility and gingival recession in
patients with poor compliance.20 Moreover, there is evidence
to suggest that design, fabrication, delivery, and materials used
for fixed dental prostheses procedures can be associated with
plaque retention, gingival recession, and loss of supporting
periodontal tissues.13,20
Lastly, it is important to point out that dental materials,
including commonly used appliances (e.g., stainless steel
crowns, space maintainers, orthodontic appliances) may be
associated with hypersensitivity reactions observed clinically
as localized inflammation. If the hypersensitivity does not
resolve with adequate measures of plaque control, additional
treatment may be required, including removal of material
or appliance. However, it appears that adequate periodontal
assessment and treatment, appropriate instructions, and
motivation in self-performed plaque control and compliance to
periodic maintenance protocols are the most important factors
to limit or avoid the potential negative effects on the perio-
dontium caused by fixed and removable prostheses when
hypersensitivity reactions are not suspected.13
Peri-implant diseases and conditions
The 2017 World Workshop members developed a new clas-
sification for peri-implant health, peri-implant mucositis and
peri-implantitis. The case definitions were developed based on
a review of the evidence applicable for diagnostic considera-
tions for use by clinicians for both individual case management
and population studies.6,25 Because the majority of pediatric
dentists are not the ones responsible for the placement of
osseointegrated dental implants, the reader is encouraged to
review the positional paper by Renvert et al. 25 and the con-
sensus report by Berglundh et al.9 for more comprehensive
information about the rationale, criteria, and implementation
of the new classification. Nevertheless, it is important that all
clinicians are able to diagnose potential problems, complica-
tions, and failures associated with dental implants in order
to either provide proper treatment or refer the patient to a
specialist. Case definitions and clinical criteria of these
conditions are presented below.

Peri-implant health
Clinically, peri-implant health is characterized by an absence
of visual signs of inflammation such as redness, swelling, and
profuse BoP, as well as an absence of further additional bone
loss following initial healing. Peri-implant health can occur
around implants with normal or reduced bone support.6,25
Peri-implant mucositis
Peri-implant mucositis is characterized by visual signs of in-
flammation such as redness, swelling, and line or drop of
bleeding within 30 seconds following probing, combined
with no additional bone loss following initial healing. There
is strong evidence that peri-implant mucositis is caused by
plaque, while very limited evidence for nonplaque-induced
peri-implant mucositis. Peri-implant mucositis can be reversed
with dental plaque removal measures.6,25
Peri-implantitis
Peri-implantitis is defined as a plaque-associated pathologic
condition occurring in the tissue around dental implants,
characterized by signs of inflammation in the peri-implant
mucosa, radiographic evidence of bone loss following initial
healing, increasing probing depth as compared to probing
depth values after the implant placement, and subsequent pro-
gressive loss of supporting bone. In the absence of baseline
radiographs, radiographic bone level three or more mm in
combination with BoP and probing depths six or more mm
is indicative of peri-implantitis. Peri-implantitis is preceded by
peri-implant mucositis.6,25
Recommendations
1. Periodontal disease in children is of great interest in
pediatric dentistry and a problem that should not be
ignored. Therefore, it is critical that pediatric dental pa-
tients receive a periodontal assessment as part of their
initial and periodic dental examinations. Early diagnosis
of periodontal diseases ensures the greatest opportunity
for successful treatment, primarily by reducing etiolog-
ical factors, establishing appropriate therapeutic mea-
sures, and developing an effective periodic maintenance
protocol.
2. Pediatric dentists are often the front line in diagnosing
periodontal conditions in children and adolescents and in
great position to treat or refer and coordinate, collaborate,
and/or organize the patient care activities between two
or more health care providers to ensure that the appro-
priate treatment is delivered in a timely fashion. Therefore,
clinicians should become familiarized with the current
classification of periodontal diseases and conditions,
including gingivitis, in order to properly diagnose patients
affected by these problems.
3. Monitoring gingival health or inflammation is best
documented by the parameter of bleeding on probing
since it is considered the primary parameter to set
thresholds for gingivitis and the most reliable for
BEST PRACTICES: PERIODONTAL DISEASES
monitoring patients longitudinally in clinical practice.
Clinicians are encouraged to start probing regularly when
the first permanent molars are fully erupted and the
child is able to cooperate for this procedure in order
to establish a baseline, detect early signs of periodontal
disease, and prevent disease progression.
4. Probing prior to the eruption of the first permanent
molars is encouraged in the presence or suspicion of any
clinical and/or radiographic signs of periodontal disease.
For patients with special health care needs receiving dental
treatment under sedation and/or general anesthesia,
clinicians are encouraged to utilize this opportunity to
perform the periodontal probing.
The intent of this document was to present an abbreviated
overview of the proceeding papers from the 2017 World
Workshop on the Classification of Periodontal and Peri-
implant Diseases and Conditions. Major highlights from the
2017 workshop included the recategorization of three forms
of periodontitis, the development of a multidimensional
staging and grading system for periodontitis, and the new
classification for peri-implant diseases and conditions. A best
practice document on periodontal disease therapies will be
available in a future publication of The Reference Manual of
Pediatric Dentistry.
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strual cycle on periodontal health and gingival crevicular
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40. Shourie V, Dwarakanath CD, Prashanth GV, Alampalli
RV, Padmanabhan S, Bali S. The effect of menstrual cycle
on periodontal health – A clinical and microbiological
study. Oral Health Prev Dent 2012;10(2):185-92.

41. Cianciola LJ, Park BH, Bruck E, Mosovich L, Genco RJ.
Prevalence of periodontal disease in insulin-dependent
diabetes mellitus (juvenile diabetes). J Am Dent Assoc
1982;104(5):653-60.
42. Gusberti FA, Syed SA, Bacon G, Grossman N, Loesche
WJ. Puberty gingivitis in insulin-dependent diabetic
children. I. Cross-sectional observations. J Periodontol
1983;54(12):714-20.
43. Ervasti T, Knuutila M, Pohjamo L, Haukipuro K. Relation
between control of diabetes and gingival bleeding. J
Periodontol 1985;56(3):154-7.
44. Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and
diabetes: A two-way relationship. Diabetologia 2012;55
(1):21-31.
45. Novotna M, Podzimek S, Broukal Z, Lencova E, Duskova
J. Periodontal diseases and dental caries in children with
type 1 diabetes mellitus. Mediators Inflamm 2015;2015:
379626.
46. Demirer S, Özdemir H, Şencan M, Marakoঠlu I. Gingival
hyperplasia as an early diagnostic oral manifestation in
acute monocytic leukemia: A case report. Eur J Dent
2007;1(2):111-4.
47. Lim H, Kim C. Oral signs of acute leukemia for early
detection. J Periodontal Implant Sci 2014;44(6):293-9.
48. Van der Velden U, Kuzmanova D, Chapple ILC. Micro-
nutritional approached to periodontal therapy. J Clin
Periodontol 2011;38(s11):142-58.
49. Katuri KK, Alluri JK, Chintagunta C, et al. Assessment
of periodontal health status in smokers and smokeless
tobacco users: A cross-sectional study. J Clin Diagn Res
2016;10(10):ZC143-ZC146.
50. Hatsukami DK, Stead LF, Gupta PC. Tobacco addic-
tion: Diagnosis and treatment. Lancet 2008;371(9629):
2027-38.
51. Albert DA, Severson HH, Andrews JA. Tobacco use by
adolescents: The role of the oral health professional in
evidence-based cessation program. Pediatr Dent 2006;
28(2):177-87.
52. Centers for Disease Control and Prevention. Tobacco use
among middle and high school students – United States,
2011-2016. MMWR Morb Mortal Wkly Rep 2017;
66(23):597-736. Erratum in MMWR Morb Mortal
Wkly Rep 2017;66(23):765.
BEST PRACTICES: PERIODONTAL DISEASES
53. American Lung Association. Stop Smoking. Available at:
“http://www.lung.org/stop-smoking/”. Accessed June 22,
2018.
54. U.S. Department of Health and Human Services. Preventing
Tobacco Use Among Youth and Young Adults: A Report
of the Surgeon General. U.S. Department of Health and
Human Services, Centers for Disease Control and Preven-
tion, Office on Smoking and Health, Atlanta, Georgia,
2012. Available at: “http://www.cdc.gov/tobacco/data_
statistics/sgr/2012/index.htm”. Accessed June 22, 2018.
55. Shariff JA, Ahluwalia KP, Papapanou PN. Relationship
between frequent recreational cannabis (marijuana and
hashish) use and periodontitis in adults in the United
States: National Health and Nutrition Examination
Survey 2011 to 2012. J Periodontol 2017;88(3):273-80.
56. Antoniazzi RP, Zanatta FB, Rösing CK, Feldens CA.
Association among periodontitis and the use of crack
cocaine and other illicit drugs. J Periodontol 2016;87
(12):1396-405.
57. Trackman PC, Kantarci A. Molecular and clinical aspects
of drug-induced gingival overgrowth. J Dent Res 2015;
94(4):540-6.
58. Umeizudike KA, Savage KO, Ayanbadejo PO. Severe
presentation of necrotizing ulcerative periodontitis in a
Nigerian HIV-positive patient: A case report. Med Princ
Pract 2011;20(4):374-6.
59. Marty M, Palmieri J, Noirrit-Esclassan E, Vaysse F,
Bailleul-Forestier I. Necrotizing periodontal diseases in
children: A literature review and adjustment of treatment.
J Trop Pediatr 2016;62(4):331-7.
60. U.S. National Library of Medicine. MedlinePlus Medical
Encyclopedia: Systemic. Available at: “https://medline
plus.gov/ency/article/002294.htm”. Accessed November
28, 2018.
61. National Cancer Institute: Cancer staging. Available at:
“https://www.cancer.gov/about-cancer/diagnosis-staging/
staging”. Accessed November 28, 2018.
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BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT

Risk Assessment and Management of Periodontal

Diseases and Pathologies in Pediatric Dental Patients
Adopted How to Cite: American Academy of Pediatric Dentistry. Risk assess-
2022 ment and management of periodontal diseases and pathologies in
pediatric dental patients. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:466-84.

Abstract
This best practice supports clinicians in assessing risk for and clinical decision making in the management of periodontal diseases and patholo-
gies in pediatric dental patients. This document highlights principles of periodontal disease diagnosis, risk assessment, and therapies to be
applied to pediatric dental patients with special considerations for individuals with special health care needs when indicated. Recommen-
dations on the management of contributing factors and conditions that increase the risk of periodontal disease and pathologies, as well
as treatment considerations on the use of adjunctive antibiotics and surgical therapies are reviewed. Special attention is focused on care
coordination, collaborations, and referral of care to specialists. In cases where the published data regarding periodontal diseases and
pathologies among children and adolescents was limited, recommendations were extrapolated from evidenced-based literature among
adult patients, as well as on the consensus opinions of the working group.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific
Affairs to offer information and guidance regarding risk assessment and management of periodontal diseases and pathologies in pediatric dental
patients.

KEYWORDS: PERIODONTAL DISEASE, PERIODONTAL-RISK ASSESSMENT, PERIODONTAL THERAPY, CHILD, ADOLESCENT, ANTIBIOTIC THERAPY

Purpose and/or consensus opinion by experienced researchers and

The American Academy of Pediatric Dentistry (AAPD)
recognizes the importance of periodontal health and its effect
on the well-being of pediatric patients, including those with
special health care needs (SHCN). Periodontal-risk assessment
(PRA) and management protocols are essential elements of
contemporary clinical care for pediatric dental patients. These
recommendations are intended to assist practitioners in assess-
ing risk for and clinical decision making in the management
of periodontal diseases and pathologies in pediatric dental
patients.
Methods
This best practice document was developed utilizing the
resources and expertise of AAPD members and an expert con-
sultant in periodontics operating through the Council on
Clinical Affairs. Literature searches of PubMed /MEDLINE
and Google Scholar databases were conducted using the terms:
® gingival and periodontal health at older ages.
clinicians.
Background
A periodontal examination and risk assessment are important
parts of the routine dental examination of pediatric dental
patients. The gingival and periodontal tissues in the primary,
mixed, and permanent dentition are subject to morphological
changes due to normal patterns of oral growth and develop-
ment. Gingivitis occurs in half of the population by age of
four or five years and peaks nearly to 100 percent at puberty.1,2
Distinguishing normal physiological changes during growth
and development from gingival and periodontal diseases helps
prevent erroneous diagnoses and unnecessary treatment. Main-
tenance and restoration of gingival and periodontal health
during childhood and adolescence will facilitate healthy

periodontitis as a manifestation of systemic diseases, necrotizing

periodontitis, aggressive periodontitis, localized periodontitis;
fields: all; limits: within the last 10 years, human, English,
clinical study, clinical trial, comparative study, multicenter
study, observational study, randomized clinical trial, meta-
analysis, and systematic reviews. The search returned 1,222
articles that matched the criteria. The articles were evaluated
by title and/or abstract and relevance to dental care for chil-
dren and adolescents. When data did not appear sufficient or
were inconclusive, recommendations were based upon expert
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. BoP: Bleeding on
probing. CAL: Clinical attachment loss. CEJ: Cementoenamel
junction. CHX: Chlorhexidine. MM: Millimeter. NSAIDs: Non-
steroidal anti-inflammatory drugs. PDL: Periodontal ligament.
PPD: Periodontal pocket depth. PRA: Periodontal-risk assessment.
SHCN: Special health care needs. SIB: Self-injury behavior. SRP:
Scaling and root planning. TDI: Traumatic dental injuries.

466 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT

Recommendations Risk factors are defined as characteristics of individuals that

Diagnostic phase
The diagnostic criteria for gingivitis are based on clinical
features, taking into consideration the presence of plaque and
that the inflammatory response to plaque is an age-dependent
phenomenon. Three distinct forms of periodontal disease have
been defined as: (1) periodontitis (single category grouping
the two forms of the disease formerly recognized as aggressive
or chronic); (2) necrotizing periodontitis; and (3) periodontitis
as a manifestation of systemic conditions.3 Early diagnosis
ensures more promising treatment outcomes and effective
periodic maintenance protocols.4
Periodontal-risk assessment (PRA)
In health care, risk is defined as the probability that an indi-
vidual will develop a disease during a specific time period.5,6
increase their probability to developing the disease.5,6 Risk
factors for periodontal disease are complex and may be bio-
logical, environmental (social), and behavioral.6 PRA identi-
fies risk factors that place individuals at an increased risk of
developing gingival and periodontal diseases and pathologies,
as well as factors that influence the progression of the disease.
PRA can improve clinical decision making and allow the
implementation of individualized treatment planning and
proactive targeted interventions.7 Evidenced-based PRA tools
have been developed based on studies conducted among adult
patients.8 Due to the limited literature regarding PRA among
children and adolescents, factors associated with elevated risk
were extrapolated from evidence from adult patients (Tables
1 and 2).5,9-13

Table 1. Factors Associated with the Development and Progression of Periodontal Diseases
and Pathologies for < 13 Years Old

Factors High risk Moderate risk Low risk

Biological factors
Systemic conditions/genetic susceptibility (e.g., family history of aggressive
periodontitis) and syndromes Ƚ Yes
Immunosuppressive or radiation therapy Yes
Medication(s) known to affect the periodontal tissues Yes
History of traumatic injury to the periodontal apparatus (e.g., avulsion, luxation) Yes
Traumatic gingival/oral mucosal lesions Yes
Nutritional deficiencies Yes

Social and behavioral factors

Socioeconomic stability (e.g., adequate health literacy, regular dental care) Yes
Adequate daily at-home oral hygiene either performed or supervised by caregiver Yes
Tobacco or marijuana smoking/smokeless tobacco use Yes

Clinical and radiographic factors

Adequate attached gingiva and normal frenum attachments Yes
Tooth-related factors contributing to plaque retention Yes
Physical barriers for proper oral hygiene Yes
Generalized gingivitis (≥ 30% of teeth affected) Yes
Disproportional gingival inflammation in relation to age, amount of plaque
accumulation, or oral and systemic developmental changes Yes
Presence of calculus Subgingival Supragingival None
Bleeding on probing Yes
Periodontal probing depths > 3 millimeter Yes
Chronic pericoronitis Yes
Abnormal tooth mobility Yes
Furcation involvement Yes
Radiographic alveolar bone loss Yes
Tooth loss due to periodontitis Yes

Circling those conditions that apply to a specific patient helps the practitioner and caregiver understand the factors that contribute
to the development and progression of periodontal diseases and pathologies. Clinical judgment may justify the use of one or more
factors in determining the overall risk.
Overall assessment of the child’s risk: High ˆModerate ˆLow ˆ

Ƚ Most common examples include, but are not limited to, agranulocytosis, Chédiak-Higashi syndrome, cyclic neutropenia, diabetes, Ehlers-
Danlos syndrome, human immunodeficiency virus infection, hypophosphatasia, idiopathic immune disorders, Langerhans cell histiocytosis,
leukemia, leukocyte adherence deficiency, osteoporosis, neutropenia, trisomy 21, Papillon Lefèvre syndrome, plasminogen deficiency, and
respiratory diseases.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 467

BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT

Prognosis and treatment planning
Determination of the prognosis follows the diagnostic phase
and is a dynamic process to be re-evaluated at all therapeutic
phases (i.e., systemic, behavioral, nonsurgical, surgical, mainte-
nance). Prognosis, based on the probability of disease progres-
sion and clinical parameters, can be categorized as favorable,
questionable, unfavorable, and hopeless.14
The treatment plan is formulated after completing a com-
prehensive examination, establishing a diagnosis, determining
the prognosis, and identifying the individual needs and desires
of the patient and caregiver. It addresses immediate, inter-
mediate, and long-term goals to arrest or slow down the
periodontal disease progression. Initial treatment plans may be
subject to modifications based on unforeseen developments
during care.15 Other important considerations include
emergency treatment for pain or infections, need for exodontia,
and esthetic demands.15

Table 2. Factors Associated with the Development and Progression of Periodontal Diseases
and Pathologies for ≥ 13 Years Old

Factors High risk Moderate risk Low risk

Biological factors
Systemic conditions/genetic susceptibility (e.g., family history of aggressive
periodontitis) and syndromesȽ Yes
Immunosuppressive or radiation therapy Yes
Medication(s) known to affect the periodontal tissues Yes
History of traumatic injury to the periodontal apparatus (e.g., avulsion, luxation) Yes
Traumatic gingival/oral mucosal lesions Yes
Nutritional deficiencies Yes
Mental health disorders (e.g., stress, depression) Yes
Pregnancy Yes

Social and behavioral factors

Socioeconomic stability (e.g., adequate health literacy, regular dental care) Yes
Adequate daily at-home oral hygiene Yes
Tobacco or marijuana smoking/smokeless tobacco use Yes
Drug abuse (e.g., crack cocaine, methamphetamine) Yes
Intraoral/perioral piercing and oral jewelry/accessories Yes
Individuals with special health care needs living in supported community (group) homes Yes

Clinical and radiographic factors

Adequate attached gingiva and normal frenum attachments Yes
Adequate plaque biofilm control Yes
Tooth-related factors contributing to plaque retention Yes
Physical barriers for proper oral hygiene Yes
Generalized gingivitis (≥ 30% of teeth affected) Yes
Disproportional gingival inflammation in relation to age, amount of plaque
accumulation, or oral and systemic developmental changes Yes
Presence of calculus Subgingival Supragingival None
Bleeding on probing (% of sites) > 25 10 to 25 0 to 9
Periodontal probing depths (mm) >5 3.5 to 5 < 3.5
Chronic pericoronitis Yes
Abnormal tooth mobility Yes
Furcation involvement Yes
Radiographic alveolar bone loss over 25% of sites Yes
Tooth loss due to periodontitis Yes

Circling those conditions that apply to a specific patient helps the practitioner and caregiver understand the factors that contribute to the
development and progression of periodontal diseases and pathologies. Clinical judgment may justify the use of one or more factors in determining the
overall risk.
Overall assessment of the child’s risk: High ˆModerate ˆLow ˆ

Ƚ Most common examples include, but are not limited to, agranulocytosis, Chédiak-Higashi syndrome, cyclic neutropenia, diabetes, Ehlers-Danlos syndrome, human
immunodeficiency virus infection, hypophosphatasia, idiopathic immune disorders, Langerhans cell histiocytosis, leukemia, leukocyte adherence deficiency,
osteoporosis, neutropenia, trisomy 21, Papillon Lefèvre syndrome, plasminogen deficiency, and respiratory diseases.

468 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


General considerations
• A periodontal assessment includes a discussion of the chief
complaint, detailed medical, dental, and social history
reviews, extra- and intra-oral examinations, radiographs,
and periodontal probing as indicated. Further investiga-
tions (e.g., genetic, microbiological, gingival biopsy, and
biochemical tests) may be needed on an individual basis
to differentiate types of periodontal diseases.
• Bleeding on probing (BoP) in primary teeth during early
childhood, even at a low number of sites, is indicative of
high susceptibility to periodontal diseases, due to the age-
dependent reactivity of the gingival tissues to plaque.16,17
• Probing assessments may be initiated after the eruption of
the first permanent molars and incisors and only if toler-
ated by the child. Pseudopockets (greater than three milli-
meters [mm]) may be present around partially and newly
erupted teeth.18 Probing assessment on primary teeth is
required before the eruption of the first permanent molars
and incisors when clinical and radiographic findings
indicate the presence of periodontal diseases.
• Assessing for generalized (i.e., involving 30 or more per-
cent of the teeth) gingivitis may be performed for patients
unable to undergo probing due to age, anxiety, or SHCN.19
• Alveolar bone loss in the primary dentition indicates
increased susceptibility to periodontal disease.20-22
• Good quality bitewing radiographs are necessary for diag-
nosing alveolar bone loss.22-24 While bitewing radiographs
are useful with assessing abnormal molar mobility,21,22,24,25
periapical radiographs may help rule out any other asso-
ciated pathology (e.g., root resorption). For abnormal
anterior tooth mobility, periapical radiographs are the most
appropriate images.26
• 1 ± 0.5 mm distance from the most coronal portion of the
alveolar bone crest to the cementoenamel junction (CEJ)
is considered a normal alveolar bone height in the primary
dentition,20,22,27 while a distance of more than two mm
is considered to represent bone loss20. A distance of more
than two mm may be considered normal when the bone
is adjacent to exfoliating primary teeth or erupting
permanent teeth.28
• Two-mm distance (on average, varying between 1.0 ± 3.0
mm) from the most coronal portion of the alveolar bone
crest to the CEJ is considered a normal alveolar bone
height in the permanent dentition.24”
Recommendations:
• For patients in the primary dentition, a visual assess-
ment of the gingiva should be part of every compre-
hensive examination. All dental radiographs should be
examined for evidence of caries, alveolar bone loss,
developmental anomalies, and other pathologies.
• A simplified basic periodontal examination is recom-
mended for individuals aged seven to 17 years.18 After
the eruption of the first permanent molars and incisors,
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
six index teeth (the first permanent molars, the perma-
nent maxillary right central incisor, and the permanent
mandibular left central incisor) are assessed for: (1) BoP;
(2) presence of calculus; (3) plaque retention factors;
(4) periodontal pocket depth (PPD); (5) furcation
involvement; and (6) recession.
• PRA, based on a child’s age and biological, social/
behavioral, and clinical/radiographic factors, should be
a routine component of new and periodic oral exam-
inations.
• Practitioners may use the estimated risk level to
establish a periodicity and intensity of diagnostic,
counseling, and therapeutic interventions (Table 3).
• The treatment plan should be used to establish the
methods and sequence of delivering periodontal treat-
ment and include:
– periodontal procedures to be performed;
– medical consultation or referral for treatment when
indicated;
– consideration of diagnostic testing that may
include genetic, microbiological, gingival biopsy, or
biochemical tests or monitoring during the course
of periodontal therapy;
– consideration of adjunctive restorative, prosthetic,
orthodontic, and/or endodontic consultation or
treatment;
– consideration of chemotherapeutic and antibiotic
agents for adjunctive treatment;
– provision for re-evaluation during and after peri-
odontal or dental implant therapy; and
– periodontal maintenance program.
Behavioral phase
The success of both prevention and treatment of periodontal
diseases and conditions relies significantly on the ability of the
patient/caregivers to comply with requested oral hygiene and
dietary practices (e.g., brushing, flossing, adequate nutrition)
and to change behaviors regarding harmful risk factors (e.g.
smoking, drug use). Psychological models and theories of
motivation (e.g., health belief model, motivational interview-
ing, self-determination theory) may be used to help patients
adopt healthier behaviors.29,30
Nutrition
The role of nutrition and, more specifically, the relevance of
vitamins on periodontal health31-33 are thought to be related
to the effect on inflammation. Persistent lack of vitamin C, an
essential nutrient for collagen synthesis, in the diet has been
associated with more severe periodontitis.34 This deficiency,
known as scurvy, manifests with gingival bleeding and swell-
ing, proceeds to tooth loss, and can result in death.
Systematic reviews show a positive association between
periodontal disease and obesity in children and adolescents.35-37
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 469
470
Table 3. Example of Management Pathways for Periodontal Diseases and Pathologies

Nonsurgical therapy Surgical

Counseling
therapy

Twice Healthy InjuryȽ Tobacco Use of Compliance Oral Debridement, Systemic Management Monitor Management Plastic,
daily diet and prevention use and oral with prophylaxis: scaling antibiotics of plaque previous of oral aesthetic,
brushing nutrition drug hygiene medical supragingival and root and/or use retentive traumatic conditions resective,
Risk and daily misuse ß adjunctsa care and/or plaque and planing of factorsȽ injuries to and side and/or
Diagnostics
category flossing periodontal calculus adjunctive the effects from regenerative
treatment or removal topical periodontal therapies, procedures
maintenance anti- apparatus medications,
microbials infections,
gingival
injuries, etc.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

Low risk – Recall every six Yes Yes Yes Prevention Every six
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT

to 12 months to 12
– Radiographs months
every 12 to
24 months

Moderate – Recall every six Yes Yes Yes Prevention Yes Yes Every six Every six Yes Yes Yes Yes Yes
risk months or months months
– Radiographs cessation
every six to
12 months
– Monitoring of
systemic
conditions by
laboratory
analysis and
consultation
with medical
specialists, if
indicated

High risk – Recall every Yes Yes Yes Prevention Yes Yes Every Every Yes Yes Yes Yes Yes
three months or two-four two-four
– Radiographs cessation months months
every six depending depending
months on disease on disease
severity severity
and disease and disease
response to response to
treatment treatment

Ƚ Plaque retentive factors include, but are not limited to, caries lesions, enamel defects, dental anatomical anomalies, malposed teeth, defective restorations, inadequate contoured crowns, orthodontic appliances, dental prostheses.
ß Prevention of injuries resultant of accidents, piercings, habits.
a Oral hygiene adjuncts include, but are not limited to, powered toothbrushes, interdental brushes, or oral irrigation; chemical antiplaque and anticalculus agents.

Smoking and substance misuse
The association between smoking and drug use and periodontal
diseases is clear.38-43 Compelling evidence supports the signifi-
cant benefits of tobacco use prevention and cessation on the
periodontal and oral health in general, across all ages.44-46
Recommendations:
Dental professionals should utilize psychological theories
of motivation to help patients adopt healthier behaviors and
counsel their pediatric patients and parents on:
• the role of diet in the development and progression of
periodontal conditions;
• the harms of all tobacco products to help prevent or
cease tobacco use; and
• the serious health consequences of drug misuse, as well
as refer to an appropriate provider for cessation when
the habit is identified.
Informed consent
Informed consent is essential in the delivery of healthcare.
As part of the informed consent process, the clinician shares
information and answers questions about the patient’s oral
health conditions and the nature, risks, and benefits of recom-
mended and alternative treatments, including no treatment.
For periodontal conditions, the discussion would also include
the need for maintenance treatment due to the possibility of
disease recurrence or progression. Written consent is advis-
able as it may decrease the liability from miscommunication,
especially if risks, complications, or possibility of failure are
expected with the proposed therapy. Referral is indicated when
treatment needs are beyond the treating dentist’s scope of
practice. Patients should also be informed if referrals to other
specialists are needed.47
Nonsurgical periodontal therapy (phase I)
The major goal of phase I therapy is to control the factors
responsible for periodontal inflammation; this involves edu-
cating the patient in the removal of bacterial plaque biofilm.
Phase I therapy also includes scaling, root planing, and other
therapies such as caries control, replacement of defective
restorations, occlusal therapy, orthodontic tooth movement,
and cessation of confounding habits such as tobacco use.”48
Management of bacterial plaque biofilm and calculus
Controlling gingival inflammation is the primary preventive
strategy for periodontitis, as well as the secondary preventive
strategy for recurrence of periodontitis.49 A systematic review
demonstrated antiplaque effectiveness for toothpastes contain-
ing stannous fluoride or chlorhexidine (CHX).50,51 Toothpastes
containing pyrophosphates reduce the formation of new
supragingival calculus,1,52 but no improvements have been
reported in gingival inflammation and subgingival calculus.
Mouthrinses with antiplaque agents significantly improve
gingival inflammation and plaque levels when compared to
toothpastes with such agents.50 The use of 0.12 percent CHX
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
gluconate can help improve dental plaque, gingival bleeding,
and gingival inflammation indices.53-58 Adverse effects of use
(e.g., alteration in taste sensation; unpleasant taste; calculus
formation; brown staining of teeth, tongue, and restorations)
compromise patient acceptance50,51,59,60 and are most common
when used for four weeks or longer56,57. Rinses have higher
antiplaque efficacy than sprays.59 The CHX-containing mouth-
rinse may be applied via toothbrush for patients unable to
spit or at risk of aspirating the agents. Different proposed
regimens of CHX include: (1) once or twice a day for one
week every month; and (2) once or twice a day for two weeks
every three months.55-58 Preferred active agent, patients’ prefer-
ence, economic cost, compliance, and adverse effects influence
selection of a delivery system.50 Although CHX allergy is
extremely rare, prolonged exposure to CHX may lead to
contact sensitization, allergic contact dermatitis or stomatitis,
or even anaphylactic shock when used during surgery.61-63
Oral prophylaxis along with scaling and root planing (SRP)
are the basis of professional mechanical plaque control.21,48,51,64
Oral prophylaxis removes supragingival plaque and calculus
via hand or powered instruments. Subgingival instrumenta-
tion, considered the gold standard of periodontal treatment,
is divided into three procedures: (1) debridement (removal of
subgingival plaque); (2) scaling (removal of supra- and sub-
gingival plaque, calculus, and stains); and (3) root planing
(removal of cementum or surface dentin that is rough,
impregnated with calculus, or contaminated with toxins or
microorganisms).48 Supra- and subgingival instrumentation is
an important component of initial and recall dental
appointments. When comparing subgingival instrumentation
modes, hand instruments (e.g., curettes) remove a significantly
greater amount of calculus and leave a smoother root surface
than ultrasonic scalers.51 On the other hand, ultrasonic devices
cause less soft tissue trauma, require a shorter treatment time,
and are less technique and operator sensitive.51
Recommendations:
• Dental professionals should provide oral self-care in-
structions that are individualized and include
appropriate adjuncts.
• For adolescents and individuals with SHCN who ex-
hibit poor oral hygiene, clinicians should consider the
use of chemical antiplaque agents in mouthrinses or
incorporated into fluoridated toothpastes to control
plaque accumulation and gingival inflammation, along
with instituting more frequent recall appointments.
• Because plaque or biofilm and calculus serve as physi-
cal barriers for proper home oral hygiene execution, a
dental prophylaxis and SRP should be performed at
both initial and recall dental appointments when
necessary.
• Use of ultrasonic devices and mouthrinses may be
contraindicated for patients who are unable to expecto-
rate and at risk for aspiration.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 471
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
Management of local factors for periodontal disease and
pathologies
In addition to plaque or biofilm and calculus, other local
factors can contribute to plaque retention and physical
barriers for proper oral hygiene execution increasing the risk
of periodontal disease and pathology initiation and progression
among pediatric patients.21,48,64-68
Caries lesions. Caries prevention and adequate restoration of
dental caries lesions are of great importance for the perio-
dontal health of pediatric patients. Gingival inflammation is
highly associated with dental caries and dependent on the
degree of tooth destruction, the presence of bacteria in the
biofilm, and host response.21 Gingivitis and interproximal
alveolar bone loss have been observed in young children
with severe caries.69,70 The alveolar bone loss occurs with
extensive interproximal caries due to food impaction and
biofilm retention in the interdental area.70 Due to the dys-
biotic nature of the caries-association microbiome, temporary
or permanent restorations remove the reservoir of bacteria
in these lesions helping to maximize the healing of the
periodontal tissues.48 Restorations with adequate proximal
contour will promote healing of alveolar bone defects.70
Defective restorations. The use of minimally-invasive
restorative dentistry, when clinical conditions allow, can help
avoid negative effects of restorations on the periodontal
tissues. Gingivitis and clinical attachment loss (CAL) have
been associated with defective restorations and crowns (i.e.,
subgingival restorations, margin discrepancies, overhanging
restorations).48 In addition, a study among 354 children aged
six to nine years revealed radiographic interproximal alveolar
bone loss adjacent to proximal surfaces in the primary molar
area in 30.8 percent of the sites without an adequate
amalgam restoration and 25.8 percent of the sites with
inadequate crown restoration.70 Inadequately contoured stain-
less steel crowns and residues of set cement remaining in
contact with the gingival sulcus also may cause gingival
inflammation and abnormal bone resorption.69,70 If meticu-
lous oral hygiene is not maintained, interproximal lesions of
posterior teeth treated with caries-arresting agents (e.g., silver
diamine fluoride, silver nitrate) but not restored are capable
of food impaction that can potentially cause severe gingival
inflammation, bleeding, and patient discomfort.67 Arrested
cavitated lesions may benefit from receiving a restoration in
order to prevent food impaction or caries lesion progression.71
Malocclusion and orthodontic appliances. An increased risk
for periodontal disease has been associated with malocclusion,
especially in cases of severe anterior dental crowding and
gingivitis among children and adolescents wearing orthodontic
appliances.64,65,72 Gingival overgrowth, recession, and invagina-
tion are among the most cited soft tissues changes during
orthodontic treatment.65 Due to dental plaque accumulation
around appliances, patients undergoing orthodontic treatment
472 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
with deficient oral hygiene are at higher risk of developing
gingival inflammation, white spot lesions, and dental caries.
Inflammatory changes associated with puberty gingivitis may
be exacerbated in adolescent patients undergoing orthodontic
treatment.68
Dental enamel defects and other dental anomalies. Children
and adolescents with dental defects (e.g., enamel hypoplasia,
amelogenesis imperfecta) may present with less ideal oral
hygiene due to the sensitivity associated with the condition.
Desensitizing toothpastes containing remineralization com-
pounds, fluoride varnishes, and toothbrushes with soft bristles
may minimize the sensitivity and, consequently, allow better
oral hygiene.21,73
Many teeth with dental defects are prone to fractures
close to the gingival margin; crown-lengthening surgery is
sometimes necessary to facilitate placement of restorations
with cleansable margins.21 Other dental anomalies, such as
enamel projections, enamel pearls, proximal and palatogingival
grooves, and fused and supernumerary teeth, may impact
periodontal health. Some of these anomalies, for instance,
are associated with gingivitis and CAL due to the impedi-
ment of proper oral hygiene or mucogingival problems as a
consequence of developmental aberrations in eruption and
deficiencies in the thickness of the periodontium.64,68
Recommendations:
• Clinicians should consider restoring open, arrested
cavitated lesions when food impaction causes gingival
inflammation, bleeding, or patient discomfort.
• Defective or failing restorations should be corrected by
smoothing rough surfaces, removing overhangs with
burs and/or hand instruments, or replacement.48,64
• When placing preformed crowns, well-adapted restora-
tions (i.e., contoured, well-fitted, and crimped) are rec-
ommended to maintain the health of the periodontium.
• Because orthodontic appliances often hinder brushing
and flossing, clinicians should:
– consider more frequent recall appointments and
prophylaxis depending on home oral hygiene com-
pliance and degree of periodontal inflammation,
and
– consider suspension of the orthodontic treatment if
the patient is not able to maintain proper oral hygiene.
• In cases of sensitivity associated with dental defects,
desensitizing toothpastes, fluoride varnishes, tooth-
brushes with soft bristles, and sealing the enamel of the
teeth should be considered.
Topical antimicrobial adjuncts and systemic antibiotics
Topical (local) agents, available as fibers, gels, chips, micro-
spheres, and solutions, are delivered directly inside the perio-
dontal pocket and present fewer side effects than systemic
agents.51,74-76 Compared to systemic agents, they utilize a
smaller total dosage and provide higher localized concentration

of the drug, but lack the capability to reach different oral
surfaces and saliva.51,74-76 Although systematic reviews have
reported that adjunctive local antibiotics improve PPD and
CAL in short-term studies and PPD in long-term studies,
their use is controversial due to high cost and small
magnitude of clinically-relevant benefits.75,76 Local antibiotic
therapies have been used more commonly during the mainte-
nance phase to treat remaining and isolated recurrent pockets.75
SRP is effective in improving clinical parameters (e.g., BoP,
PPD, CAL) for most patients with periodontitis, but not
those with advanced periodontitis and deep periodontal
pockets.51,76-78 Several clinical trials, systematic reviews, and
meta-analyses support the adjunctive effect of systemic anti-
biotics to improve the outcomes of SRP during both non-
surgical and surgical therapies.75,76,78-83 Systemic antibiotic
therapy will be most effective if the disruption of subgingival
biofilm by SRP occurs immediately before or during the
antibiotic therapy.51,79 Stand-alone antibiotic therapy, however,
is not effective in the treatment of periodontal disease.51,77
Systemic antibiotics are indicated when patients exhibit
moderate periodontitis with three to four mm of CAL and
PPD of less than five mm.82 Younger patients with perio-
dontitis characterized by rapid attachment and bone
loss51,76-78,83, patients with necrotizing periodontitis77,78, and
those with periodontitis as a manifestation of systemic condi-
tions51,78,84-86 may benefit significantly from adjunctive anti-
biotic therapies in combination with SRP. Several factors
(e.g., patient’s clinical parameters, health history, dental history,
drug allergy, medication compliance, personal/parental prefer-
ences, adverse effects, bacterial resistance, treatment response
in primary versus permanent dentitions) influence the decision
to use topical or systemic antibiotic adjuncts to SRP.74,79,80,87,88
Systemic antibiotics have the advantage of reaching all oral
surfaces and fluids, as well as the potential to reach periodon-
tal pathogens that ultimately invade the host’s tissues.76,83 In
addition, antibiotic therapy may reduce bacterial endotoxins
helping to minimize the local inflammatory response.89,90
Disadvantages of systemic administration include adverse drug
effects (e.g., gastrointestinal symptoms, allergic reaction), poor
patient compliance, and, very importantly, development of
bacterial resistance due to indiscriminate use.76,83 When com-
pared to SRP alone, the combination of amoxicillin and
metronidazole (and, to a lesser degree, azithromycin and metro-
nidazole) as an adjunctive therapy has shown to reduce the
number of major periodontopathogenic bacteria, significantly
improve CAL gain, and promote higher percentage of pocket
closure, as well as reduce BoP, PPD, and frequency of pockets
of greater than four mm.75,76,79-83,91-93 Regimen durations of
one to two weeks have been cited in the literature with
respective advantages and disadvantages.51,79 For patients
allergic to penicillin, antibiotic regimen using metronidazole
alone is an alternative treatment.93 Additionally, azithromycin
is effective against periodontal pathogens with positive
immunomodulatory properties and has been proven effective
in treating aggressive periodontitis in young patients94 as well
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
as adults95. Azithromycin is one of the safest antibiotics for
patients allergic to the penicillins, but there are risks of cardiac
complications including cardiotoxicity.96,97 Cardiac risk in
pediatric patients seems to be due to an increased risk of
QT prolongation associated with higher dosage levels98, and
caution should be exercised in patients with cardiac risk factors.
The Reference Manual of Pediatric Dentistry includes informa-
tion on recommended antibiotic dosage for children and
adolescents, as well as for adults, available at https://www.
aapd.org/globalassets/r_usefulmeds.pdf.99 Having the child
drink a small cup of grape soda immediately after ingesting
liquid antimicrobials may help mask the unpleasant smell
and taste of the medication and increase compliance with the
antibiotic regimen.100
Recommendations:
• Stand-alone antibiotic therapy is not recommended in
the treatment of periodontal disease.
• Adjunctive antibiotic therapy to SRP should be
considered for patients with advanced or aggressive
periodontal disease.
• When adjunctive antibiotic therapy to SRP is indicated,
the decision to use topical or systemic antibiotics should
be carefully evaluated and based on patient’s general
health status, periodontal disease severity, compliance,
and response to SRP.
Re-evaluation (determining success or lack of success of nonsurgical
therapy)
After procedures of phase I (e.g., debridement, scaling, root
planing, caries control, correction of defective restorations) are
completed, the periodontal tissues will go through a process of
healing that may take four or more weeks to occur.48 Transient
tissue sensitivity is often observed during the healing process
and usually diminished with good home plaque or biofilm
control.48 Re-evaluation findings help determine the need for
any further nonsurgical therapy procedure or periodontal
surgery.48
Recommendations:
• Components of re-evaluation appointments should
include probing the periodontal tissues, examining
all related anatomic structures, reinforcing home care
regimens, and discussing existing harmful habits with
a goal of cessation.
• The frequency of supportive periodontal therapy must
be individualized and based on the patient’s symptoms,
clinical and radiographic findings, risk factors, initial
severity of the disease, as well as residual diseased sites
at the end of the active periodontal treatment in relation
to the patient’s age, treatment outcome, caries risk, and
plaque or biofilm control.
Systemic phase
The Reference Manual of Pediatric Dentistry includes informa-
tion on several genetic and nongenetic systemic diseases and
pathologies associated with manifestations on periodontal
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 473
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
tissues.101 General characteristics, diagnostic criteria, clinical
and radiographic findings, as well as treatment considerations
are presented for some of the conditions observed in
pediatric patients.
Recommendations:
• Clinicians should consider systemic diseases and
conditions that can affect the periodontal attachment
apparatus or the course of periodontal diseases in order
to achieve accurate diagnoses and plan treatment.84,102
• Consultation with the patient’s medical care provider
may be necessary for management of at-risk patients.84,102
Special management considerations
Respiratory diseases affecting the periodontium
Health of the periodontium depends on saliva’s mechanical
cleansing and antimicrobial properties. Respiratory diseases,
either directly (e.g., mouth breathing) or through side effects
(e.g., xerostomia) of therapeutic agents, may alter salivary
flow.103,104 Nasopharyngeal obstruction from adenoid and
tonsillar hypertrophy, as well as significant neuromuscular
weakness with a history of snoring, can also affect periodon-
tal health.103 Depending on the individual oral/dental needs
of patients with respiratory diseases, the pediatric dentist plays
an important role in early diagnosis of general and oral health
problems associated with respiratory diseases, care manage-
ment, and establishment of a multidisciplinary approach that
may include, but is not limited to, orthodontists, primary care
providers, otolaryngologists, and speech pathologists.103 Regular
dental check-ups with oral hygiene instructions for proper
home plaque control, mouth rinsing after medications, and
use of fluoridated toothpaste are important preventive regi-
mens to reduce the risk of periodontal disease and dental
caries among patients with respiratory diseases.103
Recommendations:
• Clinicians should carefully evaluate the patient’s health
history and medications in order to identify respiratory
conditions and medications that impact salivary flow
and dental and periodontal health.
• If airway obstruction is determined to affect perio-
dontal health, an evaluation by an otolaryngologist is
recommended.
• Clinicians should consider a multidisciplinary ap-
proach, referral, and/or care coordination for patients
with general and/or oral health problems associated
with respiratory diseases.
Oral conditions related to immunosuppressive or radiation therapies
Patients undergoing immunosuppressive or radiation thera-
pies may present with periodontal problems associated with
treatment. Gingival bleeding, soft tissue necrosis, salivary
gland dysfunction, opportunistic infections (e.g., candidiasis,
herpes simplex virus), and oral graft-versus-host disease are
among the many acute and long-term complications associated
with these therapies.105-109 Special attention should be given to
partially-erupted molars that may be at risk for pericoronitis.107,108
474 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
When definitive periodontal therapy cannot be rendered,
extraction of hopeless periodontally-involved teeth is the
treatment of choice.107-109 A periodontal assessment and appro-
priated therapy are indicated before patients undergoing
cancer treatment receive bisphosphonates.109 Refer to AAPD's
Dental Management of Pediatric Patients Receiving Immuno-
suppressive Therapy and/or Head and Neck Radiation109 for addi-
tional information on managing periodontal considerations in
these circumstances.”
Recommendations: Clinicians should work closely with the
patient and his caregivers, as well as with his multidisciplinary
health care team, to ensure that any medically-necessary
dental treatment is integrated, coordinated, and delivered in
a timely and safe manner before, during, and after immuno-
suppression or radiation therapy.105
Drug-influenced gingival enlargements
Drug-influenced gingival enlargements have been associated
with three types of medications: anticonvulsants (e.g., pheny-
toin, sodium valproate), calcium channel blockers (e.g.,
veramapil, diltiazem), and immunosuppressants (e.g., cyclo-
sporine).19,111,112 In most cases, the gingival enlargement is
induced by the combination of the drugs (i.e., fibrotic aspect)
and the bacterial biofilm (i.e., inflammatory aspect).111 Treat-
ment options may include: (1) possible drug discontinuation
or change; (2) biofilm control by means of home oral hygiene,
use of antimicrobial agents (e.g., CHX), frequent professional
cleaning and SRP, removal of plaque-retentive areas (e.g.,
faulty restorations); and (3) surgical removal of enlarged gingiva
(e.g., gingivectomy using a scalpel or laser-assisted therapy,
flap surgery, or electrosurgery).111,112
Periodontal flap surgery to manage gingival enlarge-
ments are favored over gingivectomy in terms of minimizing
the amount of tissue and time recurrences.111 However, in
general, gingivectomy is indicated for small areas of gingival
enlargement (i.e., up to six teeth) where there is no evidence
of CAL or the need for osseous surgery; while flap surgery is
indicated for larger areas (i.e., more than six teeth) with evid-
ence of CAL or the need for osseous surgery.111 Antibiotic
therapy as an adjunctive antimicrobial and anti-inflammatory
agent has been proposed as another step in the management
of gingival enlargements.111,112
Recommendations:
• Clinicians should understand the etiology of gingival
enlargements before considering the best management
approach.
• Biofilm control, SRP, and timely evaluation of the
initial treatment response should occur before consid-
ering surgical therapy.
Oral soft-tissue and tooth-supporting structure injuries
Orofacial trauma can result in extraoral and intraoral soft
tissue injuries such as lacerations, contusions, abrasions, and
avulsions.113,114 Traumatic dental injuries (TDI) almost
always involve the periodontal tissues which may undergo

ischemia, crushing, or loss.21,66 Injuries to the periodontal
ligament (PDL) may range from minor lacerations with dental
concussion, tearing of the fibers with subluxation, to partial or
complete separation with luxation or avulsion, and loosening
and displacement of the tooth can occur.115,116 When foreign
bodies (e.g., gravel, tooth fragment) may be embedded within
the injured soft tissues, clinical inspection is supplemented
by a soft-tissue radiograph.113 Removal of foreign bodies is
necessary to avoid tissue infection, scarring, or tattoo-
ing.117,118 Cleansing, debridement, hemostasis, and closure are
the major steps in managing soft tissue injuries with the
goals to maintain tissue vascularity, enhance healing, and
prevent tissue devitalization, as well as to minimize the risk of
gingival recession and bone/root exposure.118 Reapproximated
soft tissue wounds are sutured using the minimal amount of
small-diameter sutures.117,118 Because determining which
wounds are tetanus prone is not possible, need for tetanus
prophylaxis is based on the patient’s current immunization
status.119 A decision for antibiotic prophylaxis is based on the
severity and contamination status of the tissue injury.120
Splinting stabilizes traumatized teeth with the goals to
optimize PDL reattachment and healing and to protect the
teeth against further insult.121,122 Characteristics of an ideal
splint for mobile traumatized teeth include being passive,
flexible, and non-irritating to surrounding soft tissues as well
as allowing for physiological tooth mobility and proper oral
hygiene.121,122 Alveolar bone fractures require a more rigid
splint with longer splinting time.123
The risk of PDL healing complications is very low for
concussion, subluxation, and extrusive and lateral luxation
injuries and significantly more for TDI involving multiple
teeth and teeth with full root development.115,116 The most
common complications are “repair-related resorption (surface
resorption), infection-related resorption (inflammatory resorp-
tion), ankylosis-related resorption (replacement resorption),
marginal bone loss, and tooth loss”.116 Ankylosis-related root
resorption is an expected outcome in replanted teeth, especi-
ally with an extra-alveolar dry time longer than 60 minutes
or transport medium other than one capable of maximizing
the vitality of the PDL cells (e.g., milk, Hanks’ Balanced
Salt Solution).123,124
Recommendations:
• Management of orofacial soft tissue injuries should
include cleansing, debridement, establishing hemosta-
sis, and closure of wounds in a manner that maintains
tissue vascularity, enhances healing, and prevents tissue
devitalization.
• The clinician should determine the need for tetanus
prophylaxis based on the patient’s current immuniza-
tion status. When immunization status is in doubt,
evaluation by a physician within 48 hours is indicat-
ed.117,120,123,125
• A decision for antibiotic prophylaxis should be based
on the severity and contamination status of the tissue
injury.117,120 Because the PDL of an avulsed tooth may
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
have been contaminated by oral or environmental
bacteria, systemic prophylactic antibiotics are recom-
mended following tooth replantation.123
• Depending on the extent of the injury suffered by the
periodontium, collaboration between the primary care
dentist and a periodontologist may be needed to allow
effective and successful clinical outcomes following
dentoalveolar trauma.
Infections of bacterial, fungal, and viral origins
The gingiva may demonstrate a variety of lesions that are
not caused by plaque and usually do not resolve after plaque
removal.3 Infections of bacterial (e.g., necrotizing gingivitis),
fungal (e.g., candidiasis), and viral (e.g., primary herpetic
gingivostomatitis, recurrent intraoral herpes simplex infection)
origins are some examples of nonplaque-induced gingival
lesions observed in the pediatric population.68 Successful
treatment of infectious lesions requires clinicians to perform
a thorough medical history appraisal, assessment of local and
systemic contributing factors, and comprehensive oral exami-
nation aimed to achieve appropriate diagnoses and treatment
plan. Elimination or reduction of all local and systemic risk
factors that contribute to the infection initiation or progres-
sion is needed for treatment completeness, followed by close
monitoring to assess treatment effectiveness, patient compliance,
and risk of recurrence.
Recommendations:
• Initial therapy should focus on alleviating acute
symptoms of pain and distress. This could include oral
analgesics to control fever, malaise, and pain, as well as
fluids to prevent dehydration.
• Antimicrobial therapy should be considered when an
infection is not self-limiting or if there are frequent
recurrences.
Traumatic gingival and oral mucosa lesions
Traumatic lesions can be accidental, iatrogenic, or self-
inflicted and are physical (e.g., oral piercing, aggressive
toothbrushing), chemical (e.g., dental materials, topical
cocaine), or thermal (e.g., overheated foods and drinks) in
nature.126,127 The appearance of the lesion (e.g., acute ulcera-
tions vs chronic gingival defects) and a detailed history are
crucial in achieving a diagnosis. Self-injury behavior (SIB)
has been reported among individuals with psychiatric illnesses
(e.g., personality disorders, bipolar disorder, major depres-
sion, anxiety disorders, obsessive-compulsive disorder) and
congenital insensitivity to pain (e.g., familial dysautonomia),
as well as a variety of developmental and intellectual disabilities
(e.g., autism).128 Gingival picking/scratching is among the
most common oral SIB.127-132 Management of self-inflicted
traumatic lesions may be complicated due to lack of patient’s
compliance. The patient’s primary care provider may help
rule out any medical reasons for SIB (e.g., otitis media,
infection, pneumonia) or specific genetic disorders (e.g.,
Lesch-Nyhan syndrome) or determine comorbid psychiatric
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 475
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
conditions. An approach that includes medical and behavioral
specialists may be indicated. Periodontal plastic surgery (e.g.,
placing a graft to create or widen the attached keratinized
tissue)133 may be necessary for permanent gingival defects.127,129,131
Recommendations:
• Management of traumatic oral lesions requires removal
of the offending agent and symptomatic therapy.
• Treatment of SIB should be individualized; diagnosis
and treatment of the underlying mechanism comprise
the most successful approach.132
• Behavior modification, pharmacotherapy, immobiliza-
tion devices, oral appliances to control harmful habits,
and/or psychological or psychiatric support may be
beneficial.128,132
• Re-evaluation and monitoring management approaches
should occur while treating self-inflicted traumatic
lesions.
Pericoronitis
Pericoronitis refers to an inflammatory lesion developed when
food debris and bacteria are present beneath the excess flap of
soft tissue surrounding partially-erupted teeth, most frequently
involving mandibular third molars.134 The pericoronal flap of
soft tissue may be chronic without any symptoms; however,
when acute, patients may experience severe pain, mouth
opening restriction, gingival abscess, cellulitis, fever, lymph-
adenopathy, and presence or risk for systemic complications.135
A rare complication is Ludwig’s angina, a life-threatening con-
dition that occurs when infection spreads to submandibular,
sublingual, and submental spaces thereby compromising the
patient’s airway.135 The first course of treatment for acute
pericoronitis is management of infection and pain.134,135 Non-
steroidal anti-inflammatory drugs (NSAIDs) are the analgesics
of choice since the control of inflammation helps to control
acute pain.136 Patient compliance for home oral hygiene is
also key for treatment success.135 Once acute symptoms resolve,
decisions can be made regarding the need for further treat-
ment (e.g., pericoronal tissue surgery or tooth extraction).134,135
Recommendations:
• Management during the acute phase should consist
of134,135:
– debridement and irrigation of the pericoronal area,
– drainage of purulence to relieve pressure,
– occlusion evaluation to determine the need to
reduce soft tissue or adjust occlusion of opposing
tooth,
– pain control using NSAIDs,
– antibiotics if the infection is not localized or there
are systemic signs and symptoms, and
– home care plan to include oral cleaning, warm saline
rinses, antiseptic agents (e.g., CHX), and sufficient
fluid intake.
• After the acute phase, practitioners should134,135 evaluate
prognosis and likelihood that the tooth involved will
either erupt without complications or continue to pose
476 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
a risk for pericoronitis recurrence and decide to either
remove the pericoronal flap (if not removed during the
acute phase) or extract the tooth to prevent recurrence.
• Ludwig’s angina requires early recognition, immediate
intervention (e.g., early and aggressive antibiotic therapy,
surgical drainage, nutrition, hydration), and close mon-
itoring. Due to the threat of rapid airway compromise,
emergency referral to an otolaryngologist or an oral and
maxillofacial surgeon should occur without delay.137
Considerations for treatment, coordination and/or referral
of care with a periodontist
Most pediatric patients will attain periodontal disease control
with nonsurgical therapy and not require further surgical inter-
vention. When PPD are greater than five mm, referral to a
periodontal specialist may be indicated. Periodontal surgery
may improve tooth support through pocket reduction, bone
augmentation, and regeneration procedures.48 Other con-
siderations for referral include: (1) extent of the disease
(generalized or localized periodontal involvement); (2) presence
of short-rooted teeth; (3) teeth hypermobility; (4) difficulty
in SRP deep pockets and furcations; (5) possibility of
damage to the developing permanent successor tooth; (6)
restorability and importance of particular teeth for recon-
struction; (7) lack of resolution of inflammation after
thorough plaque or biofilm removal and excellent SRP; (8)
presence of systemic diseases and other conditions that
compromise the host response; and (9) very importantly for
the pediatric population, the age of the patient.48 Younger
patients, both systemically healthy and compromised, with
extensive CAL are more likely to have aggressive forms
of periodontitis that can be rapidly destructive necessitating
timely advanced therapy. Early loss of primary teeth and bone
loss visible on posterior bitewing radiographs are important
indicators of aggressive forms of periodontitis that require
further follow-up and/or referral.138 The possibility of an
underlying systemic disease cannot be discarded.
The treatment for periodontitis as a manifestation of sys-
temic conditions is dependent on the systemic disorder. Two
fundamental treatment differences exist: (1) patients for whom
the systemic disease and a conservative periodontal treatment
approach do not represent grave danger to life; and (2) pa-
tients for whom the systemic disease (e.g., hypophosphatasia,
leukocyte adhesion deficiency syndrome, neutropenia) and a
conservative periodontal treatment approach may represent
grave danger to life. Managing the periodontal diseases in
these children, even when extractions of primary teeth at an
early age is the treatment of choice, is crucial since such
systemic diseases may endanger the children’s lives.139-142
In terms of coordination and referral of care with a perio-
dontist, important considerations include143,144:
• the primary care dentist will be working closely with
the medical team, and all pertinent patient information
needs to be available to the periodontist to determine
the necessity of advanced periodontal therapies;

• the level and frequency of communication between the
primary care dentist and the periodontist will be more
than is required for healthy patients. Timely commu-
nication before and after each diagnostic and surgical
appointment is essential; and
• the types and levels of behavioral and pharmacologic
pain and anxiety control available in the periodontal
office may not be ideal for the young patient. Seeing
the patient together may help meet these needs.
Recommendations:
• The treatment of periodontitis as a manifestation of
systemic disease where a conservative periodontal treat-
ment approach may represent grave danger to the child’s
life should include communication with the pediatri-
cian or medical specialist, as well as a periodontist, to
consider the risk and benefit of conservative periodontal
treatment versus tooth extractions. Extraction may be
the best treatment with a continuing periodontal infec-
tion causing severe destruction of bone and developing
permanent teeth and endangering the child’s life.
• The treatment of periodontitis as a manifestation of
systemic disease where a conservative periodontal treat-
ment approach does not represent grave danger to the
child’s life should include:
– communication with the child’s pediatrician or
medical specialist about the systemic condition, its
diagnosis based on the oral, laboratory and systemic
findings, as well as coordination of systemic and
periodontal treatments;
– consultation, coordination, and/or referral of care
with a periodontist if beyond the scope of pediatric
dentistry practice;
– nutritional evaluation and counseling;
– assessment of traumatic gingival lesions, harmful
habits, and self-injurious behavior;
– oral prophylaxis, SRP, and individualized patient
oral hygiene instruction;
– consideration of chemical adjunctive antiplaque
and anticalculus agents;
– management of risk factors (e.g., caries lesions,
defective restorations, dental trauma);
– consideration of topical antimicrobial adjuncts and
systemic antibiotics;
– consideration of periodontal surgery for severe
gingival or periodontal diseases; and
– recall appointments based on each individual com-
pliance and treatment achievements.
Surgical therapy (phase II)
Periodontal surgical therapy, which includes “plastic, aesthetic,
resective, and regenerative procedures, becomes necessary when
access for root therapy is required or correction of anatomic
or morphologic defects is necessary”.133 Placement of dental
implants can also be part of phase II therapy. The main goals
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
of surgical therapy are to improve prognosis of the teeth
and their replacements, as well as improve aesthetics.133
During this phase, the role of the primary care dentist is to
provide treatment or refer/coordinate the care with a perio-
dontal specialist when the needed treatment exceeds the
practitioner’s scope of practice. Prior to any surgical therapy,
clinicians should provide the patient an opportunity to have
questions answered and obtain written informed consent
to proceed with the therapy proposed. Following are some
surgical therapy considerations.
Pocket reduction surgery
The primary goal of surgical pocket reduction is to create
access for professional SRP and reduce PPD.51,133 It is especi-
ally useful for areas with bony defects and/or with furcation
involvement133 and best limited for pockets depths greater
than five mm51. If successful, surgery will enable the patient
to perform adequate home cleaning and maintain long-term
periodontal health. The most common pocket reduction surgi-
cal procedures are resective (e.g., gingivectomy and flaps) and
regenerative (e.g., flaps with graphs or membranes).133
Resective surgery
Gingivectomy. The indication for gingivectomy in the treat-
ment of periodontal disease is to remove the soft tissue of the
pocket wall in order to create visibility and access for complete
SRP. In combination with gingivoplasty (i.e., recontouring of
the gingiva), gingivectomy can achieve a favorable environment
for soft-tissue healing and physiological gingival contour.133,145
The two main advantages of gingivectomy are the ease and
simplicity of this surgical procedure.111 Due to secondary
wound closure, gingivectomy procedures cause more post-
operative discomfort and bleeding when compared to perio-
dontal flap surgeries.111 With advances in flap surgeries,
gingivectomy is less utilized133 but remains beneficial in the
treatment of gingival enlargements and suprabony pockets
when the pocket wall is firm and fibrous.145,146 Gingivectomy
is not indicated in cases when access to bone is required, the
keratinized tissue zone is narrow, aesthetics is a concern, and
risk for postoperative bleeding is increased.111,146
Flap surgery. Periodontal flap surgery, the most widely used
procedure for pocket therapy, provides great access for SRP,
periodontal regeneration, and gingival and osseous resections133
in moderate and deep posterior pockets. Due to esthetic con-
cerns, nonsurgical periodontal treatment in the anterior
maxillary area is preferred; however, surgery is indicated when
better visualization and SRP access are needed.111,133 In addi-
tion, flap surgery allows primary closure improving both
wound healing and patients’ post-surgical discomfort.133,145
Conversely, the periodontal flap approach is more technically
difficult compared to gingivectomy.111
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 477
BEST PRACTICES: PERIODONTAL RISK ASSESSMENT AND MANAGEMENT
Regenerative surgery
Periodontal regeneration aims to restore the lost periodontal
tissues and their respective functions by the formation of new
alveolar bone, cementum, and PDL.147-150 In addition to man-
aging intrabony and furcation defects resultant of periodontal
diseases,149 regeneration may correct undesirable outcomes
associated with resective surgical techniques such as loss of
CAL and soft tissue recession.151 In cases of hopeless teeth,
regeneration therapy is less costly when compared to extrac-
tions and dental implants.152 Several regeneration therapies
including guided tissue regeneration and bone grafts (e.g.,
autogenous, allogenic, xenogenic, synthetic or alloplastic) have
been studied.148-151 Systematic and meta-analysis reviews have
shown periodontal regeneration in intrabony defects results
in shallower residual PPD and greater CAL gain than flap
surgeries.150,151 In addition, a combination of regenerative
approaches appears to be more effective when compared to
regenerative monotherapies.151 Disadvantages of regenerative
therapies include their technically-demanding surgical proce-
dures and dependence on patients’ compliance with home
oral hygiene and professional maintenance care, as well as the
need for longitudinal randomized clinical trials to provide
more evidence regarding their long-term benefits.149-151
Laser therapy
Lasers have been used successfully in several periodontal
therapies such as gingivectomy/gingivoplasty, frenectomy,
drug-induced gingival overgrowth reshaping, crown lengthen-
ing and exposure, depigmentation, and management of excess
tissue in gummy smile and pericoronitis.153,154 Advantages
associated with the use of lasers include better visualization
during the surgical procedure due to hemostasis and coagula-
tion, easier use than scalpels, reduced need of sutures, wound
detoxification, enhanced healing, better patient acceptance,
and postoperative pain control.154-157 Laser-assisted new attach-
ment procedure (LANAP) has shown to initiate regeneration
and improve clinical outcomes in the nonsurgical treatment
of moderate to advanced periodontitis, as either a monotherapy
or as an adjunct to SRP154,155, due to its benefits of detoxifi-
cation, calculus removal, minimally invasive access for SRP,
and killing of periodontal pathogens154-156 However, more data
is needed to support the use of lasers as adjuncts to resective
and regenerative therapies.155,156 The greatest risk associated
with lasers is unintentional tissue necrosis due to excessive
temperatures.154 The use of laser in labial frenectomies has
shown to be superior to scalpel regarding postoperative pain
and discomfort during speech and mastication157, while its use
for lingual frenotomies has not shown to be superior to
other techniques158.
Extractions of teeth due to periodontal reasons
Extraction of periodontally-compromised teeth may be the
best management for some patients. Important considerations
include previous unsuccessful therapies, dental implants as
an alternative, cost-effectiveness of periodontal procedures, as
478 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
well as the patient’s systemic health, compliance, and fi-
nances.148-150,152 For pediatric patients, extraction of primary
teeth may be indicated if the periodontal lesion approximates
the developing permanent successor, endangering the dental
development.
Dental implants
The placement of dental implants in younger patients requires
a carefully coordinated and multidisciplinary team approach.
In general, conservative treatment is indicated for growing
patients with missing teeth. Important considerations include:
• the number of missing teeth along with soft and hard
tissue anatomy,
• growth and development,
• systemic conditions and psychological and behavioral
maturity159, and
• alternative therapies such as orthodontic and prosthetic
treatments.
Assessment of growth and development is key to success-
ful outcomes for dental implants in pediatric patients. Early
placement of implants in the growing patient can result in
rotation of the dental implant and infra-occlusion as the
adjacent teeth continue to erupt and the jaw grows.159 Patients
vary considerably in their growth patterns, and individual
patients may have periods of rapid and slower growth.160
Thus, chronological age is not a good indicator of completion
of growth. In contrast, skeletal maturation, assessed by cepha-
lometric analysis or hand wrist radiographs, is a good
determinant.161 While age is not the determining factor for
when implants are appropriate and the evidence from long-
term studies is still evolving, case reports give some indication
of success.161,162 A general recommendation exists for the age
of 15 in girls and 17 for boys for implants in the maxillary
anterior region.143,161,162
Recommendations:
• If PPD inhibits subgingival access or anatomic/
morphologic defects require correction, the clinician
should inform the patient of the need for and
benefits/risks of periodontal surgical therapy, as well as
treatment alternatives.
• Extraction of periodontally-compromised teeth may be
the best management for some patients.
• Clinicians should consider referral to a specialist when
the surgical interventions are beyond their scope of
practice.
• Determination for advisability and timing of implant
placement must be based on the specific circum-
stances of the individual patient. The patient’s stage of
growth and development is critical to treatment success.
Maintenance phase
The long-term success of periodontal therapy outcomes is
highly associated with the quality of recall maintenance.51,163

Following are some considerations of the maintenance ther-
apy phase:
• determination of recall procedures (i.e., prophylaxis,
periodontal maintenance).
• determination of recall interval based on risk factors
and history of disease.
• use of antimicrobial adjuncts during maintenance.
• individualized home care reinforcement.
• decision to when re-enter phase I or phase II therapy.
A classic study164 assessing the efficacy of a maintenance
care program demonstrated that patients placed on a three-
month recall maintained excellent oral hygiene parameters
and stable periodontal attachment levels for two to six years
following periodontal therapy, while the nonrecall control
group demonstrated significant periodontal attachment loss.
A 30-year outcome report165 from this study164 demonstrated
that patients placed on an individualized maintenance pro-
gram with a three- to 12-month recall interval maintained
stable periodontal conditions for 30 years. A review163 assess-
ing predefined periodontal recall intervals conducive to
periodontal health and stability concluded that evidence
supports a two- to four-month recall interval for patients
affected by moderate to advanced periodontal disease. More-
over, evidence supports a maintenance therapy program with
at least 12-month interval recalls for patients who are perio-
dontally healthy, are stable periodontally, or have mild forms
of periodontitis.163
Recommendations:
• Clinicians should educate their patients and caregivers
about the importance of supportive periodontal ther-
apy to prevent disease relapse and provide individual-
ized periodontal supportive care when needed.
• Every two to four months and at least every 12-month
interval recalls are recommended for patients with
higher and lower periodontal disease risk, respectively.
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 BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Management Considerations for Pediatric Oral

Surgery and Oral Pathology
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Management
2020 considerations for pediatric oral surgery and oral pathology. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:485-94.

Abstract
This best practice defines, describes clinical presentation, and establishes criteria and therapeutic goals for common pediatric oral surgery
procedures and oral pathological conditions. Pediatric oral surgery requires special considerations such as parental consent, knowledge
of developing anatomy and dentition, potential for adverse effects on growth, behavior guidance. and peri- and postoperative manage-
ment. Odontogenic infections usually are managed with pulp therapy, extraction, or incision and drainage. However, cases with systemic
manifestations require antibiotic therapy. Extraction of erupted, unerupted, impacted, and supernumerary teeth are discussed with emphasis
on a careful approach to avoid injury to adjacent teeth, permanent successors, and other hard and soft tissues. Considerations for surgical
correction of frenulum attachments are reviewed. Guidance is provided for biopsies, a procedure which can establish a definitive diagnosis
for most oral lesions. Common lesions in infants include Epstein pearls, Bohn nodules, and dental lamina cysts, and rare lesions include
congenital epulis of the newborn and melanotic neuroectodermal tumor of infancy. Management of these lesions and natal and neonatal
teeth is reviewed. Oral lesions in children and adolescents including eruption cysts, mucoceles, recurrent aphthous stomatitis, and pyogenic
granuloma also are addressed. While most lesions are mucosal conditions, developmental anomalies, or inflammatory lesions, practitioners
should be vigilant for neoplastic diseases.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance on management considerations for pediatric oral surgery and oral pathology.

KEYWORDS: ORAL SURGICAL PROCEDURES, PATHOLOGY, ORAL, TOOTH EXTRACTION, DIAGNOSIS, ORAL

Purpose
The American Academy of Pediatric Dentistry (AAPD)
intends this document to define, describe clinical presentation,
and set forth general criteria and therapeutic goals for com-
mon pediatric oral surgery procedures and oral pathological
conditions.
Methods
Recommendations on management considerations for pediatric
oral surgery and oral pathology were developed by the
Council on Clinical Affairs and adopted in 2005.1 This
document is a revision of the previous version, last revised in
2015.2 It is based on a review of the current dental and med-
ical literature related to pediatric oral surgery, including a
®
search of the PubMed /MEDLINE database using the terms:
pediatric AND oral surgery, oral pathology, extraction,
odontogenic infections, impacted canines, third molars,
supernumerary teeth, mesiodens, mucocele, eruption cyst,
eruption hematoma, gingival keratin cysts, Epstein pearls,
Bohn’s nodules, congenital epulis of newborn, dental lamina
cysts, natal teeth, neonatal teeth, squamous papilloma, verruca
vulgaris, irritation fibroma, recurrent aphthous stomatitis,
localized juvenile spongiotic gingival hyperplasia, and pyogenic
granuloma; fields: all; limits: within the last 10 years, humans,
English, clinical trials. Papers for review were chosen from
the list of articles matching these criteria and from references
with selected articles. When data did not appear sufficient
or were inconclusive, recommendations were based upon
expert and/or consensus opinion by experience researchers
and clinicians. In addition, the manual Parameters of Care:
Clinical Practice Guidelines for Oral and Maxillofacial Surgery,3
developed by the American Association of Oral and Maxil-
lofacial Surgeons (AAOMS), was consulted.
General considerations
Surgery performed on pediatric patients involves special
considerations unique to this population. Several critical issues
deserve to be addressed.
Preoperative considerations
Informed consent
Before any surgical procedure, informed consent must be
obtained from the parent or legal guardian. For more infor-
mation, refer to AAPD's Informed Consent.4
ABBREVIATIONS
AAOMS: American Association of Oral and Maxillofacial Surgeons.
AAPD: American Academy of Pediatric Dentistry. HPV: Human
papilloma virus. VKDB: Vitamin K deficiency bleeding.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 485

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
Medical evaluation
Important considerations in treating a pediatric patient include
obtaining a thorough medical history, obtaining appropriate
medical and dental consultations, anticipating and preventing
emergency situations, and being prepared to treat emergency
situations.5
Dental evaluation
It is important to perform a thorough clinical and radiographic
preoperative evaluation of the dentition as well as a clinical
examination of extraoral and intraoral soft tissues.5-7 Radio-
graphs can include intraoral films and extraoral imaging if the
area of interest extends beyond the dentoalveolar complex.
Surgery involving the maxilla and mandible of young patients
is complicated by the presence of developing tooth follicles.
Knowledge of the anatomy of a child’s developing maxilla and
mandible and the avoidance of injury to the dental follicles
can prevent complications.8 To minimize the negative effects
of surgery on the developing dentition, careful planning
using radiographs, tomography,9 cone beam computed tomo-
graphy,10 and/or three-dimensional imaging techniques11 is
necessary to provide valuable information to assess the presence,
absence, location, and/or quality of individual crown and root
development.8,12,13
Growth and development
The potential for adverse effects on growth from injuries and/
or surgery in the oral and maxillofacial region markedly
increases the potential for risks and complications in the
pediatric population. Traumatic injuries involving the maxil-
lofacial region can adversely affect growth, development, and
function. Therefore, a thorough evaluation of the growing
patient must be done before surgical interventions are per-
formed to minimize the risk of damage to the growing facial
complex.14
Behavioral evaluation
Behavioral guidance of children in the operative and periopera-
tive periods presents a special challenge. Many children benefit
from modalities beyond local anesthesia and nitrous oxide/
oxygen inhalation to minimize their anxiety.4,14 Management
of children under sedation or general anesthesia requires
extensive training and expertise.15,16 Special attention should be
given to the assessment of the social, emotional, and psycho-
logical status and cognitive level of the pediatric patient prior
to surgery.14 Children have many unvoiced fears concerning
the surgical experience, and their psychological management
requires that the dentist be cognizant of their emotional
status. Answering questions concerning the surgery is impor-
tant and should be done in the presence of the parent.
Peri- and postoperative considerations
Metabolic management of children following surgery fre-
quently is more complex than that of adults. Special consider-
ation should be given to caloric intake, fluid and electrolyte
486 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
management, and blood replacement. Comprehensive man-
agement of the pediatric patient following extensive oral and
maxillofacial surgery usually is best accomplished in a facility
that has expertise and experience in the management of young
patients (i.e., a children’s hospital).14
Recommendations
Odontogenic infections
In children, odontogenic infections may involve more than
one tooth and usually are due to caries lesions, periodontal
problems, pathology (e.g., dens invaginatus), or a history of
trauma.17,18 Untreated odontogenic infections can lead to pain,
difficulty eating or drinking, abscess, cellulitis, septicemia,
airway compromise, and life-threatening infections.19 Facial
cellulitis results from unresolved abscess that has spread to
cutaneous or subcutaneous soft tissue planes in the head and
neck region.19 In these children, dehydration is a significant
consideration; prompt treatment of the source of infection is
imperative.
With infections of the upper portion of the face, patients
usually complain of facial pain, fever, and malaise.20 Care must
be taken to rule out sinusitis or non-odontogenic infections,
as symptoms may mimic an odontogenic infection. Occasionally
in upper face infections, it may be difficult to find the true
cause.14 Infections of the lower face usually involve pain, swelling,
and trismus.3,17 They frequently are associated with teeth, skin,
local lymph nodes, and salivary glands.17 Most odontogenic
infections occur in the upper face; however, infections in the
mandibular region are more frequent in older children.20
Most odontogenic infections can be managed with pulp
therapy, extraction, or incision and drainage. 5 Infections of
odontogenic origin with systemic manifestations (e.g., elevated
temperature [102 to 104 degrees Fahrenheit], facial cellulitis,
difficulty in breathing or swallowing, fatigue, nausea) require
antibiotic therapy.19 Severe but rare complications of odonto-
genic infections include cavernous sinus thrombosis and
Ludwig’s angina.17,19 These conditions can be life threatening
and may require immediate hospitalization with intravenous
antibiotics, incision and drainage, and referral/consultation
with an oral and maxillofacial surgeon.17,19
Extraction of erupted teeth
Maxillary and mandibular anterior teeth
Most primary and permanent maxillary and mandibular central
incisors, lateral incisors, and canines have conical single roots.
In most cases, extraction of anterior teeth is accomplished
with a rotational movement due to their single root
anatomy.5 However, there have been reported cases of ac-
cessory roots observed in primary canines.21,22 Radiographic
examination is helpful to identify differences in root anatomy
prior to extraction.21 Care should be taken to avoid placing
any force on adjacent teeth that could become luxated or
dislodged easily due to their root anatomy.

Maxillary and mandibular molars
Primary molars have roots that are smaller in diameter and
more divergent than permanent molars. Root fracture in
primary molars is not uncommon due to these characteristics
as well as the potential weakening of the roots caused by the
eruption of their permanent successors.5 Prior to extraction,
the relationship of the primary roots to the developing suc-
cedaneous tooth should be assessed. To avoid inadvertent
extraction or dislocation of or trauma to the permanent
successor, pressure should be avoided in the furcation area or
the tooth may need to be sectioned to protect the developing
permanent tooth.
Molar extractions are accomplished by using slow conti-
nuous palatal/lingual and buccal force allowing for the
expansion of the alveolar bone to accommodate the divergent
roots and reduce the risk of root fracture.5 When extracting
mandibular molars, care should be taken to support the
mandible to protect the temporomandibular joints from
injury.5
Fractured primary tooth roots
The presence of a root tip should not be regarded as a positive
indication for its removal. The dilemma to consider when
managing a retained primary tooth root is that removing the
root tip may cause damage to the succedaneous tooth, while
leaving the root tip may increase the chance for postopera-
tive infection and delay eruption of the permanent successor.5
Radiographs can assist in the decision process. Expert opinion
suggests that if the fractured root tip can be removed easily,
it should be removed.5 If the root tip is very small, located
deep in the socket, situated in close proximity to the permanent
successor, or unable to be retrieved after several attempts, it is
best left to be resorbed.5 The parent must be informed and a
complete record of the discussion must be documented. The
patient should be monitored at appropriate intervals to eval-
uate for potential adverse effects.
Management of unerupted and impacted teeth
There is a wide clinical spectrum of disorders of eruption in
both primary and permanent teeth in children. These may
be syndromic or nonsyndromic and include ankyloses,27-28
secondary retention,28 tooth impaction, or primary failure of
eruption29. Clinically, it may be difficult to differentiate be-
tween the various disruptions; however, there have been many
reports30,31 to assist the clinician in making a diagnosis.
Increasing evidence supports a genetic etiology for some
eruption disruptions which may help in a definitive
diagnosis.29 Management of unerupted teeth will depend on
whether the affected tooth is likely to respond to orthodontic
forces. If not, surgical extraction is the preferred treatment
option.29
Impacted canines
Tooth impaction may occur due to a mechanical obstruction.
Permanent maxillary canines are second to third molars in
BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
frequency of impaction.32 Early detection of an ectopically
erupting canine through visual inspection, palpation, and
radiographic examination is important to maximize success of
an intervention.33 Routine evaluation of patients in mid-mixed
dentition should involve identifying signs such as lack of ca-
nine bulges and asymmetry in pattern of exfoliation. Abnormal
angulation or ectopic eruption of developing permanent cus-
pids can be assessed radiographically.33 When the cusp tip of
the permanent canine is just mesial to or overlaying the distal
half of the long axis of the root of the permanent lateral incisor,
canine palatal impaction usually occurs.32 Extraction of the
primary canines is the treatment of choice to correct palatally
displaced canines or to prevent resorption of adjacent teeth.32
One study showed that 78 percent of ectopically erupting
permanent canines normalized within 12 months after removal
of the primary canines; 64 percent normalized when the
starting canine position overlapped the lateral incisor by more
than half of the root; and 91 percent normalized when the
starting canine position overlapped the lateral incisor by less
than half of the root.32 If no improvement in canine position
occurs in a year, surgical and/or orthodontic treatment were
suggested.32,33 A Cochrane review34 and a systematic review35
reported no evidence to support extraction of primary canines
to facilitate eruption of ectopic permanent maxillary canines.
A prospective randomized clinical trial demonstrated that
extraction of primary canines is an effective measure to correct
palatally displaced maxillary canines and is more successful in
children with an early diagnosis.36 Consultation between the
practitioner and an orthodontist may be useful in the final
treatment decision.
Third molars
Panoramic or periapical radiographic examination is indicated
in late adolescence to assess the presence, position, and devel-
opment of third molars.7 The AAOMS recommends that a
decision to remove or retain third molars should be made
before the middle of the third decade.3 Evidence-based research
supports the removal of third molars when pathology (e.g.,
cysts or tumors, caries, infection, pericoronitis, periodontal
disease, detrimental changes of adjacent teeth or bone) is asso-
ciated and/or the tooth is malpositioned or nonfunctional
(i.e., an unopposed tooth).37-39 There is no evidence to
support37-40 or refute3 the prophylactic removal of disease-free
impacted third molars. Factors that increase the risk for
surgical complications (e.g., coexisting systemic conditions,
location of peripheral nerves, history of temporomandibular
joint disease, presence of cysts or tumors)38,39 and position
and inclination of the molar in question41 should be assessed.
The age of the patient is only a secondary consideration.41
Referral to an oral and maxillofacial surgeon for consultation
and subsequent treatment may be indicated. When a decision
is made to retain impacted third molars, they should be
monitored for change in position and/or development of
pathology, which may necessitate later removal.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 487
BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
Supernumerary teeth
Supernumerary teeth and hyperdontia are terms to describe
an excess in tooth number. Supernumerary teeth are thought
to be related to disturbances in the initiation and proliferation
stages of dental development.21 Although some supernumerary
teeth may be syndrome-associated (e.g., cleidocranial dysplasia)
or of familial inheritance pattern, most supernumerary teeth
occur as isolated events.21
Supernumerary teeth can occur in either the primary or
permanent dentition.21,42,43 In 33 percent of the cases, a super-
numerary tooth in the primary dentition is followed by the
supernumerary tooth complement in the permanent denti-
tion.44 Reports in incidence of supernumerary teeth can be
as high as three percent, with the permanent dentition being
affected five times more frequently than the primary dentition
and males being affected twice as frequently as females.21
Supernumerary teeth will occur 10 times more often in
the maxillary arch versus the mandibular arch.21 Approxi-
mately 90 percent of all single tooth supernumerary teeth are
found in the maxillary arch, with a strong predilection to the
anterior region.21,42 The maxillary anterior midline is the most
common site, in which case the supernumerary tooth is known
as a mesiodens; the second most common site is the maxillary
molar area, with the tooth known as a paramolar.21,42 A me-
siodens can be suspected if there is an asymmetric eruption
pattern of the maxillary incisors, delayed eruption of the
maxillary incisors with or without any overretained primary
incisors, or ectopic eruption of a maxillary incisor. 45 The
diagnosis of a mesiodens can be confirmed with radiographs,
including occlusal, periapical, or panoramic films,46 or com-
puted tomography.9,10 Three-dimensional information needed
to determine the location of the mesiodens or impacted tooth
can be obtained by taking two periapical radiographs using
either two projections taken at right angles to one another or
the tube-shift technique (buccal object rule or Clark’s rule) 47
or by cone beam computed tomography.10,12,13
Complications of supernumerary teeth can include delayed
and/or lack of eruption of the permanent tooth, crowding,
resorption of adjacent teeth, dentigerous cyst formation, peri-
coronal space ossification, and crown resorption.42,48 Early
diagnosis and appropriately timed treatment are important in
the prevention and avoidance of these complications. Because
only 25 percent of all mesiodens erupt spontaneously, surgical
management often is necessary.44,49 A mesiodens that is conical
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
treatment objective for a nonerupting permanent mesiodens
is to minimize eruption problems for the permanent incisors.48
Surgical management will vary depending on the size, shape,
and number of supernumeraries and the patient’s dental
development. 48 The treatment objective for a nonerupting
primary mesiodens differs in that the removal of these teeth
usually is not recommended, as the surgical intervention may
disrupt or damage the underlying developing permanent
teeth.50 Erupted primary tooth mesiodens typically are left
488 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
to shed normally upon the eruption of the permanent
dentition.50
Extraction of an unerupted primary or permanent mesio-
dens is recommended during the mixed dentition to allow the
normal eruptive force of the permanent incisor to bring itself
into the oral cavity.43 Waiting until the adjacent incisors have
at least two-thirds root development will present less risk to
the developing teeth but still allow spontaneous eruption of
the incisors. 3 In 75 percent of the cases, extraction of the
mesiodens during the mixed dentition results in spontaneous
eruption and alignment of the adjacent teeth.50,51 If the adja-
cent teeth do not erupt within six to 12 months, surgical
exposure and orthodontic treatment may be necessary to aid
their eruption.45,47
Frenulum attachments
Frenulum attachments and their role in oral function increas-
ingly have become topics of interest among a variety of health
care specialists. Ankyloglossia (tongue-tie) and hypertrophic/
restrictive maxillary frenula have been implicated in difficulties
breastfeeding53, incorrect speech articulation54,55, caries forma-
tion56,57, gingival recession58, and aberrant skeletal growth59.
Studies have shown differences in treatment recommendations
among pediatricians, otolaryngologists, lactation consultants,
speech pathologists, surgeons, and dental specialists.54,60-66 Clear
indications and timing of surgical treatment remain controver-
sial due to lack of consensus regarding accepted anatomical and
diagnostic criteria for degree of restriction and relative impact
on growth, development, feeding, or oral motor function.54,60-66
When indicated, frenuloplasty/frenotomy (various methods
to release the frenulum and correct the anatomic situation) or
frenectomy (simple cutting of the frenulum) may be a success-
ful approach to alleviate the problem.54,60,65,67 Each of these
procedures involves surgical incision, establishing hemostasis,
and wound management.68 Dressing placement or the use of
antibiotics is not necessary.68 Recommendations include
maintaining a soft diet, regular oral hygiene, and analgesics
as needed.69 The use of electrosurgery or laser technology for
frenectomies has demonstrated a shorter operative working
time, a better ability to control bleeding, reduced intra- and
postoperative pain and discomfort, fewer postoperative
complications (e.g., swelling, infection), no need for suture
removal, and increased patient acceptance.62,69,70 These proce-
dures require extensive training as well as skillful technique
and patient management.54,60,65,67,71-75
Pediatric oral pathology
A wide spectrum of oral lesions occurs in children and ad-
olescents, including soft and hard tissue lesions of the oral
maxillofacial region. There is limited information on the pre-
valence of oral lesions in the pediatric population. The largest
epidemiologic studies in the United States place the prevalence
rate in children at four to 10 percent with the exclusion of
infants.76,77 Although the vast majority of these lesions represent
mucosal conditions, developmental anomalies, and reactive

or inflammatory lesions, it is imperative to be vigilant for
neoplastic diseases.
Regardless of the age of the child, it is important to estab-
lish a working diagnosis for every lesion. This is based on
obtaining a thorough history, assessing the risk factors and
documenting the clinical signs and symptoms of the lesion.
Based on these facts, a list of lesions with similar characteris-
tics is rank ordered from most likely to least likely diagnosis.
The entity that is judged to be the most likely disease becomes
the working diagnosis and determines the initial management
approach.
For most oral lesions, a definitive diagnosis is best made by
performing a biopsy. By definition, a biopsy is the removal
of a piece of tissue from a living body for diagnostic study
and is considered the gold standard of diagnostic tests.78 The
two most common biopsies are the incisional and excisional
types. Excisional biopsies usually are performed on small
lesions, less than one centimeter in size, for the total removal
of the affected tissue. An incisional biopsy is performed when
a malignancy is suspected, the lesion is large in size or diffuse
in nature, or a multifocal distribution is present. Multiple
incisional biopsies may be indicated for diffuse lesions in
order to obtain a representative tissue sample. Fine needle
aspiration, the cytobrush technique, and exfoliative cytology
may assist in making a diagnosis, but they are considered
adjunctive tests because they do not establish a definitive
diagnosis.79,80
It is considered the standard of care that any tissue
removed from the oral and maxillofacial region be submitted
for histopathologic examination.81 Exceptions to this rule in-
clude carious teeth that do not have soft tissue attached, extirpated
pulpal tissue, and clinically normal tissue, such as tissue from
gingival recontouring.81 Gross description of all tissue that is
removed should be entered into the patient record. In general,
a soft tissue biopsy should be performed when a lesion persists
for greater than two weeks despite removal of the suspected
causative factor or empirical drug treatment. It is also imper-
ative to submit hard or soft tissue for evaluation to a pathologist
if the differential diagnosis includes at least one significant
disease or neoplasm. Histopathologic examination not only
furnishes a definitive diagnosis, but it provides information
about the clinical behavior and prognosis and determines the
need for additional treatment or follow-up. Another valuable
outcome is that it allows the clinician to deliver evidence-based
medical/dental care, increasing the likelihood for a positive
result.78 Furthermore, it presents important documentation
about the lesion for the patient record, including the pro-
cedures taken for establishing a diagnosis.78
Many oral biopsies are within the scope of practice for a
pediatric dentist to perform. If the tissue is excised, the follow-
ing steps should be taken for optimum results:78-81
1. select the most representative lesion site and not the area
that is the most accessible.
2. remove an adequate amount of tissue. If the biopsy is too
small or too superficial, a diagnosis may be compromised.
BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
3. avoid crushing or distorting the tissue. Damage is most
often observed from the forces of the tissue forceps,
tearing the tissues or overheating the tissue from the use
of electrosurgery or laser removal.
4. immediately place the tissue in a fixative, which for most
samples is 10 percent formalin. It is critical not to dilute
the fixative with water or other liquids because tissue
autolysis will render the sample nondiagnositic.
5. proper identification of the specimen is essential. The
formalin container should be labelled with the name
of the patient and the location. Multiple tissue samples
from different locations should not be placed in the
same container, unless they are uniquely identified, such
as tagged with a suture.
6. complete the surgical pathology form including patient
demographics, the submitting dentist’s name and address,
and a brief but accurate history. It is important to have
legible records so that the diagnosis is not delayed.
Clinical photographs and radiographs often are very
useful for correlating the microscopic findings.
Worldwide, the most frequently oral biopsied lesions in
children include82:
• mucocele;
• fibrous lesions;
• pyogenic granuloma;
• dental follicle;
• human papillomavirus (HPV) lesion;
• chronic inflammation;
• giant cell lesions (soft tissue);
• hyperkeratosis;
• peripheral ossifying fibroma;
• gingivitis;
• gingival hyperplasia;
• hemangioma;
• ulcer;
• lymphangioma;
• sialadentis;
• Burkitt’s lymphoma;
• melanotic macule;
• pleomorphic adenoma;
• nevus; and
• neurofibroma.
Lesions of the newborn
Palatal cysts of the newborn include Epstein pearls and Bohn
nodules. These cysts are found in up to 85 percent of new-
borns.53,83-90 Epstein pearls occur in the median palatal raphe
area53,83-85 as a result of trapped epithelial remnants along the
line of fusion of the palatal halves. 49,51 Bohn nodules are
remnants of salivary gland epithelium and usually are found
on the buccal and lingual aspects of the ridge, away from the
midline.83,85 Gingival cysts of the newborn, or dental lamina
cysts, are found on the crests of the dental ridges, and are most
commonly are seen bilaterally in the region of the first primary
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 489
BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
molars. 84 They result from remnants of the dental lamina.
Palatal and gingival cysts of the newborn typically present as
asymptomatic one to three millimeter nodules or papules.
They are smooth, whitish in appearance, and filled with
keratin.83,84 No treatment is required, as these cysts usually
disappear during the first three months of life.53,83
Congenital epulis of the newborn
Congenital epulis of the newborn, also known as granular
cell tumor or Neumann’s tumor, is a rare benign tumor seen
only in newborns. 91 This lesion is typically a protuberant
mass arising from the gingival mucosa. It is most often
found on the anterior maxillary ridge.86,87 Patients typically
present with feeding and/or respiratory problems.87 Congenital
epulis has a marked predilection for females at 8:1 to 10:1.86-88
Treatment normally consists of surgical excision. 86-88 The
newborn usually heals well, and no future complications or
treatment should be expected. Congenital epulis never recurs
after excision. 88 There have been reports of spontaneous
regression of untreated congenital epulis.88,91
Melanotic neuroectodermal tumor of infancy
Melanotic neuroectodermal tumor of infancy is a rare occur-
rence that develops during the first year of life.88 This lesion
may be present at birth. It occurs in the anterior maxilla 70
percent of the time.83 Less frequently, melanotic neuroecto-
dermal tumor of infancy occurs in the skull, mandible,
epididymis and testis, and brain.83,88 The classic presentation
is a bluish or black rapidly expanding mass of the anterior
maxilla. Radiographic findings include an ill-defined
unilocular radiolucency with the displacement of tooth buds.88
There can be a floating tooth appearance.83 Surgical excision is
required, and there is a 20 percent recurrence rate. Although
this is a benign lesion, seven percent of reported cases have
behaved malignantly resulting in metastasis and death.88
Natal and neonatal teeth
Natal and neonatal teeth can present a challenge when deciding
on appropriate treatment. Natal teeth have been defined as
those teeth present at birth, and neonatal teeth are those that
erupt during the first 30 days of life.92,93 The occurrence of
natal and neonatal teeth is rare; the incidence varies from
1:1,000 to 1:30,000.92,93 The teeth most often affected are the
mandibular primary incisors.94 In most cases, anterior natal
and neonatal teeth are part of the normal complement of the
dentition.92,93 Natal or neonatal molars have been identified in
the posterior region and may be associated with systemic condi-
tions or syndromes (e.g., Pfieffer syndrome, histiocytosis X).94-96
Although many theories exist as to why the teeth erupt prema-
turely, currently no studies confirm a causal relationship with
any of the proposed theories. The superficial position of the
tooth germ associated with a hereditary factor seems to be the
most accepted possibility.93
If the tooth is not excessively mobile or causing feeding
problems, it should be preserved and maintained in a healthy
490 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
condition if possible.93,95,96 Close monitoring is indicated to
ensure that the tooth remains stable and is not an aspiration
risk to the infant.
Riga-Fede disease is a condition caused by the natal or
neonatal tooth rubbing the ventral surface of the tongue
during feeding, leading to ulceration.75,92 Failure to diagnose
and properly treat this lesion can result in dehydration and
inadequate nutritional intake for the infant. 96 Treatment
should be conservative and focus on creating round, smooth
incisal edges.93-96 If conservative treatment does not correct the
condition, extraction is the treatment of choice.93-96
An important consideration when deciding to extract a natal
or neonatal tooth is the potential for hemorrhage. Extraction
is contraindicated in newborns due to risk of hemorrhage.97
Unless the child is at least 10 days old, consultation with the
pediatrician regarding adequate hemostasis may be indicated
prior to extraction of the tooth. In particular, infants may be
at risk for vitamin K deficiency bleeding (VKDB) if they did
not receive a dose of vitamin K shortly after birth (within six
hours of birth).98 Infants can be at risk for VKDB until the
age of six months if they do not receive a vitamin K injection.98
Lesions occurring in children and adolescents
Eruption cyst (eruption hematoma)
The eruption cyst is a soft tissue cyst that results from a
separation of the dental follicle from the crown of an erupting
tooth.83,99 Fluid accumulation occurs within this created fol-
licular space.85,89,100 Eruption cysts most commonly are found in
the mandibular molar region.89 Color of these lesions can range
from normal to blue-black or brown, depending on the amount
of blood in the cystic fluid.85,89,100 The blood is secondary to
trauma. If trauma is intense, these blood-filled lesions some-
times are referred to as eruption hematomas.85,89,100 Because the
tooth erupts through the lesion, no treatment is necessary.85,89,100
If the cyst does not rupture spontaneously or the lesion becomes
infected, the roof of the cyst may be opened surgically.85,89
Mucocele
The mucocele is a common lesion in children and adolescents
resulting from the rupture of a minor salivary gland excretory
duct, with subsequent leakage of mucin into the adjacent
connective tissues that later may be surrounded in a fibrous
capsule.83,85,99-101 Most mucoceles are well-circumscribed bluish
translucent fluctuant swellings that are firm to palpation,
although deeper and long-standing lesions may range from
normal in color to having a whitish keratinized surface.85,99,100
Mucoceles most frequently are observed on the lower lip, usually
lateral to the midline.88 Mucoceles also can be found on the
buccal mucosa, ventral surface of the tongue, retromolar region,
and floor of the mouth (ranula).99-101 Superficial mucoceles and
some other mucoceles are short-lived lesions that burst spon-
taneously, leaving shallow ulcers that heal within a few
days.85,100 Local mechanical trauma to the minor salivary gland
is often the cause of rupture.50,53,86,87 Many lesions, however,
require treatment to minimize the risk of recurrence.85,100

Squamous papilloma
Squamous papilloma is a benign lesion caused by HPV types 1
and 6.83 Squamous papilloma presents as soft painless, pink
to white, pedunculated (stalked) lesions. The surface may
display multiple fingerlike projections and may have a
cauliflower like appearance.83,102,103 These lesions can occur
anywhere in the oral cavity, but the tongue, lips, and soft
palate are the most common sites.103 Squamous papilloma
generally occurs in adulthood, but 20 percent have been
noted prior to age 20. 91 Although they are viral in origin,
the infectivity is low.83,102 Squamous papilloma do not have
malignant potential.103 Excision is the treatment of choice,
and recurrence is uncommon.83,103
Verruca vulgaris
Verruca vulgaris, or the common wart, is a lesion induced by
HPV type 2 and generally found on the skin of the hand.102
Finger or thumb sucking can cause autoinoculation resulting
in the development of intraoral lesions.102 Verruca vulgaris is
similar in appearance to the squamous papilloma. This le-
sion can be sessile (broad based) or pedunculated and can
display a rough bumpy surface. 103 Verruca vulgaris can be
found on the lips, tip of tongue, and labial mucosa.83 There is
no risk of malignant transformation.83 Excision of the entire
lesion is recommended and recurrence is uncommon.103
Irritation fibroma
The irritation fibroma is a reactive lesion occurring as a re-
sponse to chronic trauma of the mucosa. The irritation fibroma
presents as a firm nontender pink nodule and is composed of
fibrous connective tissue.103 The lesion does not exceed two
millimeters in diameter.104 The irritation fibroma can be found
on buccal and labial mucosa, the tongue, and attached gingiva.
Excisional biopsy is recommended. These can reoccur if the
source of the irritation is not removed.103,104
Recurrent aphthous stomatitis
Recurrent aphthous stomatitis is one of the most common oral
lesions, occurring in 20-30 percent of children.83 Recurrent
aphthous stomatitis is caused by a T-cell mediated immu-
nologic reaction to a triggering agent. 105 Three variants of
aphthous ulcers are recognized:
1. Minor aphthous ulcerations. Minor aphthous ulcerations
are the most common form, accounting for almost 80
percent of aphthous ulcers.105 They have a yellowish-
white membrane and are surrounded by an erythematous
halo. These ulcers are three to 10 millimeters in diameter.
Minor aphthous ulcers occur on nonkeratinized mu-
cosa.105 One to five ulcers often present during a single
outbreak, and they heal in seven to 14 days without
scarring.106
2. Major aphthous ulcerations. Major aphthous ulcerations
are larger and deeper and have a longer duration than
the minor aphthous ulcer. These occur most commonly
BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
on the labial mucosa, soft palate, and the tonsillar
fauces.105 The major aphthous ulcer can take up to six
weeks to heal with potential scarring.105
3. Herpetiform aphthous ulcerations. Herpetiform aphthous
ulcerations can occur on any intraoral site.106 As many as
100 small ulcerations can be present in a single occur-
rence.105 The ulcerations may resemble primary herpetic
stomatitis. These ulcerations may coalesce to form a
larger ulceration. 105 Herpetiform aphthous ulcers heal
within seven to 10 days, but recurrences are frequent.106
Aphthous ulcers may be treated with topical anesthetics
for relief of pain. Topical and systemic steroids, chlorhexidine
rinses, and laser treatments can be used to manage these
lesions.83
Localized juvenile spongiotic gingival hyperplasia
Localized juvenile spongiotic gingival hyperplasia was originally
known as puberty gingivitis.107 It is thought to be an isolated
patch of sulcular or junctional epithelium that is subjected to
local factors such as mouth breathing or orthodontic appli-
ances.83 The lesion presents as an isolated bright red velvety
patch or enlargement of anterior facial gingiva. This lesion
bleeds easily and does not respond to oral hygiene measures.
There is a female predilection.83 Most lesions occur under the
age of 20, with the median age at diagnosis being 12 years.107
Excision is the treatment of choice, and up to 16 percent will
recur.83
Pyogenic granuloma
Pyogenic granuloma is a painless smooth or lobulated vascular
lesion. The pyogenic granuloma is usually ulcerated and bleeds
easily.83,107 This lesion can occur at any age but is most common
in children and young adults. There is a female predilection,83
and the pyogenic granuloma can occur in up to five percent
of pregnancies.108 The pyogenic granuloma is thought to be
an exuberant tissue response to a local irritant or trauma. 108
Pyogenic granuloma most commonly occurs on maxillary
anterior attached gingiva (75 percent) but can be found on
tongue, lower lip, or buccal mucosa.108 Treatment is complete
excision with the removal of the source of irritant.83,108 This
lesion can recur in three to 15 percent of cases.83
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66. Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM.
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67. Devishree G, Gujjari SK, Shubhashini PV. Frenectomy:
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69. Shetty K, Trajtenberg C, Patel C, Streckfus C. Maxillary
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72. Hogan M, Wescott C, Griffiths M. Randomized, controlled
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 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-
2022 biotic therapy for pediatric dental patients. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:495-9.

Abstract
This best practice provides clinicians with guidance in the appropriate use of antibiotics to treat oral infections in children. When correctly
prescribed and administered, antibiotics can be effective in the treatment of oral bacterial infections. Antibiotic stewardship is important
given the rise in antibiotic-resistant microorganisms and potential for adverse drug reactions. This document addresses the following
clinical conditions: oral wounds, pulpitis/apical periodontitis/draining sinus tract/localized intraoral swelling, acute facial swelling of dental
origin, dental trauma, periodontal diseases, and salivary gland infections and offers guidance on the judicious use of antibiotics in their
management. Antibiotics are not indicated in the management of conditions of viral origin. Potential interactions between antibiotics and
oral contraceptives are addressed. Health care providers must be prudent in their prescribing practices to maximize effectiveness and
minimize bacterial resistance and adverse reactions.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and guidance on the use of antibiotic therapy for pediatric dental patients.
KEYWORDS: ANTIBIOTICS, ANTIMICROBIAL RESISTANCE, DENTAL INFECTION CONTROL, BACTERIAL INFECTIONS

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the increasing prevalence of antibiotic-resistant
microorganisms and potential for adverse drug reactions and
interactions. These recommendations are intended to provide
guidance in the proper and judicious use of antibiotic therapy
in the treatment of oral conditions. The use of antibiotic
prophylaxis for dental patients at risk for infection is ad-
dressed in a separate best practices document.1 Information
regarding commonly prescribed antibiotics can be found in
AAPD’s Useful Medications for Oral Conditions.2
Methods
Recommendations on the use of antibiotic therapy were devel-
oped by the Council on Clinical Affairs, adopted in 20013,
and last revised in 2019.4 This revision was based upon a new
®
literature search of the PubMed /MEDLINE database using
the terms: pediatric dental antibiotic therapy AND antibac-
terial agents, antimicrobial agents, dental trauma, oral wound
management, orofacial infections, periodontal disease, viral
disease, and oral contraception; fields: all; limits: within the
last 10 years, humans, English, clinical trials, birth through
age 18. Four hundred seventy-eight articles matched these
criteria. Papers for review were chosen from this search and
from hand searching. When data did not appear sufficient or
were inconclusive, recommendations were based upon expert
and/or consensus opinion by experienced researchers and
clinicians.
Background
Antibiotics are beneficial to patient care when prescribed and
administered correctly for bacterial infections. However, the
widespread use of antibiotics has permitted common bacteria
to develop resistance to drugs that once controlled them.5,6
Drug resistance is prevalent throughout the world.5,6 Each
year in the United States, nearly three million antibiotic-
resistant infections occur and result in more than 35,000
deaths.5 Some microorganisms may develop resistance to a
single antimicrobial agent, while others develop multi-drug-
resistant strains.6 To diminish the rate at which resistance is
increasing, health care providers must be prudent in the use
of antibiotics.5,7 A study showed 80 percent of prescriptions of
antibiotics before dental procedures were unnecessary as risk-
factors were not present.8 This highlights a concern on the
appropriateness for prescribed antibiotic prophylaxis for dental
procedures.8 While use of antibiotic prophylaxis is indicated
for certain patients undergoing invasive dental procedures,
overall emphasis should focus on establishment of a dental
home, the prevention of disease, establishment and mainte-
nance of good oral health care habits, and regular dental care.9,10
Conservative use of antibiotics is indicated to minimize the
risk of developing resistance to current antibiotic regimens.5,6,9
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. JRP: Juvenile
recurrent parotitis.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 495

BEST PRACTICES: USE OF ANTIBIOTIC THERAPY
Adverse events such as allergic reactions, development of
Clostridioides difficile infection, or drug interactions and side
effects can occur.5,11 Antibiotic adverse drug events are a com-
mon cause of emergency department visits for adverse drug
events in children under the age of 18 years, with amoxicillin
as the most commonly implicated drug in children less than
nine years and sulfamethoxazole-trimethoprim in children
aged 10-19.12
Amoxicillin, considered the first drug of choice for dental
infections in non-allergic children13, is effective against a wide
variety of gram-positive bacteria and offers greater gram-
negative coverage than penicillin. 14 It has been shown to be
effective against oral flora15, be well absorbed from the gastro-
intestinal tract9, provide high, sustained serum concentrations9,
and have a low incidence of adverse effects15. The American
Heart Association no longer recommends clindamycin for
prophylaxis against infective endocarditis due to frequent and
severe reactions.9 Clindamycin has been associated with signi-
ficant adverse drug reactions related to community-acquired
C. difficile infections. 9 Up to 15 percent of community-
acquired C. difficile infection has been attributed to antibiotics
prescribed for dental procedures.9 Doxycycline is recommended
as an alternative to penicillin, cephalosporin, and macrolide
allergy.9 Short-term use (less than 21 days) of doxycycline had
not been associated with tooth discoloration in children under
eight years of age.16-18 Azithromycin is one of the safest anti-
biotics for patients allergic to penicillins, but there are risks of
cardiac complications including cardiotoxicity.19 The small,
heightened risk appears to be related to pre-existing cardiovas-
cular risk factors including prior myocardial infarction, diabetes,
age, and gender.20 Cardiac risk in pediatric patients seems to
be due to an increased risk of QT prolongation associated with
higher dosage levels.19
Recommendations
Practitioners should adhere to the following general principles
for antibiotic usage for the pediatric dental patient.9,21
• Prevention of dental diseases should be emphasized
in order to reduce the need for antibiotic intervention.
• Antibiotics should be prescribed only when truly
needed for a bacterial infection and only as an adjunct
to, not an alternative for, other interventions (e.g.,
pulp therapy, extraction, scaling and root planing)
implemented to control the infection source.
• Antibiotics should be selected based on properties of
the agent (e.g., spectrum of coverage, safety), previous
antibiotic use, and patient considerations (e.g., medical
history, drug allergies, current medication use, ease of
use) and then prescribed at an adequate pediatric dose.
• The most effective route of drug administration (in-
travenous versus intramuscular versus oral) must be
considered. If the patient is receiving parenteral anti-
microbial therapy for treatment of existing infections,
the same antibiotic can be continued. 9 Consultation
496 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
with an infectious disease physician is recommended
if there is concern for resistant infections.
• The traditional minimal duration of drug regimen is
five days beyond the point of substantial improve-
ment (e.g., improved healing of wound, reduction of
erythema or swelling, reduction of signs and symptoms).
Usually, this is a five- to seven-day course of treatment,
dependent upon the specific drug selected.22,23
• However, in light of the growing problem of drug
resistance, discontinuation of antibiotics should be
considered following determination of either ineffec-
tiveness or cure prior to completion of a full course of
therapy.24,25
• If an infection is not responsive to the initial drug
selection, a culture and sensitivity testing from the in-
fection site or, in some cases, a blood microbiology and
culture and sensitivity may be indicated.5,25
• Prescriptions should be documented in the patient’s
dental record.26
• Individuals suspected to have an allergy to antibiotics
should receive testing to confirm or refute the presence
of a true allergy.
Additional considerations for specific clinical circumstances
are discussed below.
Oral wounds
Factors related to host risk (e.g., age, systemic illness, co-
morbidities, malnutrition) and type of wound (e.g., laceration,
puncture) must be evaluated when determining the risk for
infection and subsequent need for antibiotics. Wounds can be
classified as clean, potentially contaminated, or contaminated/
dirty. Facial lacerations and puncture wounds may require
topical antibiotic agents.27 Intraoral puncture wounds and
lacerations that appear to have been contaminated by extrinsic
bacteria, debris (e.g., dirt, soil, gravel), foreign body, open
fractures, and joint injury have an increased risk of infection
and should be managed by systemic antibiotics.27 If antibiotics
are deemed beneficial to the healing process, the timing of
their administration is critical to supplement the natural host
resistance in bacterial killing. The drug should be administered
as soon as possible for the best result.5
Pulpitis/apical periodontitis/draining sinus tract/localized
intraoral swelling
Bacteria can gain access to the pulpal tissue through caries,
exposed pulp or dentinal tubules, cracks into the dentin, and
defective restorations. If a child presents with acute symp-
toms of pulpitis, treatment (i.e., pulpotomy, pulpectomy, or
extraction) should be rendered. Antibiotic therapy is not
indicated nor effective if the dental infection is contained
within the pulpal tissue or the immediate surrounding tissue.
In this case, the child will have no systemic signs of an
infection (i.e., no fever, no facial swelling).28

Consideration for use of antibiotics should be given in
cases of advanced non-odontogenic bacterial infections such as
staphylococcal mucositis, tuberculosis, gonococcal stomatitis,
and oral syphilis. If suspected, referral for microbiology,
culture and sensitivity testing, biopsy, or other laboratory tests
for documentation and definitive treatment is indicated.
Acute facial swelling of dental origin
A child presenting with a facial swelling or facial cellulitis
secondary to an odontogenic infection should receive prompt
dental attention. The clinician should consider age, coopera-
tion, the ability to obtain adequate anesthesia (local versus
general), the severity of the infection, the medical status, and
any social issues of the child.29,30 For odontogenic infections
with nonlocalized and progressive swelling and systemic
manifestations (e.g., fever, difficulty breathing or swallowing),
immediate surgical intervention and medical management
with intravenous antibiotic therapy contribute to a more rapid
cure.30-33 Signs of systemic involvement and septicemia (e.g., fever,
malaise, asymmetry, facial swelling, lymphadenopathy, trismus,
tachycardia, dysphagia, airway compromise, respiratory distress)
warrant emergency treatment. 31,32 Additional imaging (e.g.,
radiographs, ultrasound, computed tomography scan) and test-
ing (e.g., complete blood examination, c-reactive protein,
bacterial culture and sensitivity testing) can aid in assessment
and diagnosis.29,30 Penicillin derivatives remain the empirical
choice for odontogenic infections; however, consideration of
additional adjunctive antimicrobial therapy such as metro-
nidazole can be given for anaerobic bacterial involvement.24,35
Cephalosporins could be considered as an alternative choice
for management of odontogenic infections, especially when a
child has had previous course(s) of penicillin/amoxicillin or
if the child has a penicillin allergy.35
Avulsions
Systemic antibiotics have been recommended as adjunctive
therapy for avulsed permanent incisors with an open or closed
apex.15 Amoxicillin or penicillin is the drug of choice due to
effectiveness against oral flora and low incidence of adverse
effects. 15 Doxycycline is recommended as an alternative to
penicillin. 15 Doxycycline exhibits antimicrobial, anti-
inflammatory, and antiresorptive properties which make its
use appropriate for dental trauma.15,36 Using topical antibiotics
(minocycline or doxycycline) to enhance pulpal revasculari-
zation and periodontal healing in immature nonvital
traumatized teeth has shown potential in animal studies, but
usage has not been proven effective in human studies, remains
controversial, and has not been recommended by the
International Association of Dental Traumatology.15 Further
randomized clinical trials are needed. 15 Antibiotics can be
warranted in cases of concomitant soft tissue injuries (see
Oral wounds) and when dictated by the patient’s medical
status.
BEST PRACTICES: USE OF ANTIBIOTIC THERAPY
Pediatric periodontal diseases
Three distinct forms of periodontal disease have been defined
as: (1) periodontitis (grouping the two forms formerly recog-
nized as aggressive or chronic); (2) necrotizing periodontitis;
and (3) periodontitis as a manifestation of systemic disease.37
Patients diagnosed with what formerly was known as aggres-
sive periodontal disease may require adjunctive antimicrobial
therapy in conjunction with localized treatment.38-40 In pedi-
atric periodontal diseases associated with systemic conditions
(e.g., severe congenital neutropenia, Papillon Lefèvre syndrome,
leukocyte adhesion deficiency), the immune system is unable
to control the growth of periodontal pathogens and, in some
cases, treatment may involve antibiotic therapy or antibiotic
prophylaxis.10,38 Culture and susceptibility testing of isolates
from the involved sites are helpful in guiding the drug selec-
tion.41 In severe and refractory cases, extraction is indicated.41
Viral diseases
Conditions of viral origin such as acute primary herpetic gin-
givostomatitis should not be treated with antibiotic therapy.11
Salivary gland infections
For acute salivary gland swellings of bacterial nature, antibiotic
therapy is indicated.42 If the patient does not improve in 24-48
hours on antibiotics alone, incision and drainage may be war-
ranted.5 Amoxicillin/clavulanate is used as empirical therapy
to cover both staphylococcal and streptococcal species as most
bacterial infections of the salivary glands originate from oral
flora.42
The most common inflammatory salivary gland disorder
in the United States is juvenile recurrent parotitis (JRP), with
first onset of symptoms between the ages of three and six,
continuing to puberty.43 Although JRP is self-limiting, admin-
istration of `-lacatam antibiotics may shorten symptom
duration.43 For both acute bacterial submandibular sialadenitis
and chronic recurrent submandibular sialadenitis, antibiotic
therapy is included as part of the treatment.44
Oral contraceptive use
Although caution previously was advised with the concomitant
use of antibiotics and oral contraceptives,45,46 a 2018 systematic
review of drug interactions between non-rifamycin antibiotics
and hormonal contraception found that most women can
expect no reduction in hormonal contraceptive effect with
the concurrent use of non-rifamycin antibiotics.47 The World
Health Organization also reported in 2015 that most broad-
spectrum antibiotics do not affect the contraceptive effective-
ness of combined oral contraceptives, combined contraceptive
patch, or the combined contraceptive vaginal ring.48 In addition,
no differences in ovulation were found when oral contraceptives
were combined with ampicillin, doxycycline, temafloxacin,
ofloxacin, ciprofloxacin, clarithromycin, roxithromycin, diri-
thromycin, or metronidazole.47 Women should be encouraged
to take oral contraceptives correctly and consistently at all times,
including during periods of illness. 47 Rifamcyin antibiotics,
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 497
BEST PRACTICES: USE OF ANTIBIOTIC THERAPY
such as rifampin or rifabutin, induce hepatic enzymes that are
required for hormonal contraceptive metabolism, which could
compromise the contraceptive or antibiotic effect.47,48 Con-
sultation with the medical practitioner regarding use of other
contraceptives is recommended with long-term use of these
medications.48
References
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2. American Academy of Pediatric Dentistry. Useful med-
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3. American Academy of Pediatric Dentistry. Appropriate
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4. American Academy of Pediatric Dentistry. Use of anti-
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5. Centers for Disease Control and Prevention. Antibiotic/
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7. Aidasani B, Solankis M, Khetarpal S, Ravi Pratap S. An-
tibiotics: Their use and misuse in paediatric dentistry. A
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8. Suda KJ, Calip GS, Zhou J, et al. Assessment of the
appropriateness of antibiotic prescriptions for infection
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9. Wilson WR, Gweitz M, Lockhart PB, et al. Prevention
of viridans group streptococcal infective endocarditis: A
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tion. Circulation 2021;143(20):e963-e978. Available at:
“https://www.ahajournals.org/doi/pdf/10.1161/ CIR.000
0000000000969”. Accessed March 26, 2022. Erratum
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10. Squire JD, Gardner PJ, Moutsopoulos NM, Leiding JW.
Antibiotic prophylaxis for dental treatment in patients
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11. Centers for Disease Control and Prevention. Antibiotic
Prescribing and Use. Antibiotic Use in Outpatient Set-
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12. Lovegrove MC, Geller A, Fleming-Dutra KE, Shehab N,
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dren, 2011-2015. J Pediatric Infect Dis Soc 2019;8(5):
384-91.
13. Ahmadi H, Ebrahimi A, Ahmadi F. Antibiotic therapy in
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14. Akhavan BJ, Khanna NR, Vijhani P. Amoxicillin. [Updated
2021 Aug 17]. In: StatPearls [Internet]. Treasure Island,
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“https:// www.ncbi.nlm.nih.gov/books/NBK482250/”.
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15. 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. Dental Traumatology 2020;36(4):
331-42.
16. Todd SR, Dahlgren FS, Traeger MS, et al. No visible
dental staining in children treated with doxycycline for
suspected Rocky Mountain Spotted Fever. J Pediatr
2015;166(5):1246-51. Available at: “https://doi: 10.1016/
j.jpeds.2015.02.015”. Accessed January 24, 2022.
17. American Academy of Pediatrics. Tetracyclines. In: Kim-
berlin DW, Barnett ED, Lynfield R, Sawyer MH, eds.
Red Book: 2021-2024 Report of the Committee on
Infectious Diseases. Elk Grove Village, Ill.: American
Academy of Pediatrics; 2021:905-6.
18. Stultz JS, Eiland LS. Doxycycline and tooth discoloration
in children: Changing of recommendations based on
evidence of safety. Ann Pharmacother 2019;53(11):
1162-6. Available at: “https://doi: 10.1177/1060028019
863796”. Accessed September 26, 2021.
19. Zeng L, Xu P, Choonara I, et al. Safety of azithromycin in
pediatrics: A systematic review and meta-analysis. Eur J
Clin Pharmacol 2020;76(12):1709-21.
20. Bartold PM, du Bois AH, Gannon S, Haynes DR, Hirsch
RS. Antibacterial and immunomodulatory properties of
azithromycin treatment implications for periodontitis.
Inflammopharmacology 2013;21(4):321-38.
21. Centers for Disease Control and Prevention, National Center
for Emerging and Zoonotic Infectious Diseases. Division
of Healthcare Quality Promotion. Checklist for antibiotic
prescribing in dentistry. 2019. Available at: “https://www.
cdc.gov/antibiotic-use/community/downloads/dental-fact
-sheet-FINAL.pdf ”. Accessed March 11, 2022
22. Kuriyama T, Karasawa T, Nakagawa K, Saiki Y, Yamamoto
E, Nakamura S. Bacteriological features and antimicrobial
susceptibility in isolates from orofacial odontogenic infec-
tions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000;90(5):600-8.
23. Prieto-Prieto J, Calvo A. Microbiological basis of oral
infections and sensitivity to antibiotics. Med Oral Patol
Oral Cir Bucal 2004;9(suppl S):11-8.

24. American Academy of Pediatrics. Group A Streptococcal
Infections. In: Kimberlin DW, Barnett ED, Lynfield R,
Sawyer MH, eds. Red Book: 2021-2024 Report of the
Committee on Infectious Diseases. Elk Grove Village, Ill.:
American Academy of Pediatrics; 2021:694-915.
25. Engleberg NC. Strategies to combat bacterial infections.
In: Engleberg NC, DiRita VJ, Imperiale MJ, eds.
Schaechter’s Mechanisms of Microbial Disease. 6th ed.
Philadelphia, Pa.: Wolters-Kluwer; 2022:436.
26. American Academy of Pediatric Dentistry. Record
keeping. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:521-8.
27. Nakamura Y, Daya M. Use of appropriate antimicrobials
in wound management. Emerg Med Clin North Am
2007;25(1):159-76.
28. Fluent MT, Jacobsen PL, Hicks LA. Considerations for
responsible antibiotic use in dentistry. J Am Dent Assoc
2016;147(8):683-6.
29. Johri A, Piecuch JF. Should teeth be extracted immediately
in the presence of acute infection? Oral Maxillofac Surg
Clin North Am 2011;23(4):507-11.
30. Thikkurissy S, Rawlins JT, Kumar A, Evans E, Casamassimo
PS. Rapid treatment reduces hospitalization for pediatric
patients with odontogenic-based cellulitis. Am J Emerg
Med 2010;28(6):668-72.
31. Adewumi AO. Oral surgery in children. In: Nowak AJ,
Christensen JR, Mabry TR, Townsend JA, Wells MH, eds.
Pediatric Dentistry Infancy through Adolescence. 6th ed.
St Louis, Mo.: Elsevier; 2019:399-409.
32. Baker S, Parico L. Pathologic paediatric conditions asso-
ciated with a compromised airway. Int J Paediatr Dent.
2010;20(2):102-11.
33. Solankis M, Khetarpal S, Ravi Pratap S. Antibiotics: Their
use and misuse in paediatric dentistry. A systematic review.
Eur J Paediatr Dent 2019;20(2):133-8.
34. Zirk M, Buller J, Goeddertz P, et al. Empiric systemic an-
tibiotics for hospitalized patients with severe odontogenic
infections. J Craniomaxillofac Surg 2016;44(8):1081-8.
35. Andreason JO, Storgaard Jensen S, Sae-Lim V. The role
of antibiotics in presenting healing complications after
traumatic dental injuries: A literature review. Endod
Topics 2006;14:80-92.
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36. Caton JC, Armitage G, Berglundh T, et al. A new classifi-
cation scheme for periodontal and peri-implant diseases
and conditions: Introduction and key changes from the
1999 classification. J Periodontol 2018;89(Suppl 1):
S1-S8.
37. American Academy of Pediatric Dentistry. Classification of
periodontal diseases in infants, children, adolescents, and
individuals with special health care needs. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:451-65.
38. Keestra JAJ, Grosjean I, Coucke W, Quirynen M, Teughels
W. Non-surgical periodontal therapy with systemic anti-
biotics in patients with untreated aggressive periodontitis:
A systematic review and meta-analysis. J Periodont Res
2015;50(6):689-706.
39. Rabelo CC, Feres M, Gocalves C, et al. Systematic anti-
biotics in the treatment of aggressive periodontitis. A
systematic review and a Bayesian Network meta-analysis.
J Clin Periodontol 2015;42(7):647-57.
40. Schmidt JC, Walter C, Rischewski JR, Weiger R. Treat-
ment of periodontitis as a manifestation of neutropenia
with or without systemic antibiotics: A systematic review.
Pediatr Dent 2013;35(2):E54-E63.
41. Patel A, Karlis V. Diagnosis and management of pediatric
salivary gland infections. Oral Maxillofacial Surg Clin
North Am 2009;21:345-52
42. Garavello W, Redaelli M, Galluzzi, F. Juvenile recurrent
parotitis: A systematic review of treatment studies. Int J
Pediatr Otorhinolaryngol 2018;112:151-7.
43. Carlson ER. Diagnosis and management of salivary gland
infections. Oral Maxillofac Surg Clin North Am 2009;21
(3):293-312.
44. DeRossi SS, Hersh EV. Antibiotics and oral contraceptives.
Pediatr Clin North Am 2002;46(4):653-64.
45. Becker DE. Adverse drug interactions. Anesth Prog 2011;
58(1):31-41.
46. Simmons K, Haddad L, Nanda K, Curtis, K. Drug inter-
actions between non-rifamycin antibiotics and hormonal
contraception: A systematic review. Am J Obstet Gynecol
2018;218(1):88-97.
47. World Health Organization. Medical Eligibility Criteria
for Contraceptive Use. 5th ed. Geneva, Switzerland: World
Health Organization; 2015. Available at: “https:// www.
who.int/ reproductivehealth/publications/family _planning/
MEC-5/en/”. Accessed January 24, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 499
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-
2022 phylaxis for dental patients at risk for infection. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:500-6.

Abstract
This best practice offers recommendations regarding antibiotic prophylaxis to minimize or eliminate transient bacteremia in at-risk dental
patients undergoing invasive dental procedures. Evidence supporting the efficacy and use of antibiotic prophylaxis is limited among children.
Considering the potential to contribute to antibiotic-resistant microorganisms and possible risk of adverse events, prudence is needed when
determining whether prophylaxis is necessary. Antibiotic prophylaxis is warranted for some patients with cardiac conditions and compromised
immunity when undergoing dental procedures that involve the manipulation of gingival tissue or the periapical region of teeth or perforation
of oral mucosa. While recommendations for certain conditions are discussed within the document, consultation with the patient’s physician
is recommended for management of other patients potentially at risk due to immune compromise, indwelling vascular catheters or shunts,
or implanted devices. Dentists should be familiar with current evidence-based antibiotic prophylaxis recommendations, and specific antibiotic
regimens aimed at the microorganisms mainly implicated in infective endocarditis are included.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance on antibiotic prophylaxis for dental patients at risk for infection.
KEYWORDS: PREMEDICATIONS, ANTIBIOTICS, ANTIBIOTIC PROPHYLAXIS, ENDOCARDITIS, ANTIMICROBIAL RESISTANCE

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes that numerous medical conditions predispose patients
to bacteremia-induced infections. Prophylactic antibiotics are
recommended when patients with a high risk of adverse
outcomes from bacteremia and infection undergo invasive oral/
dental procedures. These recommendations are intended to
help practitioners make decisions regarding antibiotic pro-
phylaxis for dental patients at risk.
Methods
Recommendations on antibiotic prophylaxis for dental patients
at risk for infection were developed by the Clinical Affairs
Committee, adopted in 19901, and last revised in 20192. This
revision is based on a review of Prevention of Infective Endo-
carditis: Guidelines from the American Heart Association3,
Infective Endocarditis in Childhood: 2015 Update: A Scientific
Statement From the American Heart Association4, the American
Dental Association (ADA) report The Use of Prophylactic Anti-
biotics Prior to Dental Procedures in Patients with Prosthetic
Joints5, and the 2021 guideline on Prevention of Viridans Group
Streptococcal Infective Endocarditis: A Scientific Statement From
the American Heart Association6. It also included PubMed /
MEDLINE database searches using key terms: infective endo-
® AAPD: American Academy of Pediatric Dentistry. ADA: American
carditis (IE), bacteremia, antibiotic prophylaxis, and dental
infection. Articles were evaluated by title and/or abstract
and relevance to dental care for children, adolescents, and
those with special health care needs. Two hundred forty-three
articles met these criteria. When data did not appear sufficient
or were inconclusive, recommendations were based upon expert
and/or consensus opinion by experienced researchers and
clinicians.
Background
Bacteremia (bacteria in the bloodstream) is anticipated follow-
ing invasive dental procedures and can lead to complications
in an immunodeficient patient.7,8 High-risk cardiac disease,
immunosuppression, and immunodeficiencies may compromise
one’s ability to fight simple infection. The rationale for anti-
biotic prophylaxis is to reduce or eliminate transient bacteremia
caused by invasive dental procedures.9,10
Antibiotic usage may result in the development of resistant
organisms.11 Utilization of antibiotic prophylaxis for patients
at risk does not provide absolute prevention of infection.
Postprocedural symptoms of acute infection (e.g., fever,
malaise, weakness, lethargy) may indicate antibiotic failure
and need for further medical evaluation.
ABBREVIATIONS
Dental Association. AHA: American Heart Association. CIED: Cardio-
vascular implantable electronic device. GI: Gastrointestinal. GU:
Genitourinary. IE: Infective endocarditis. VGS: Viridans group
Streptococcal.

500 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


The decision to use antibiotic prophylaxis should be made
on an individual basis. Some medical conditions that may
predispose patients to postprocedural infections 12 are dis-
cussed below. This list is not intended to be exhaustive;
rather, the categorization should help practitioners identify
children who may be at increased risk. If a patient reports a
syndrome or medical condition with which the practitioner is
not familiar, it is appropriate to discuss the risk and suscep-
tibility to bacteremia-induced infections with the child's
physician prior to any invasive dental procedures.
To date, randomized controlled clinical trials supporting the
efficacy and use of antibiotic prophylaxis are limited, especially
in the pediatric population. Many recommendations are based
on expert consensus.4,6,10,13-16 A study found 80 percent of pre-
procedural antibiotic prescriptions unnecessary as risk-factors
were not present, highlighting a concern regarding the appro-
priateness of prescribed prophylaxis. 17 Conservative use of
antibiotics helps minimize the risk of developing resistance to
current antibiotic regimens.3,18-20 Given the increasing number
of organisms that have developed resistance to antibiotic regi-
mens, as well as the potential for an adverse anaphylactic
reaction to the drug administered21, antibiotic/antimicrobial
stewardship and the judicious use of antibiotics for the preven-
tion of IE or other distant-site infections are critical for safe
and effective care.6,11,17,18 While use of antibiotic prophylaxis is
indicated for certain patients undergoing invasive dental pro-
cedures, the prevention of oral disease by maintenance of good
home care habits and regular dental care is considered more
important.6,22 This may prevent the frequent need for the use
of antibiotic therapy and, thus, decrease the risks of resistance
and adverse events related to use of antibiotics.9,16,23
Recommendations
Antibiotic prophylaxis for patients at the highest risk of adverse
outcomes from bacteremia-induced infections is recommended
with certain dental procedures3,4,6,7,9,16,24 and should be directed
against the most likely infecting organism. Antibiotic steward-
ship and judicious use are integral to preventing adverse
reactions and resistance. Table 1 shows the recommended antibi-
otic regimen for at-risk patients undergoing invasive procedures,
with amoxicillin as the first choice.6,10 Recent changes to the
American Heart Association (AHA) guidelines have removed
the use of clindamycin due to frequent and severe reactions.6
Clindamycin has been associated with significant adverse drug
reactions related to community-acquired Clostridium difficile
infections.21 Doxycycline is recommended as an alternative
for patients unable to tolerate a penicillin, cephalosporin, or
macrolide (Table 1).6 Short-term use (less than 21 days) of
doxycycline had not been associated with tooth discoloration
in children under eight years of age.25-27 Antibiotic prophylaxis
should be given 30-60 minutes prior to the procedure; however,
it can be given up to two hours after a dental procedure.6 A
different class of antibiotics is indicated if the patient is already
on oral antibiotic therapy or has an allergy or anaphylactic
reaction.6 If unsure of a reported history of an allergic reaction,
BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS
consultation with an allergy specialist and skin testing can help
determine severity of allergic reactions and course of antibiotic
regimen.6 If the patient is receiving parenteral antimicrobial
therapy for IE or other infections, the same antibiotic can be
continued for the dental procedure.6 If possible, elective pro-
cedures should be delayed 10 days after completion of short
course antibiotic therapy.6 When procedures involve infected
tissues or are performed on a patient with a compromised
host response, additional doses or a prescribed pre- and post-
operative course of antibiotics may be necessary.
Patients with cardiac conditions
The AHA has published guidelines for the prevention of IE
and reducing the risk of producing resistant strains of bacte-
ria.3,6 IE is an example of an uncommon but life-threatening
complication resulting from bacteremia. The incidence of pedi-
atric admissions due to IE was between 0.05 and 0.12 cases per
1000 admissions in a multicenter study of United States
children’s hospitals from 2003-2010.4 Although there is no
high-quality data showing mortality from or frequency of
viridans group streptococcal (VGS) infective endocarditis in
children, there also has been no convincing evidence of an
increase in these cases among high-risk patients since the
publication of the 2007 AHA guidelines.6,10,28
Only a limited number of bacterial species have been im-
plicated in resultant postoperative infections; viridans group
streptococci, Staphylococcus aureus and Enterococcus species are
the main microorganisms implicated in IE.3,4,29 Enterococcal
and other organisms such as Haemophilus species, Aggregati-
bacter species, Cardiobacterium hominis, Eikenella corrodens,
and Kingella species are less common.4 When compared to
dental procedures, routine daily activities such as toothbrush-
ing, flossing, and chewing contribute more to the incidence of
bacteremia.4 Thus, focus for preventing IE has shifted from
antibiotic prophylaxis to an emphasis on oral hygiene and the
prevention of oral diseases with regular dental care.4,6,9,14-16,24
A summary of key findings and suggestions by the AHA
2021 scientific statement writing group are outlined in
Table 2.
The AHA guidelines recommend antibiotic prophylaxis
prior to certain dental procedures (Table 3) for patients with
the highest risk of adverse outcomes from VGS IE (Table
4).6,20 Comorbidities such as obesity, diabetes, cardiopulmonary
disease, vascular disease, hemodialysis, lack of access to tertiary
hospitals, or immunosuppression affect the morbidity and
mortality of patients with IE.7,20 Global consensus with regards
to the benefit of antibiotic prophylaxis for prevention of IE is
lacking.6,9,16,24,28
Children with cyanosis with specific periodontal concerns
may have an increased risk of IE.3,4,6 At-risk patients with poor
oral hygiene and gingival bleeding after routine activities (e.g.,
toothbrushing) have shown an increased incidence of bac-
teremia as a measure for risk of IE. 3,29 These patients and
their parents need to be educated and motivated to maintain
personal oral hygiene, including flossing and regular professional
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 501
BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS

Table 1. ANTIBIOTIC REGIMENS FOR A DENTAL PROCEDURE REGIMEN: SINGLE DOSE 30 TO 60 MINUTES
BEFORE PROCEDURE
Situation Agent Adults Children
Oral Amoxicillin 2g 50 mg/kg
Ampicillin OR 2 g IM or IV 50 mg/kg IM or IV
Unable to take oral medication
Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV

Cephalexin* † OR 2g 50 mg/kg
Allergic to penicillin or ampicillin
Azithromycin or clarithromycin OR 500 mg 15 mg/kg
—oral
Doxycycline 100 mg < 45 kg, 2.2 mg/kg
> 45 kg, 100 mg
Allergic to penicillin or ampicillin Cefazolin or ceftriaxone† 1 g IM or IV 50 mg/kg IM or IV
and unable to take oral medication

Clindamycin is no longer recommended for antibiotic prophylaxis for a dental procedure.

IM indicates intramuscular; and IV, intravenous.
* Or other first-or second-generation oral cephalosporin in equivalent adult or pediatric dosing.
† Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin.

Table 2. SUMMARY OF FINDINGS AND SUGGESTIONS

Key findings
VGS IE is much more likely to develop as a result of transient VGS bacteremia attributable to routine daily activities
such as chewing food and toothbrushing than from a dental procedure.
An exceedingly small number of cases of VGS IE could be prevented by AP for a dental procedure, even if
prophylaxis is 100% effective.
If AP for a dental procedure is effective in preventing a very small number of cases of VGS IE, it should be
suggested only for those patients with the highest risk of adverse outcome from VGS IE.
There is no convincing evidence of an increased frequency of or morbidity or mortality from VGS IE in patients
at low, moderate, or high risk of adverse outcome since publication of the 2007 document.
AP for a dental procedure is not suggested solely on the basis of an increased lifetime risk of acquisition of VGS IE

Suggestions
AP for a dental procedure that involves manipulation of gingival tissues, periapical region of teeth, or perforation
of the oral mucosa is suggested only for patients with the highest risk of adverse outcome from VGS IE.
Maintenance of good oral health and regular access to dental care are considered more important to prevent VGS
IE than AP for a dental procedure. We suggest that patients have biannual dental examinations when such care
is available.
Shared decision making is important between patients and health care providers. There may be instances when a
health care provider and a patient disagree with the suggestions in the 2021 scientific statement. In these cases,
the health care provider should be familiar with and understand the 2021 suggestions to adequately inform
patients of the risks and benefits of AP for a dental procedure so that an informed decision may be made.

AP indicates antibiotic prophylaxis; IE=Infective endocarditis; VGS=Viridans group streptococcal.

Table 3. DENTAL PROCEDURES AND AP

AP suggested
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation
of the oral mucosa.

AP not suggested
Anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prostho-
dontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets,
shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa.

The antibiotic regimens suggested for prophylaxis for a dental procedure in patients at a high risk of adverse outcome from viridans
group streptococcal infective endocarditis are shown in Table 1.
AP indicates antibiotic prophylaxis.

All tables reprinted with permission. © 2021 American Heart Association, Inc.
Circulation 2021;143(20):e963-e978. Erratum in: Circulation 2021;144(9):e192. Available at: "https://www.ahajournals.org/doi/10.1161/CIR.0000000000000969".
 BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS

Table 4. AP FOR A DENTAL PROCEDURE: UNDERLYING CONDITIONS FOR WHICH AP IS SUGGESTED

Prosthetic cardiac valve or material

Presence of cardiac prosthetic valve
Transcatheter implantation of prosthetic valves
Cardiac valve repair with devices, including annuloplasty, rings, or clips
Left ventricular assist devices or implantable heart
Previous, relapse, or recurrent IE
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 transcatheter
during the first six months after the procedure
Repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device
Surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit

Cardiac transplantation recipients who develop cardiac valvulopathy

AP for a dental procedure not suggested

Implantable electronic devices such as a pacemaker or similar devices

Septal defect closure devices when complete closure is achieved
Peripheral vascular grafts and patches, including those used for hemodialysis
Coronary artery stents or other vascular stents
CNS ventriculoatrial shunts
Vena cava filters
Pledgets

AP=indicates antibiotic prophylaxis; CHD=congenital heart disease; CNS=central nervous system; and IE=Infective endocarditis.

Table reprinted with permission. © 2021 American Heart Association, Inc.

Circulation 2021;143(20):e963-e978. Erratum in: Circulation 2021;144(9):e192. Available at: "https://www.ahajournals.org/doi/10.1161/CIR.0000000000000969".

preventive dental care, and to be discouraged from getting
tattoos or piercings.3,6,14-16,23,24 Professional prevention strategies
should be based upon the individual’s assessed risk for caries
and periodontal disease.30
In addition to those diagnoses listed in the AHA guidelines,
patients with a reported history of injection drug use may be
considered at risk for developing IE.20 Consultation with the
patient’s physician may be necessary to determine suscepti-
bility to bacteremia-induced infections.
Antibiotics are recommended for all dental procedures that
involve manipulation of gingival tissue or the periapical region
of teeth or perforation of the oral mucosa for cardiac patients
with the highest risk for adverse outcomes from IE3,6 (Tables
3 and 4). Specific antibiotic regimens can be found in Table
3. Practitioners and patients/ parents can review the entire
AHA guidelines in the AHA Circulation archives6 (available
at “https://www.ahajournals.org/doi/10.1161/CIR.000000000
0000969") for additional background information as well as
discussion of special circumstances (e.g., patients already re-
ceiving antibiotic therapy, patients on anticoagulant therapy).
Patients with shunts, indwelling vascular catheters, or
medical devices
The AHA found no convincing evidence that microorgan-
isms associated with dental procedures cause infection of
cardiovascular implantable electronic devices (CIED) and non-
valvular devices at any time after implantation.6,29,31 The infec-
tions occurring after device implantation most often are caused
by Staphylococcus aureus and coagulase-negative staphylococci or
other microorganisms that are non-oral in origin but are asso-
ciated with surgical implantation or other active infections.29,32
The AHA does not recommend antibiotic prophylaxis for
prosthetic cardiovascular devices such as CIED, septal defect
closure devices, peripheral vascular grafts and patches, central
nervous system ventriculoatrial shunts, vena cava filters and
pledgets. (Table 4) Consultation with the child’s physician is
recommended for management of patients with nonvalvular
devices.
Ventriculoatrial (VA), ventriculocardiac (VC), or ventricu-
lovenus (VV) shunts for hydrocephalus were considered at
risk of bacteremia-induced infections due to their vascular
access, while ventriculoperitoneal (VP) shunts were not
deemed vulnerable.31,33 Antibiotic prophylaxis is no longer
recommended for patients with VA and VP shunts.6,33 If con-
cerned, consultation with the child’s physician is recommended
for management of patients with vascular shunts.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 503

BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS
Table 5. 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”.
Patients with compromised immunity
Noncardiac patients with a compromised immune system may
be at risk for complications of bacteremia and distant site
infection following invasive dental procedures. Existing evidence
does not support the extensive use of antibiotic prophylaxis;
prophylaxis should be limited to immunocompromised
patients and those at high risk for adverse outcomes from
distant site infection. 23 Consultation with the patient’s
physician is recommended for management of patients with
a compromised immune system. High-risk patients who
should be considered for use of prophylaxis includes, but is
not limited to, those with6,14,15,22,31:
1. immunosuppression* secondary to:22,34
a. human immunodeficiency virus (HIV);
b. severe combined immunodeficiency (SCIDS)
and other primary immunodeficiency diseases;
c. neutropenia and other neutrophil-related disor-
ders (e.g., severe congenital neutropenia, leukocyte
adhesion deficiency, Chédiak-Higashi syndrome);
d. cancer chemotherapy, immunosuppressive therapy
and/or radiation therapy; or
e. hematopoietic stem cell or solid organ trans-
plantation.
2. history of head and neck radiotherapy.22,34
3. autoimmune disease (e.g., juvenile arthritis, systemic
lupus erythematosus).
4. sickle cell anemia.35,36
5. asplenism, status post splenectomy, or complement
deficiencies.22
504 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
6. chronic high-dose steroid usage.
7. uncontrolled diabetes mellitus.
8. medication-related osteonecrosis of the jaw
(MRONJ).37,38
9. hemodialysis.
Patients with prosthetic joints
Given the lack of evidence and recognizing the increase in
antibiotic resistance and adverse drug reactions, antibiotic
prophylaxis prior to dental procedures is no longer recom-
mended for patients with a history of total joint arthroplasty
or prosthetic joint infections.5,17,39 (Table 5) If unsure of med-
ical history or risk, consultation with the child’s physician is
recommended for invasive dental management.5,31,39,40
References
1. American Academy of Pediatric Dentistry. Antibiotic
chemoprophylaxis for pediatric dental patients. Boston,
Mass.: American Academy of Pediatric Dentistry; 1990.
2. American Academy of Pediatric Dentistry. Antibiotic
prophylaxis for dental patients at risk for infection. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2019:416-21.
3. Wilson W, Taubert KA, Gevitz M, et al. Prevention of in-
fective endocarditis: Guidelines from the American Heart
Association—A Guideline from the American Heart
Association Rheumatic Fever, Endocarditis and Kawasaki
Disease Committee, Council on Cardiovascular Disease
in the Young, and the Council on Clinical Cardiology,

Council on Cardiovascular Surgery and Anesthesia, and
the Quality of Care and Outcomes Research Interdis-
ciplinary Working Group. Circulation 2007;116(15):
1736-54. E-published April 19, 2007. Available at:
“https://www.ahajournals.org/doi/full/10.1161/CIR
CULATIONAHA.106.183095#”. Accessed September
22, 2022. Erratum in Circulation 2007;116(15):e376-e7.
4. Baltimore RS, Gweitz M, Baddour LM, et al. Infective
endocarditis in childhood: 2015 update: A scientific
statement from the American Heart Association. Circu-
lation 2015;132(15):1487-515.
5. Sollecito TP, Abt E, Lockhart PB, et al. The use of pro-
phylactic antibiotics prior to dental procedures in patients
with prosthetic joints: Evidence-based clinical practice
guideline for dental practitioners–A report of the
American Dental Association Council on Scientific
Affairs. J Am Dent Assoc 2015;146(1):11-6.
6. Wilson WR, Gweitz M, Lockhart PB, et al. Prevention
of viridans group streptococcal infective endocarditis:
A scientific statement from the American Heart Associ-
ation. Circulation 2021;143(20)e963-e978. Available
at: “https://www.ahajournals.org/doi/pdf/10.1161/CIR.
0000000000000969”. Accessed March 26, 2022.
Erratum in: Circulation 2021;144(9):e192.
7. Lockhart PB, Brennan MT, Kent ML, Norton JH,
Weinrib DA. Impact of amoxicillin prophylaxis on the
incidence, nature, and duration of bacteremia in children
after intubation and dental procedures. Circulation 2004;
109(23):2878-84.
8. Roberts GJ, Jaffrey EC, Spract DA, Petrie A, Greville C,
Wilson M. Duration, prevalence and intensity of bac-
teremia after dental extractions in children. Heart 2006;
92(9):1274-7.
9. Daly CG. Antibiotic prophylaxis for dental procedures.
Aust Prescr 2017;40(5):184-8.
10. Laufaurie GI, Noriega LA, Torres CC, et al. Impact of
antibiotic prophylaxis on the incidence, nature, magnitude,
and duration of bacteremia associated with dental pro-
cedures: A systematic review. J Am Dent Assoc 2019;150
(11):948-59.
11. Centers for Disease Control and Prevention. Antimicro-
bial resistance. About antimicrobial resistance: A brief
overview. December, 2021. Available at: “https://www.
cdc.gov/drugresistance/about.html”. Accessed January 24,
2022.
12. Buonavoglia A, Leone P, Solimando AG, et al. Antibiotics
or no antibiotics, that is the question: An update on effi-
cient and effective use of antibiotics in dental practice.
Antibiotics (Basel) 2021;10(5):550.
13. Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington
HV. Antibiotics for the prophylaxis of bacterial endocar-
ditis in dentistry. Cochrane Database System Rev 2013;
4(10):CD003813. Available at: “https://doi-org.proxy.
library.adelaide.edu.au/10.1002/14651858.CD003813
pub4”. Accessed March 8, 2022.
BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS
14. Cahill TJ, Dayer M, Prendergast B, Thornhill M. Do
patients at risk of infective endocarditis need antibiotics
before dental procedures? BMJ 2017;358:j3942.
15. Cahill TJ, Harrison JL, Jewell P, et al. Antibiotic prophy-
laxis for infective endocarditis: A systematic review and
meta-analysis. Heart 2017;103(12):937-44.
16. National Institute for Health and Care Excellence. Con-
text In: Prophylaxis against infective endocarditis:
Antimicrobial prophylaxis against infective endocarditis in
adults and children undergoing interventional procedures.
2008. Updated July 8, 2016. London: NICE. Available
at: “https://www.nice.org.uk/guidance/cg64”. Accessed
January 24, 2022.
17. Suda KJ, Calip GS, Zhou J, et al. Assessment of the
appropriateness of antibiotic prescriptions for infection
prophylaxis before dental procedures, 2011 to 2015.
JAMA Netw Open 2019;2(5):e193909.
18. Fluent MT, Jacobsen PL, Hicks LA. Considerations for
responsible antibiotic use in dentistry. J Am Dent Assoc
2016;147(8):683-6.
19. Watters W, Rethman MP, Hanson NB, et al. Prevention of
orthopaedic implant infection in patients undergoing
dental procedures. J Am Acad Orthop Surg 2013;21(3):
180-9.
20. Baddour LM, Shafiyi A, Lahr BD, et al. A contemporary
population-based profile of infective endocarditis using
the expanded Rochester Epidemiology Project. Mayo
Clin Proc 2021;96(6):1438-45.
21. Thornhill MH, Dayer MJ, Prendergast B, Baddour LM,
Jones S, Lockhart PB. Incidence and nature of adverse
reactions to antibiotics used as endocarditis prophylaxis.
J Antimicrob Chemother 2015;70(8):2382-8.
22. Squire JD, Gardner PJ, Moutsopoulos NM, Leiding JW.
Antibiotic prophylaxis for dental treatment in patients
with immunodeficiency. J Allergy Clin Immunol Pract
2019;7(3):819-23.
23. Habib G, Hoen B, Tornos P, et al. Guidelines on the
prevention, diagnosis, and treatment of infective endo-
carditis (new version 2009): The Task Force on the
Prevention, Diagnosis, and Treatment of Infective
Endocarditis of the European Society of Cardiology
(ESC). Eur Heart J 2009;30(9):2369-413.
24. National Heart Foundation of New Zealand Advisory
Group. Guideline for the prevention of infective endo-
carditis associated with dental and other medical inter-
ventions. Auckland: National Heart Foundation of New
Zealand. December, 2008. Available at: “http://www.
ttophs.govt.nz/vdb/document/312”. Accessed March 8,
2022.
25. Todd SR, Dahlgren FS, Traeger MS, et al. No visible
dental staining in children treated with doxycycline for
suspected Rocky Mountain Spotted Fever. J Pediatr
2015;166(5):1246-51.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 505
BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS
26. American Academy of Pediatrics. Tetracyclines. Red Book:
2021-2024 Report of the Committee on Infectious Dis-
eases. In: Kimberlin DW, ed, Barnett ED Lynfield R,
Sawyer MH, associate eds. 32nd ed. Elk Grove Village,
Ill.: American Academy of Pediatrics; 2021:978-1-61002-
578-2.
27. Stultz JS, Eiland LS. Doxycycline and tooth discoloration
in children: Changing of recommendations based on
evidence of safety. Ann Pharmacother 2019;53(11):
1162-6
28. Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart
PB, Thornhill MH. Incidence of infective endocarditis in
England, 2000-13: A secular trend, interrupted time-series
analysis. Lancet 2015;385(9974):1219-28.
29. Baddour LM, Epstein AE, Erickson CC, et al. Update
on cardiovascular implantable electronic device infections
and their management. Circulation 2010;121(3):458-77.
30. American Academy of Pediatric Dentistry. Periodicity of
examination, preventive dental services, anticipatory
guidance/counseling, and oral treatment for infants, chil-
dren, and adolescents. The Reference Manual of Pediatric
Dentistry. Chicago, Ill: American Academy of Pediatric
Dentistry; 2022:253-65.
31. Lockhart PB, Loven B, Brennan MT, Fox PC. The
evidence base for the efficiency of antibiotic prophylaxis
in dental practice. J Am Dent Assoc 2007;138(4):458-74.
32. Hong CHL, Allred R, Napenas JJ, Brennan MT, Baddour
LM, Lockhart PB. Antibiotic prophylaxis for dental
procedures to prevent indwelling venous catheter-related
infections. Am J Med 2010;123(12):1128-33.
33. Baddour LM, Bettman MA, Bolger AF, Bolger A, Ferrieri
P. Nonvalvular cardiovascular device-related infections.
Circulation 2003;108(16):2015-31.
506 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
34. American Academy of Pediatric Dentistry. Dental manage-
ment of pediatric patients receiving immunosuppressive
therapy and/or head and neck radiation. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:507-16.
35. Tate AR, Norris CK, Minniti CP. Antibiotic prophylaxis
for children with sickle cell disease: A survey of pediatric
dentistry residency program directors and pediatric hema-
tologists. Pediatr Dent 2006;28(3):332-5.
36. Hsu LL, Fan-Hsu J. Evidence-based dental management
in the new era of sickle cell disease: A scoping review. J
Am Dent Assoc 2020;151(9):668-77.e9.
37. Montefusco V, Gay F, Spina F, et al. Antibiotic prophyl-
axis before dental procedures may reduce the incidence
of osteonecrosis of the jaw in patients with multiple
myeloma treated with bisphosphonates. Leuk Lymphoma
2008;49(11):2156-62.
38. Yarom N, Shapiro CL, Peterson DE, et al. Medication-
related osteonecrosis of the jaw: MASCC/ISOO/ASCO
Clinical Practice Guideline. J Clin Oncol 2019;37(25):
2270-90.
39. Rethman MP, Watters W, 3rd, Abt E, et al. The American
Academy of Orthopedic Surgeons and the American
Dental Association clinical practice guideline on the
prevention of orthopaedic implant infection in patients
undergoing dental procedures. J Bone Joint Surg 2013;
95(8):745-7.
40. Berbari EF, Osmon DR, Carr A, et al. Dental procedures
as risk factors for prosthetic hip or knee infection: A
hospital-based prospective case-control study. Clin Infect
Dis 2010;50(1):8-16. Erratum in Clin Infect Dis 2010;
50(6):944.
 BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY

Dental Management of Pediatric Patients Receiving

Immunosuppressive Therapy and /or Head and Neck
Radiation
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Dental man-
2022 agement of pediatric patients receiving immunosuppressive therapy
and/or head and neck radiation. The Reference Manual of Pediatric Den-
tistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:507-16.

Abstract
This best practice provides recommendations for oral health care for children undergoing immunosuppressive therapy and/or head and neck
radiation. These children have unique oral health needs and are at risk of developing multiple associated oral and systemic complications.
Dentists play an essential role in diagnosing, preventing, stabilizing, and treating oral health problems that can compromise a patient’s
quality of life before, during, and following such therapies. All children undergoing immunosuppressive therapy and/or head and neck
radiation should have an oral examination before such treatment commences. Dental interventions must be performed promptly, efficiently,
and with attention to the patient’s unique circumstances and treatment protocol. Preventing new dental problems and treating existing
dental conditions before immunosuppressive therapy and/or head and neck radiation is paramount. Preventive strategies include oral
hygiene, diet, fluoride, and patient education. When completing all dental care prior to therapy is not feasible, priorities should be treatment
of odontogenic and periodontal infections, extractions, periodontal care, and removal of sources of tissue irritation. Recommendations for
management of caries lesions, pulp therapy, orthodontia, periodontal conditions, and extractions are included. Strategies to manage oral
conditions related to immunosuppressive therapies and head and neck radiation are addressed. For children undergoing hematopoietic cell
transplantation, all dental treatment should be completed before the patient becomes immunosuppressed and elective care postponed
until immunological recovery has occurred.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance regarding dental management of pediatric patients receiving immunosuppressive
therapy and/or head and neck radiation.
KEYWORDS: IMMUNOSUPPRESSION, DENTAL CARE, RADIATION THERAPY, MUCOSITIS, TREATMENT PROTOCOL, PHOTOBIOMODULATION

Purpose and associated oral manifestations and appropriately address

The American Academy of Pediatric Dentistry (AAPD)
recognizes that the pediatric dental professional plays an
important role in the diagnosis, prevention, stabilization, and
treatment of oral and dental problems that can compromise
the child’s quality of life before, during, and after immuno-
suppressive therapy and/or head and neck radiation. Immuno-
suppression may be the intended goal of therapies to prevent
rejection of a donor organ or hematopoietic cell transplantation
(HCT), or it may be a consequence of anti-neoplastic chemo-
therapy or HCT conditioning. Children undergoing such
therapies will benefit from dental interventions that are
prompt, efficient, and modified according to the patient’s
medical history, cancer treatment protocol, and health status.
Immunosuppressive therapy and/or head and neck radiation
may cause many acute and long-term side effects in the oral
cavity. Furthermore, any existing or potential sources of oral/
dental infections and/or soft tissue trauma can compromise
medical treatment, leading to greater morbidity and mortality,
as well as higher hospitalization costs. It is imperative that the
pediatric dentist be familiar with the patient’s medical history
dental concerns in conjunction with the patient’s medical team.
Methods
Developed by the Clinical Affairs Committee as Management
of Pediatric Dental Patients Receiving Chemotherapy and/or
Radiation and adopted in 19861, this best practice was last
revised in 20182. This revision is based upon a review of current
dental and medical literature related to immunosuppressive
therapy, head and neck radiation, and best current practice.
The revision by the Council on Clinical Affairs included a
®
new literature search of the PubMed /MEDLINE database
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ANC: Absolute neu-
trophil count. CBC: Complete blood count. GVHD: Graft versus
host disease. HCT: Hematopoietic cell transplantation. MASCC /
ISOO: The Multinational Association of Supportive Care in Cancer/
International Society of Oral Oncology. /mm3: per cubic millimeter.
MRONJ: Medication-related osteonecrosis of the jaw. OM: Oral
mucositis. PBM: Photobiomodulation.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 507

BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
using the terms: pediatric cancer, pediatric oncology, hemato-
poietic cell transplantation, bone marrow transplantation, im-
munosuppressive therapy, mucositis, stomatitis, chemotherapy,
radiotherapy, acute effects, long-term effects, dental care, oral
health, pediatric dentistry, practice guideline; field: all; limits:
within the last 10 years, humans, English, birth through age
18. Two thousand sixty-five articles matched these criteria.
Ninety-five papers were chosen for review from this list and
from the references within selected articles. When data did not
appear sufficient or were inconclusive, recommendations were
based upon expert and/or consensus opinion by experienced
researchers and clinicians.
Background
A multidisciplinary approach involving physicians, nurses,
dentists, social workers, dieticians, and other related health
professionals is essential to care for the child before, during and
after immunosuppressive therapy and/or head and neck
radiation.3,4 Acute and chronic oral complications that may
occur as sequelae of such therapies include oral mucositis
(OM) and associated pain, bleeding, taste dysfunction, oppor-
tunistic infections (e.g., candidiasis, herpes simplex virus),
dental caries, dry mouth (e.g., salivary gland dysfunction,
xerostomia), neurotoxicity, mucosal fibrosis, gingival hyper-
trophy, osteoradionecrosis, medication-related osteonecrosis,
soft tissue necrosis, trismus, craniofacial and dental develop-
mental anomalies, and oral graft versus host disease (GVHD).4-8
All patients undergoing immunosuppressive therapy and/
or head and neck radiation should have an oral examination
prior to initiation of treatment3,4 to identify any existing or
potential source of oral disease or infection that may compli-
cate the patient’s medical treatment.9,10 Every patient requires
an individualized management approach. Consultations with
the patient’s physicians and, when appropriate, other dental
specialists, should be sought before dental care is instituted.4
Additionally, the key to success in maintaining a healthy oral
cavity during therapy is patient compliance. Educating the
child and the parents regarding the possible acute and long-
term side effects of cancer therapies is essential, as this may
improve patient motivation to adhere to oral care protocols
during cancer therapy.8,10-13
Recommendations
Dental and oral care before the initiation of immunosup-
pressive therapy or head and neck radiation
Objectives13,14
The objectives of a dental/oral examination before therapy
starts are three-fold:
• to identify and stabilize or eliminate existing and poten-
tial sources of infection and local irritants in the oral
cavity—without needlessly delaying the treatment or
inducing complications.
• to communicate with the medical team regarding the
patient’s oral health status, plan, and timing of treatment.
508 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• to educate the patient and parents about the importance
of optimal oral care to minimize oral problems and dis-
comfort before, during, and after treatment and to
inform them about the possible acute and long-term
effects of the therapy in the oral cavity and the craniofacial
complex.
Initial evaluation
Medical history review: should include disease/condition (type,
stage, prognosis), treatment protocol (conditioning regimen,
surgery, chemotherapy, location and dose of radiation), medica-
tions (including bisphosphonates and other bone modifying
agents), allergies, surgeries, secondary medical diagnoses,
hematological status (e.g. complete blood count [CBC]),
immunosuppression status, presence of an indwelling venous
access line, and contact of medical team/primary care physi-
cian(s).4 For HCT patients, the type of transplant, HCT source
(i.e., bone marrow, peripheral stem cells, cord blood stem cells),
matching status, donor, conditioning protocol, expected date
of transplant, and GVHD prophylaxis should be elicited.
Dental history review: includes information such as fluoride
exposure, habits, trauma, symptomatic teeth, previous care,
preventive practices, oral hygiene, and diet.
Oral/dental assessment: should include a thorough head,
neck, and intraoral examination, oral hygiene assessment, and
radiographic evaluation based on history and clinical findings.
Preventive strategies
Oral hygiene: Brushing of the teeth and tongue two to three
times daily should be performed with a regular soft nylon-
bristled or electric toothbrush, regardless of hematological
status.11,12,15.16 Ultrasonic brushes and dental floss should only
be allowed if the patient is properly trained.12 If capable, the
patient should gently floss daily. If pain or excessive bleeding
occurs, the patient should avoid the affected area, but floss
the other teeth. 4 Patients with poor oral hygiene and/or
periodontal disease may use chlorhexidine rinses until the
tissue health improves or mucositis develops. 10,17 The high
alcohol content of commercially-available chlorhexidine
mouthwash may cause discomfort and dehydrate the tissues
in patients with mucositis. An alcohol-free chlorhexidine
solution is indicated in this situation.
Diet: Dental practitioners should discuss the importance of
a healthy diet to maintain nutritional status and emphasize
food choices that do not promote caries. Patients and parents
should be advised about the high cariogenic potential of
carbohydrate-rich dietary supplements and sucrose-sweetened
medications.18,19 They should also be instructed that sharp,
crunchy, spicy, and highly-acidic foods and alcohol should
be avoided during chemotherapy, head and neck radiation,
and HCT.4

Fluoride: Preventive measures include the use of fluoridated
toothpaste, fluoride supplements if indicated, neutral fluoride
gels/rinses, or applications of fluoride varnish for patients at
risk for caries and/or dry mouth. A brush-on technique is
convenient and may increase the likelihood of patient com-
pliance with topical fluoride therapy.12
Lip care: Lanolin-based creams and ointments are more
effective in moisturizing and protecting against damage than
petrolatum-based products.20
Trismus prevention/treatment: Patients who receive head and
neck radiation may develop trismus. Thus, daily oral stretch-
ing exercises/physical therapy should start before radiation
is initiated and continue throughout treatment.11,21
Reduction of head and neck radiation to healthy oral tissues:
The use of lead-lined stents, prostheses, and shields, as well as
salivary gland sparing techniques (e.g., three-dimensional
conformal or intensity modulated radiotherapy, concomitant
cytoprotectants, surgical transfer of salivary glands), should be
discussed with the radiation oncologist.
Education: Patient and parent education includes the import-
ance of optimal oral care in order to minimize oral problems
and discomfort before, during, and after treatment and the
possible acute and long-term effects of the therapy in the
craniofacial complex.4,17
Dental care
Dental providers should be aware of the patient’s hematologic
status and related risks of bacteremia and excessive bleeding.
Hematologic management of the patient should be directed
by the patient’s oncologist, and consultation with the medical
team is necessary to determine the need for prophylactic
interventions prior to dental treatment.
In particular, patients who are immunosuppressed may not
be able to tolerate a transient bacteremia following invasive
dental procedures. A decision regarding the need for antibiotic
prophylaxis prior to dental treatment should be made in
consultation with the child’s physician. Unless advised other-
wise, the American Heart Association’s standard regimen to
prevent endocarditis is an acceptable option for the immu-
nocompromised patient.4,16 The following parameters may be
used to guide decisions regarding need for antibiotic prophylaxis:
• Absolute neutrophil count (ANC):
— > 2,000 per cubic millimeter (/mm3): no need for
antibiotic prophylaxis;4,21
— 1,000 to 2,000/mm3: Use clinical judgment based on
the patient’s health status and planned procedures.
Some authors4 suggest that antibiotic coverage may be
prescribed when the ANC is in range. If infection is
present at the site of the planned procedure, a more
aggressive prophylactic antibiotic therapy regimen may
be discussed with the medical team; and
BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
— < 1,000/mm3: defer elective dental care.7,22 In dental
emergencies, discuss management with a course of
antibiotic therapy versus one dose of antibiotics for
prophylactic coverage with the medical team before
proceeding with treatment.
Patients undergoing cancer treatments are at risk for thrombo-
cytopenia. The following parameters may be used to determine
need for pre- and postoperative interventions:
• Platelet count:
— < 60,000/mm3: Defer elective treatment and avoid
invasive procedures when possible. When medically-
necessary dental treatment is required, a hospital set-
ting is most appropriate. Discuss supportive measures
(e.g., platelet transfusions pre- and postoperatively,
bleeding control, hospital admission and care) with
the patient’s physician before proceeding. Localized
hemostatic measures to manage prolonged bleeding may
be utilized (e.g., sutures, hemostatic agents, pressure
packs, microfibrillar collagen, topical thrombin and/or
gelatin foams). Systemic measures (e.g., aminocaproic
acid, tranexamic acid) may be recommended by the
hematologist/oncologist. If platelet transfusions are
administered, the dentist should consult with the
hematologist regarding the need for a posttransfusion
platelet count before the commencement of dental
treatment. Additional transfusions would ideally be
available in the event of excessive and persistent intra-
operative or postoperative bleeding,23
• Other coagulation tests may be in order for individual
patients.
Dental procedures:
• Ideally, all dental care should be completed before im-
munosuppressive therapy is initiated. When that is not
feasible, temporary restorations may be placed and non-
acute dental treatment may be delayed until the patient’s
hematological status is stable.4,24 The patient’s blood
counts typically start falling five to seven days after the
beginning of treatment cycle and stay low for approxi-
mately 14 to 21 days before rising again to normal levels.
Patients who require an organ transplant are best able to
tolerate dental care at least three months after transplant
when overall health improves.3
• Prioritizing procedures: In the event that definitive
dental care would result in a delay of oncologic treatment
and a resultant poorer medical prognosis, providers
may prioritize treatment of symptomatic or potentially
symptomatic caries lesions (risk of irreversible pulpitis),
infections, hopeless teeth (e.g., root tips, nonrestorable
teeth) and removal of sources of tissue irritation before the
treatment of asymptomatic carious teeth (e.g., incipient,
small asymptomatic caries lesions), root canal therapy
for asymptomatic permanent teeth, and replacement of
faulty restorations.7,21,24 It is important for the practitioner
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 509
BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
to be aware that the signs and symptoms of periodontal
disease and infection may be decreased in immunosup-
pressed patients.11,21
• Pulp therapy in primary teeth: Few studies have eval-
uated the safety of performing pulp therapy in primary
teeth prior to the initiation of chemotherapy and/or
head and neck radiation. Many clinicians choose to extract
pulpally-involved carious teeth because of the potential
for pulpal/periapical/furcal infections to become life-
threatening during periods of immunosuppression.12
Asymptomatic teeth that are already pulpally treated
and are clinically and radiographically sound should be
monitored periodically for clinical and radiographic signs
of failure.
• Endodontic treatment in permanent teeth: Symptomatic
nonvital permanent teeth ideally should receive root
canal treatment in a single visit at least one week before
initiation of immunosuppressive therapy to allow suffi-
cient time to assess treatment success.7,21 If that is not
possible, alternative options include pulpectomy and
closure with an antibacterial agent or extraction. The
need for antibiotics is determined by the patient’s health
status and should be discussed with the patient’s phys-
ician. Endodontic treatment of asymptomatic nonvital
permanent teeth may be delayed until the immunologic
status of the patient is stable.7,21 The etiology of periapical
radiolucencies associated with teeth previously treated
endodontically should be determined because they may
represent pulpal infections, inflammatory reactions, apical
scars, cysts, or malignancies.12 Periapical lesions that are
asymptomatic and most likely depict apical scars do not
need retreatment.24
• Orthodontic appliances and space maintainers: Poorly-
fitting appliances can result in a breach of oral mucosa
and increased the risk of microbial invasion into deeper
tissues.22 Fixed appliances should be removed if the
patient has poor oral hygiene or if the treatment pro-
tocol (e.g., HCT conditioning regimen, head and neck
radiation) carries a risk for the development of moderate
to severe mucositis.7 Simple appliances (e.g., band and
loops, fixed lower lingual arches) that are not irritating
to the soft tissues may be left in place in patients with
good oral hygiene.7,12 Removable appliances and retainers
that fit well may be worn as long as tolerated by the
patient with good oral care.12 Patients should be instructed
to clean their appliance daily and routinely clean appli-
ance cases with an antimicrobial solution to prevent
contamination and reduce the risk of appliance-associated
oral infections. Consider removing orthodontic bands or
adjusting prostheses that approximate gingival tissue if a
patient is expected to receive cyclosporine or other drugs
known to cause gingival hyperplasia. If band removal is
not possible, vinyl mouth guards or orthodontic wax
should be used to decrease tissue trauma.12
510 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• Periodontal considerations: Extraction is the treatment of
choice for teeth with a poor prognosis (e.g., nonrestorable
teeth, periodontal pockets greater than five millimeters,
significant bone loss, furcation involvement, mobility,
infection) that cannot be treated by definitive periodontal
therapy. Partially-erupted molars can become a source of
infection because of pericoronitis. The overlying gingival
tissue should be excised if the dentist believes it is a po-
tential risk and if the hematological status permits.12,21
• Third molars and other impacted teeth: Some practi-
tioners prefer to extract all third molars that are not fully
erupted, particularly prior to HCT. Others favor a more
conservative approach and only recommend extraction of
third molars at risk for pulpal infection, with significant
pathology, infection, periodontal disease, or pericoronitis,
or when malposed or nonfunctional.12,25,26
• Primary teeth that are mobile due to natural exfoliation
may be left alone.
• Extractions: Surgical procedures must be as atraumatic
as possible, with no sharp bony edges remaining and
satisfactory closure of the wounds. These extractions
ideally are performed three weeks (or at least 10 to 14 days)
before cancer therapy is initiated to allow for adequate
healing.12,21 If the patient is immunocompromised and
at risk of infection from transient bacteremia, antibiotic
prophylaxis should be discussed with the patient’s
physicians. Regardless of hematologic status, if there is
documented infection associated with the extracted tooth,
antibiotics (ideally chosen with the benefit of sensitivity
testing) should be administered for about one week post-
operatively.12,21
• Pediatric patients who are on bone modifying agents
(e.g., bisphosphonates, antiresorptive, agents, anti-
angiogenic agents) as part of their cancer treatment or
who have had head and neck radiation are at an increased
risk of medication-related osteonecrosis of the jaw
(MRONJ) or osteoradionecrosis27-30, although most of
the evidence has been described in the adult population28.
Patients deemed to be at a significant risk of MRONJ
or osteoradionecrosis are best managed by a dentist in
coordination with the medical team in a hospital setting.
To minimize the risk of development of osteoradione-
crosis or MRONJ, patients ideally would have all oral
surgical procedures (e.g., extractions, periodontal treat-
ment) completed before those therapies are instituted.27,28
For patients who have been on antiresorptive (e.g.,
bisphosphates, denosumab) or anti-angiogenic agents as
part of their cancer treatment or have had radiation to
the jaws and an oral surgical procedure or invasive perio-
dontal procedure is necessary, it is important to discuss
risks with the patient and caregivers prior to the procedure.
Communication:
The dentist’s communication of the comprehensive oral care
plan with the medical team is vital. Information to be shared

includes the extent of non-elective dental treatment needed,
need for supportive care (e.g., hospital admission, blood
product replacement, antibiotic coverage) and the amount of
time needed for stabilization of oral disease and healing from
the dental procedures. Discussions with the medical team can
ensure ideal coordination between needed dental services and
planned cancer therapy.4
Oral care during immunosupression periods and radiation
therapy
Preventive strategies
Oral hygiene: Maintenance of good oral care in patients
undergoing immunosuppressive therapy and head and neck
radiation is necessary to reduce the microbial load in the oral
cavity. This may decrease the host inflammatory response and
subsequent severity of OM. Furthermore, a clean oral cavity
reduces the risk of opportunistic infections.4,10-12,15,21,22 Patients
should use a soft nylon brush two to three times daily and
replace it every two to three months.12,15
Thrombocytopenia is not the sole determinant of oral hy-
giene as patients are able to brush without bleeding at widely
different levels of platelet counts.12 Fluoridated toothpaste is
effective for caries prevention, and a mildly-flavored toothpaste
may be better tolerated during periods of OM. If moderate to
severe OM develops and the patient cannot tolerate a regular
soft nylon toothbrush or an end-tufted brush, foam brushes
or super soft brushes soaked in chlorhexidine may be used.13,14
Otherwise, foam or super soft brushes are discouraged because
they do not allow for effective cleaning. The use of a regular
brush should be resumed as soon as the OM improves. 12,15
Brushes should be air-dried between uses.12 Electric or ultra-
sonic brushes are acceptable if the patient can use them
without causing trauma and irritation. If patients are skilled
at flossing without traumatizing the tissues, it is reasonable
to continue flossing throughout treatment. Toothpicks and
water irrigation devices should not be used when the patient
is pancytopenic to avoid tissue trauma.12
Dental care
During immunosuppression, elective dental care should be
deferred. If a dental emergency arises, the treatment plan
should be discussed with the patient’s physician who will
make recommendations for supportive medical therapies (e.g.,
antibiotics, platelet transfusions, analgesia). The patient’s oral
health should be reevaluated every six months (or in shorter
intervals if there is a risk of dry mouth, caries, trismus, and/or
chronic oral GVHD) during treatment, in times of stable
hematological status and always after reviewing the medical
history.
Management of oral mucositis and associated pain related to
immunosuppressive therapies
Oral mucositis: The Multinational Association of Supportive
Care in Cancer/International Society of Oral Oncology
(MASCC/ISOO) has published guidelines for treatment of
BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
OM.15,31 Currently, data for the pediatric population is limited;
thus, recommendations are based largely on adult studies. The
recommended prescriptions for prevention of OM include
good oral hygiene, bland mouth rinses (saline or sodium bi-
carbonate), benzydamine mouthrinse, cryotherapy, palifermin,
and photobiomodulation therapy (PBM).31,32 Mucosal coating
agents (e.g., hydroxypropylmethylcellulose) and film-forming
agents also have been suggested. 4 The use of sucralfate,
antimicrobial lozenges, chlorhexidine, pentoxifylline, and
granulocyte-macrophage colony stimulating factor mouthwash
for OM are not recommended.15,31
Oral cryotherapy, the cooling of intraoral tissue with ice, is
recommended as OM prophylaxis for patients receiving bolus
infusion of chemotherapy drugs with short half-lives.31,33 Oral
cryotherapy reduces the blood flow to the mouth by narrowing
the blood vessels, thus limiting the amount of chemotherapy
drugs delivered to the tissues. Cryotherapy is inexpensive and
readily available, but further research is needed to confirm the
effectiveness of oral cryotherapy in children.32,33
Palifermin (keratinocyte growth factor-1) is a drug approved
by the United States (U.S.) Food and Drug Administration
for the prevention of oral mucositis34 in patients undergoing
conditioning with high-dose chemotherapy and total body
irradiation followed by HCT.31 Palifermin exerts its effect by
stimulating epithelial cell reproduction, growth, and develop-
ment so that mucosal cells damaged by chemotherapy and
radiation are replaced quickly, accelerating the healing
process.11,35
The current MASCC/ISOO guidelines support the use of
PBM therapy to prevent OM in patients undergoing HCT
conditioning with high-dose chemotherapy with or without
total body irradiation as well as patients undergoing radiation
treatment for head and neck cancer.31 PBM can decrease pain
and the duration and severity of chemotherapy-induced OM
in children.36-38 PBM may not be available at all cancer treat-
ment centers due to the cost of the equipment and the need
for trained personnel. Appropriate protocol must be followed
when using PBM to prevent contamination and occupational
risks to the child and dental team.
With regard to chlorhexidine, most studies have not dem-
onstrated a prophylactic impact or a reduction in the severity
of OM. 11,21,39,40 Chlorhexidine is not recommended for
prevention of oral mucositis in patients undergoing head and
neck radiation.15,31
Patient-controlled analgesia is helpful in relieving pain
associated with OM, reducing the requirement for oral anal-
gesics. The use of topical anesthetics and mixtures containing
topical anesthetics (e.g., Philadelphia mouthwash, magic
mouthwash) has been suggested for pain management.15,41
However, topical anesthetics only provide short-term pain
relief. 15 In addition to possible cardiovascular and central
nervous system effects, their use may obtund or diminish taste
and the gag reflex11 and/or result in a burning sensation. Cur-
rently, the evidence for its benefit is lacking 17, and potential
for toxicity is a concern in young children.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 511
BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
Oral mucosal infections: The signs of oral mucosal inflamma-
tion and infection may be diminished during neutropenic
periods. Thus, the clinical appearance of infections may dif-
fer significantly from the expected.21 Close monitoring of the
oral cavity allows for timely diagnosis and treatment of fungal,
viral, and bacterial infections. Oral cultures and/or biopsies of
all suspicious lesions are appropriate if medical status permits.
While waiting for the results, empiric therapy typically is ini-
tiated until laboratory results dictate more specific medica-
tions.4,12,21 Of note, nystatin is not effective for the prevention
and/or treatment of fungal infections.11,42
Oral bleeding: Oral bleeding in patients undergoing immuno-
suppressive therapy commonly occurs due to thrombocyto-
penia and/or damaged vascular integrity. Management consists
of local (e.g., pressure packs, antifibrinolytic rinses or topical
agents, gelatin sponges) and systemic measures (e.g., platelet
transfusions, aminocaproic acid).11,12,21
Dental sensitivity/pain: Tooth sensitivity may be related to
dry mouth during chemotherapy or head and neck radiation
therapy and the lowered salivary pH.11,12,21 Patients who are
using plant alkaloid chemotherapeutic agents (e.g., vincristine,
vinblastine) may experience neurotoxicity that presents as
deep, constant jaw pain (affecting the mandibular molars with
greater frequency) or paresthesia in the absence of odonto-
genic pathology. The pain usually is transient and generally
subsides shortly after dose reduction and/or cessation of
chemotherapy.11,12,21
Dry mouth: Sugar-free chewing gum or candy, sucking tablets,
special dentifrices for oral dryness, saliva substitutes, frequent
sipping of water, alcohol-free oral rinses, and/or oral moistur-
izers are recommended.5,12,43 Placing a humidifier by the child’s
bedside at night may be useful.21 Fluoride rinses and gels are
highly recommended for caries prevention in these patients.
Trismus: Daily oral stretching exercises/physical therapy should
be implemented during head and neck radiation treatment.
Management of trismus may include prosthetic aids to reduce
the severity of fibrosis, trigger-point injections, analgesics,
muscle relaxants, and other pain management strategies.11,22,44
Hematopoietic cell transplantation
Hematopoietic cell transplantation is used in children to
treat malignancies and hematologic disorders, as well as
certain metabolic syndromes. Examples include:45
• malignant disorders treated with autologous HCT
– brain tumors.
– Ewing sarcoma.
– germ cell tumors.
– Hodgkin lymphoma.
– leukemia.
– neuroblastoma.
– non-Hodgkin lymphoma.
– Wilms tumor.
512 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
• malignant disorders treated with allogenic HCT
– acute lymphocytic leukemia.
– acute myeloid leukemia.
– high-risk solid tumors.
– juvenile myelomonocytic leukemia.
– myelodysplastic syndrome.
• nonmalignant disorders treated with allogenic HCT
– bone marrow failure syndromes.
– chronic granulomatous disease.
– Fanconi anemia.
– metabolic storage disorders.
– osteopetrosis.
– severe aplastic anemia.
– sickle cell anemia.
– thalessemia.
– Wiskott-Aldrich syndrome.
Specific oral complications can be correlated with phases
of HCT.3,4,7,10,15
Phase I: Preconditioning
The oral complications are related to the patient’s current
systemic and oral health, oral manifestations of the underlying
condition, and oral complications of recent medical therapy.
Oral complications observed include opportunistic infections,
gingival leukemic infiltrates, bleeding, and ulceration.4 Most
of the principles of dental and oral care before the transplant
are similar to those discussed for patients undergoing immu-
nosuppressive cancer therapy.13 The two major differences in
HCT are: 1) the patient receives extremely high dose chemo-
therapy and/or total body irradiation immediately prior to (a
few days before) the transplant, and 2) there will be prolonged
immunosuppression following the transplant. Elective den-
tistry will need to be postponed until immunological recovery
has occurred, at least 100 days following HCT. This may
be longer if chronic GVHD or other complications (e.g.,
persistent immunodeficiency) are present.12 Therefore, all
dental treatment should be completed before the patient
undergoes HCT.
Phase II: Conditioning neutropenic phase
In this phase, which encompasses the day the patient is admitted
to the hospital to begin the transplant conditioning to 30 days
post-HCT, the majority of oral complications are related to
the conditioning regimen and supportive medical therapies.12
Mucositis, dry mouth, oral pain, hemorrhage, opportunistic
infections, taste dysfunction, neurotoxicity (including dental
pain, muscle tremors), and temporomandibular dysfunction
(including jaw pain, headache, joint pain) may be present.4
Oral mucositis usually begins seven to 10 days after initiation
of conditioning, and symptoms continue approximately two
weeks after the end of conditioning.4 Among allogeneic
transplant patients, acute GVHD can occur, causing more
severe inflammation and severe mucositis symptoms. Acute
GVHD may begin as early as two to three weeks after the
start of HCT and continue up to two months posttransplant.

The timing of this presentation may help distinguish acute
GVHD from chemotherapy-induced OM.4 The patient may
be followed closely to monitor and manage the oral changes
and to reinforce the importance of optimal oral care. Elective
dental procedures are avoided in this phase due to the patient’s
severe immunosuppression. If emergency treatment is necessary,
the dentist should consult and coordinate with the attending
transplant team.
Phase III: Engraftment to hematopoietic recovery
The intensity and severity of acute complications observed in
Phase II usually begin to decrease three to four weeks after
transplantation. During this phase, acute GVHD can become
a concern for allogeneic graft recipients. Dry mouth, hemor-
rhage, neurotoxicity, temporomandibular dysfunction, and
granulomas/papillomas also are observed sometimes.4 With
regard to opportunistic infections, oral fungal infections and
herpes simplex virus infection are most likely.4 HCT patients
are particularly sensitive to intraoral thermal stimuli between
two and four months posttransplant.12 The mechanism is not
well understood, but the symptoms usually resolve sponta-
neously within a few months. Topical application of neutral
fluoride or desensitizing toothpastes helps reduce the
symptoms.12 A dental/oral examination should be performed
and invasive dental procedures, including dental cleanings and
soft tissue curettage, should be done only if authorized by the
HCT team because of the patient’s continued immunosup-
pression.12 Patients should be encouraged to optimize oral
hygiene and avoid a cariogenic diet.
Phase IV: Immune reconstitution/recovery from systemic toxicity
After day 100 post-HCT, the oral complications are predom-
inantly related to the chronic toxicity associated with the
conditioning regimen, including dry mouth, craniofacial growth
abnormalities, late viral infections, chronic oral GVHD, and
oral squamous cell carcinoma.4,12 Unless the patient is neutro-
penic or with severe chronic GVHD, mucosal bacterial infec-
tions are less frequently seen. Periodic dental examinations with
radiographs can be performed, but invasive dental treatment is
to be avoided in patients with persistent profound impairment
of immune function.12 Consultation with the patient’s physician
and parents regarding the risks and benefits of orthodontic
care is recommended.
Dental and oral care after immunosuppressive therapy and
head and neck radiation have been completed
Objectives
The objectives of a dental/oral examination after immuno-
suppressive therapy ends are three-fold:
• to maintain optimal oral health.
• to reinforce to the patient/parents the importance of
optimal oral and dental care for life.
• to address any dental issues that may arise as a result of
the long-term effects of immunosuppressive therapy or
head and neck radiation.
BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
Dental care
Periodic evaluation: The patient should be seen every six
months (or more frequently if issues such as chronic oral
GVHD, dry mouth, or trismus are present). Patients who
have experienced moderate or severe mucositis and/or chronic
oral GVHD should be followed closely for signs of malignant
transformation of their oral mucosa (e.g., oral squamous cell
carcinoma).4,10,46
Education: The importance of optimal oral and dental care
for life must be reinforced. It is also important to emphasize
the need for regular follow-ups with a dental professional,
especially for patients who are at risk for or have developed
GVHD and/or dry mouth and those who were younger than
six years of age during treatment due to potential dental de-
velopmental problems.
Orthodontic treatment: Orthodontic care may start or resume
after completion of all therapy and after at least a two-year
disease-free survival when the risk of relapse is decreased and
the patient is no longer using immunosuppressive drugs.7 A
thorough assessment of any dental developmental disturbances
caused by the therapy must be performed before initiating
orthodontic treatment. The following strategies may be
considered when providing orthodontic care for patients with
dental sequelae: (1) use appliances that minimize the risk of
root resorption, (2) use lighter forces, (3) terminate treatment
earlier than normal, (4) choose the simplest method for the
treatment needs, and (5) do not treat the lower jaw.47 How-
ever, specific guidelines for orthodontic management, including
optimal force and pace, remain undefined. Patients and their
families may be made aware of the potential for a higher risk
of orthodontic relapse among cancer survivors.48 Patients who
were on intravenous antiresorptive or anti-angiogenic agents
as part of their cancer treatment, or in those who have had
head and neck radiation, may present a challenge for ortho-
dontic care. Although bisphosphonate inhibition of tooth
movement has been reported in animals, it has not been
quantified for any dose or duration of therapy in humans.47,49
Consultation with the patient’s caregivers and physician
regarding the risks (e.g. prolonged treatment time, MRONJ,
treatment modifications)49 and benefits (e.g., reduced root
resorption, anchorage, less relapse)49 of orthodontic care in
this situation is recommended.
Oral surgery and invasive periodontal therapy: Patients at
risk for MRONJ or osteoradionecrosis should be managed
in coordination with the oncology team in the hospital set-
ting.27,28,30 Elective invasive procedures are best avoided in
these patients.27,49
Long-term concerns
Craniofacial, skeletal, and dental developmental issues are
some of the complications faced by survivors3,7,8,12 and usually
develop among children who were less than six years of age
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 513
BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
at the time of their cancer therapy.7,12 Long-term effects of
immunosuppressive therapy may include tooth agenesis,
microdontia, crown disturbances (size, shape, enamel hypo-
plasia, pulp chamber anomalies), root disturbances (early
apical closure, blunting, changes in shape or length), reduced
mandibular length, reduced alveolar process height, and
reduced vertical growth of the face.5,7,8 The severity of the
dental developmental anomaly will depend on the age and
stage of development during exposure to cytotoxic agents or
ionizing radiation. Patients may experience permanent salivary
gland hypofunction/dysfunction or dry mouth.44 Relapse or
secondary malignancies can develop at this stage.4,46 Routine
periodic examinations are necessary to provide comprehensive
oral healthcare. Careful examination of extra-oral and intra-
oral tissues (including clinical, radiographic, and/or additional
diagnostic examinations) are integral to diagnosing any
secondary malignancies in the head and neck region. Dental
treatment may require a multidisciplinary approach, involving
a variety of dental specialists to address the treatment needs
of each individual. Consultation with the patient’s physician is
recommended if relapse occurs or the patient’s immunologic
status declines.
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36. He M, Zhan B, Shen N, et al. A systematic review and
meta-analysis of the effect of low level laser therapy
(LLLT) on chemotherapy-induced oral mucositis in
pediatric and young patients. Eur J Pediatr 2018;177(1):
7-17.
37. Amadori F, Bardellini E, Conti G, et al. Low-level laser
therapy for treatment of chemotherapy-induced oral
mucositis in childhood: A randomized double-blind
controlled study. Lasers Med Sci 2016;31(6):1231-6.
38. Eduardo Fde P, Bezinelli LM, de Carvalho DL, et al. Oral
mucositis in pediatric patients undergoing hematopoietic
stem cell transplantation: Clinical outcomes in a context
of specialized oral care using low-level laser therapy.
Pediatr Transplant 2015;19(3):316-25.
39. Worthington HV, Clarkson JE, Bryan G, et al. Interven-
tions for preventing oral mucositis for patients with
cancer receiving treatment. Cochrane Database Syst Rev
2011(4):CD000978.
40. Cardona A, Balouch A, Abdul MM, et al. Efficacy of
chlorhexidine for the prevention and treatment of oral
mucositis in cancer patients: A systematic review with
meta-analysis. J Oral Pathol Med 2017;46(9):680-8.
41. Saunders DP, Rouleau T, Cheng K, et al. Mucositis Study
Group of the Multinational Association of Supportive
Care in Cancer/International Society of Oral Oncology
(MASCC/ISOO). Systematic review of antimicrobials,
mucosal coating agents, anesthetics, and analgesics for
the management of oral mucositis in cancer patients and
clinical practice guidelines. Support Care Cancer 2020;
28(5):2473-84.
42. Gøtzsche PC, Johansen HK. Nystatin prophylaxis and
treatment in severely immunodepressed patients.
Cochrane Database Syst Rev 2014;2014(9):CD002033.
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 515
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43. Carvalho CG, Medeiros-Filho JB, Ferreira MC. Guide for
health professionals addressing oral care for individuals
in oncological treatment based on scientific evidence.
Support Care Cancer 2018;26(8):2651-61.
44. Jensen SB, Vissink A, Limesand KH, Reyland ME.
Salivary gland hypofunction and xerostomia in head and
neck radiation patients. J Natl Cancer Inst Monogr
2019;2019(53):lgz016.
45. Majhail NS, Farnia SH, Carpenter PA, et al. Indications
for autologous and allogenic hematopoietic cell trans-
plantation: Guidelines from the American Society for
Blood and Marrow Transplantation. Biol Blood Marrow
Transplant 2015;21(11):1863-96.
46. Inamoto Y, Shah NN, Savani BN, et al. Secondary solid
cancer screening following hematopoietic cell transplanta-
tion. Bone Marrow Transplant 2015;50(8):1013-23.
516 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
47. Zahrowski JJ. Bisphosphonate treatment: An orthodontic
concern for a proactive approach. Am J Orthod Dento-
facial Orthop 2007;131(3):311-20.
48. Mitus-Kenig M, Derwich M, Czochrowska E, Pawlowska
E. Cancer survivors present significantly lower long-term
stability of orthodontic treatment: A prospective case-
control study. Eur J Orthod 2021;43(6):631-8. Available
at: “https://doi.org/10.1093/ejo/cjaa083”. Accessed
March 27, 2022.
49. Bhatt RN, Hibbert SA, Munns CF. The use of bisphos-
phonates in children: Review of the literature and
guidelines for dental management. Aust Dent J 2014;59
(1):9-19.
 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.:
American Academy of Pediatric Dentistry; 2022:517-20.

Abstract
Informed consent, essential in the delivery of health care, is the process by which a health care practitioner provides relevant information
about diagnosis and treatment needs to a patient so he can make a voluntary and educated decision to pursue or refuse care. For minors
and adults with intellectual disabilities, parents (as defined within this document) are authorized to provide or decline permission for
treatment. Dentists must inform patients/parents about oral health conditions observed and the nature, risks, and benefits of recommended
and alternative treatments, including no treatment. While young children do not possess the cognitive ability to participate in the informed
consent discussion, older children and adolescents can participate and assent to care.
Dental providers are encouraged to familiarize themselves with the applicable laws and regulations in their state with respect to informed
consent in health care. Although laws may differ, obtaining consent in writing before commencing treatment is recommended as it may
reduce liability due to any miscommunication. Guidance regarding written consent forms is included. However, a conversation between the
dental provider and patient/parent, not just completing a form, is the key component of obtaining informed consent.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance in obtaining informed consent for pediatric oral health care.
KEYWORDS: INFORMED CONSENT; CONSENT FORMS, INFORMED CONSENT FORMS; INFORMED CONSENT BY MINORS; DOCUMENT, INFORMED CONSENT

Purpose recommendations were based upon expert and/or consensus

The American Academy of Pediatric Dentistry (AAPD)
recognizes that informed consent is essential in the delivery of
health care. The informed consent process allows the patient
or, in the case of minors, the parent * to participate in and
retain autonomy over the health care received. Informed con-
sent also may decrease the practitioner’s liability from claims
associated with miscommunication. Informed consent is
governed by the statutes and case laws of individual states;
oral health care providers should review the applicable laws
and regulations of their state.
Methods
Recommendations on informed consent were originally
developed by the Council on Clinical Affairs and adopted in
2005.1 This document is a revision of the previous version, last
revised in 2015.2 This revision included a literature search of
®
the PubMed /MEDLINE database using the terms: informed
consent, pediatric consent, pediatric informed consent, con-
sent, informed refusal, cultural background informed consent,
linguistic background informed consent, and interpreters
informed consent; fields: all; limits: within the last 10 years,
humans, English, review of legal cases. One hundred forty-two
articles matched these criteria. Papers for review were chosen
from this list and from references within selected articles.
When data did not appear sufficient or were inconclusive,
opinion by experienced researchers and legal practitioners.
Background
Informed consent is the process by which a health care provider
gives relevant information concerning diagnosis and treatment
needs to a patient so that the patient can make a voluntary,
educated decision to accept or refuse treatment. Minor children
are legally unable to give informed consent, and intellectually
disabled adults lack capacity to give consent. Parents are
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
apply when the parent is acting on behalf of the child.3,4
Informed consent involves both ethical and legal obligations
of the health care provider to the patient. The American Dental
Association (ADA) states that dentists are “required to provide
information to patients/parents about the dental health prob-
lems the dentist observes, the nature of any proposed treatment,
the potential benefits and risks associated with that treatment,
any alternatives to the treatment proposed, and the potential
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ADA: American
Dental Association.

* 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 517

BEST PRACTICES: INFORMED CONSENT
risks and benefits of alternative treatments, including no
treatment.”7 Following the informed consent discussion, an
assessment of patient/parental understanding should be made,
and any confusion about the treatment should be clarified by
the provider before consent is granted.5,8
Autonomy over healthcare decisions is a patient’s right. A
1914 New York state court ruled that “every human being of
adult years and sound mind has a right to determine what
shall be done with his own body….”9 Additionally, ruling from
the Supreme Court of North Dakota found that laws per-
taining to a physician’s duty to obtain informed consent also
pertained to dentists. 10 As court rulings and laws differ in
each state, it is difficult to develop an inclusive recommendation.
The law generally has several criteria for selecting information
to provide to a patient/parent as part of an informed consent.
Some states follow a patient-oriented standard—that informa-
tion which a reasonably prudent patient/parent in same or
similar circumstances would wish to know.11-13 Other states
follow a practitioner-oriented standard—that information
which a health care provider, practicing within the standard
of care, would reasonably provide to a patient/parent in the
same circumstances.12-14 A hybrid approach, combining the
patient-oriented and practitioner-oriented standards, is fol-
lowed by some states.13,14 Finally, a subjective person standard
requires the practitioner to give information that the particular
patient in question would want to know.5,11
Regardless of the standard a state has chosen to follow,
the treating practitioner must disclose information that he
considers material to the patient’s/parent’s decision-making
process and provide a warning of death or serious bodily injury
where that is a known risk of the procedure.13,15 The informed
consent process generally excludes adverse consequences
associated with a simple procedure if the risk of occurrence is
considered remote and when such circumstances commonly
are understood by the profession to be so.
The ADA Code of Ethics recommends that dentists provide
information “in a manner that allows the patient to become
involved in treatment decisions.”16 Pediatric dental health care
providers have the opportunity to guide and support the child
patient to become involved in his own health care. Young chil-
dren lack the cognitive ability to participate in the informed
consent discussion, but older children and adolescents who
have gained experience as dental patients may be included.
Information should be provided to the patient in an age-
appropriate manner, and practitioners should seek assent
(agreement) from the patient whenever possible.17,18 Although
the child can be involved, the parent is the individual giving
consent, and the parent is the individual who decides to accept
or refuse treatment. The practitioner should be aware that the
adult accompanying the pediatric patient may not be a legal
guardian allowed by law to consent to medical procedures.
Examples of such an adult include a grandparent, stepparent,
noncustodial parent in instances of divorce, babysitter, or
friend of the family. A child in foster care or a ward of the state
may be accompanied by a caretaker who may or may not be
518 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
allowed to consent to medical procedures, according to indi-
vidual state law. It is advisable that the oral health care
provider obtain a copy of court orders appointing a guardian
to verify who is authorized to consent for medical treatment
for the patient.18 One option to consider is obtaining a parent’s
authorization via a consent by proxy or power of attorney
agreement for any other individual to make dental treatment
decisions for a child.13,18 In situations where individuals other
than the parent regularly bring the child to the dental office,
this can help eliminate doubt as to whether such individual
has the legal authority to provide informed consent. Practi-
tioners, however, should consult their own attorney in deciding
whether to utilize such a form in their own practice. Another
option for obtaining authorization for treatment is a telephone
conversation with the parent.18,19 The parent should be told
there are two people on the telephone and asked to verify
the patient’s name, date of birth, and address and to confirm
he/she has responsibility for the patient.19 The parent is pre-
sented with all elements of a valid informed consent followed
by documentation in the patient’s chart with signatures.18,19
Written consent is required by most states before treatment
of a patient. 13 Even if not mandated by state law, written
consent is advisable as it may decrease the liability from mis-
communication. 19 A patient’s or parent’s signing a consent
form should not preclude a thorough discussion. Studies have
shown that even when seemingly adequate information has
been presented to patients/parents, their ability to fully under-
stand the information may be limited.8,11 Dentists should be
aware of the cultural and linguistic backgrounds of their
patients and families and take care to ensure that information
is available in culturally and linguistically competent formats
to help parents in the decision-making process.20 Also, to
assure a person who is deaf or hearing impaired can consent,
a dentist carefully should consider the patient’s self-assessed
communication needs before any treatment. Practitioners may
need to provide access to translation services (e.g., in person,
by telephone, by subscription to a language line) and sign lan-
guage services.3,20 Practitioners who receive federal funding, as
well as those in a significant number of states, are mandated to
provide these services at no cost to the patient.3,20 Supplements
such as informational booklets, videos, or models may be
helpful to the patient in understanding a proposed procedure.
The oral discussion between provider and patient, not the com-
pletion of a form, is the important issue of informed consent.
The consent form should document the oral discussion of
the proposed therapy, including risks, benefits, and possible
alternative therapy, as well as no treatment.4,17,20
Informed refusal occurs when the patient/parent refuses
the proposed and alternative treatments. 7,19 The dentist must
inform the patient/parent about the consequences of not
accepting the proposed treatment. It is recommended by the
ADA that informed refusal be documented in the chart and
that the practitioner should attempt to obtain an informed
refusal signed by the parent for retention in the patient record.
An informed refusal, however, does not release the dentist from

the responsibility of providing a standard of care. 7 If the
dentist believes the informed refusal violates proper standards
of care, he/she should recommend the patient seek another
opinion7 and/or dismiss the patient from the practice. If the
dentist suspects dental neglect, appropriate authorities should
be informed.21
When a consent form is utilized, it is best to use simple
words and phrases. A modified or customized form is pre-
ferred over a standard form and should be written so that it is
readily understandable to a lay person.4,7,19,20 Overly broad state-
ments such as “any and all treatment deemed necessary…”
or “all treatment which the doctor in his/her best medical
judgment deems necessary, including but not limited to…”
should be avoided. Courts have determined it to be so broad
and unspecific that it does not satisfy the duty of informed
consent. Informed consent discussion, when possible, should
occur on a day separate from the treatment, and the practi-
tioner should avoid downplaying the risks involved with the
proposed therapy. 8 Items that should appear on a consent
form are listed under Recommendations.
Informed consent and informed refusal forms22 should be
procedure specific, with multiple forms likely to be used.
For example, risks associated with restorative procedures will
differ from those associated with an extraction. Separate forms,
or separate areas outlining each procedure on the same form,
would be necessary to accurately advise the patient regarding
each procedure.7 Consent for sedation, general anesthesia, or
behavior guidance techniques such as protective stabilization
(i.e., immobilization) should be obtained separately from con-
sent for other procedures.6,23 Consent may need to be updated
or changed accordingly as changes in treatment plans occur.
When a primary tooth originally planned for pulp therapy
is determined to be nonrestorable at the time of treatment,
consent will need to be updated to reflect the change in treat-
ment. Depending on state laws, this update may be in oral or
written form. Dentists should consult their own attorney and
state dental association as informed consent laws vary by state.7
Recommendations
Informed consent is the process of providing the patient with
relevant information regarding diagnosis and treatment needs
so that an educated decision regarding treatment can be made
by the patient. In the case of a minor or intellectually disabled
adult, the parent gives informed permission with assent or
agreement from the patient whenever possible. The oral discus-
sion between provider and patient or parent, not the comple-
tion of a form, is the important issue of informed consent. A
written consent form serves as documentation of the consent
process and is required by most states. Other states allow the
oral discussion to be documented in the patient record. Dentists
should be aware of the cultural and linguistic backgrounds of
their patients and families and take care to ensure that infor-
mation is available in culturally- and linguistically-competent
formats to help patients and parents in the decision-making
process.
BEST PRACTICES: INFORMED CONSENT
Statutes and case law of individual states govern informed
consent. Oral health practitioners should review applicable
state laws to determine their level of compliance. Consent
forms should be procedure specific, utilize simple terms, and
avoid overly broad statements. When a practitioner utilizes
an informed consent form, the following should be included:
1. legal name and date of birth of pediatric patient.
2. legal name and relationship to the pediatric patient/
legal basis on which the person is granting permission
on behalf of the patient.
3. patient’s diagnosis.
4. nature and purpose of the proposed treatment in
simple terms.
5. potential benefits and risks associated with that
treatment.
6. professionally-recognized or evidence-based alternative
treatment – including no treatment – to recommended
therapy and risk(s).
7. place for parent to indicate that all questions have
been asked and adequately answered.
8. places for signatures of the parent, dentist, and an
office staff member as a witness.
References
1. American Academy of Pediatric Dentistry. Informed
consent. Pediatr Dent 2005;27(suppl):182-3.
2. American Academy of Pediatric Dentistry. Informed
Consent. Pediatr Dent 2015;37(special issue):315-7.
3. American Academy of Pediatrics Committee on Bioethics.
Informed consent in decision-making in pediatric practice
Pediatrics 2016;138(2):e20161484.
4. American Medical Association. AMA code of medical
ethics opinions on consent, communication and decision
making. Available at: “https://www.ama-assn.org/sites/
default/files/media-browser/code-of-medical-ethics-
chapter-2.pdf ”. Accessed March 24, 2019.
5. De Bord J. Informed Consent. Available at: “https://
depts.washington.edu/bioethx/topics/consent.html#ref1”.
Accessed March 24, 2019.
6. American Academy of Pediatric Dentistry. Protective
stabilization for pediatric dental patients. Pediatr Dent
2018;40(special issue):268-73.
7. American Dental Association Division of Legal Affairs.
Dental Records. Chicago, Ill.: American Dental Asso-
ciation; 2010:16.
8. Reid K. Informed consent in dentistry. J Law Med Ethics
2017;45(1):77-94.
9. Schloendorffer v Society of New York Hospital (105 N.E.
92); 1914.
10. Koapke v Herfendal, 660 NW 2d 206 (ND 2003).
11. Kinnersley P, Phillips K, Savage K, et al. Interventions
to promote informed consent for patients undergoing
surgical and other invasive healthcare procedures (Review).
Cochrane Database Syst Rev 2013;(7):CD009445.
References continued on the next page.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 519
BEST PRACTICES: INFORMED CONSENT
12. Sanbar SS, American College of Legal Medicine. Informed
consent to medical and surgical treatment. In: Legal
Medicine. 7th ed. Philadelphia, Pa.: Mosby/Elsevier;
2007;337-43.
13. LeBlang TR, Rosoff AJ, White C. Informed consent to
medical and surgical treatment. In: Legal Medicine. 6th
ed. Philadelphia, Pa.: Mosby; 2004.
14. Nathanson v Kline, 350 P2d 1093 (Kan 1960).
15. Harris DM. Contemporary Issues in Healthcare Law
and Ethics. 4th ed. Chicago, Ill.: Health Administration
Press; 2014:241-5.
16. American Dental Association. Principles of Ethics &
Code of Professional Conduct. With official advisory
opinions revised to November 2018. Available at: “https:
//www.ada.org/~/media/ADA/Member%20Center/
Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions
_Revised_to_November_2018.pdf?la=en”. Accessed
October 11, 2019.
17. Adewumi A, Hector MP, King JM. Children and in-
formed consent: A study of children’s perceptions and
involvement in consent to dental treatment. Br Dent J
2001;191(5):256-9.
520 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
18. American Academy of Pediatrics Committee on Medical
Liability. Consent by proxy for non urgent pediatric
care. Pediatrics 2017;139(2):e20163911.
19. Watterson DG. Informed consent and informed refusal
in dentistry. Registered Dental Hygienist. September
2012. Available at: “http://www.rdhmag.com/articles/
print/volume-32/issue-9/features/informed-consent-and-
informed-refusal.html”. Accessed March 24, 2019.
20. Joint Commission. Informed consent: More than getting
a signature. Available at: “https://www.jointcommission.
org/assets/1/23/Quick_Safety_Issue_Twenty-One_
February_2016.pdf ”. Accessed March 24, 2019.
21. American Academy of Pediatric Dentistry, American
Academy of Pediatrics. Oral and dental aspects of child
abuse and neglect. Pediatr Dent 2018;40(6):243-9.
22. Professional Protector Plan for Dentists. Dental risk
management sample letters and consent forms. Available
at: “http://www.protectorplan.com/forms”. Accessed
March 24, 2019.
23. American Academy of Pediatric Dentistry. Behavior
guidance for the pediatric dental patient. Pediatr Dent
2018;40(special issue):254-67.
 BEST PRACTICES: RECORDKEEPING

Recordkeeping
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Recordkeep-
2021 ing. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:521-8.

Abstract
This best practice presents recommendations regarding recordkeeping for dental patients. The patient record is an essential component of
the delivery of competent and quality oral health care. Electronic dental records are being adopted by more dental practices and may assist
with quality and efficiency of health care. Data security and privacy of identifiable health information are important considerations in record-
keeping. The patient record allows the provider, the patient, and authorized third parties to access the history and details of patient
assessment and communications between dentists and patients, as well as specific treatment recommendations, alternatives, and risks and
care provided. This document provides dental professionals with guidance on several pertinent aspects of dental recordkeeping including
general charting considerations, components of a patient record, patient medical and dental histories, comprehensive and limited clinical
examinations, treatment planning and informed consent, progress notes, correspondence and consultations, records transfer, corrections to
records, retention of records, and patient access to their health records. The scope of information to include and formatting for consistency
and ease of interpretation are addressed.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and guidance on recordkeeping.

KEYWORDS: DENTAL RECORDS, ELECTRONIC HEALTH RECORDS, MEDICAL RECORDS, DOCUMENTATION

Purpose
The American Academy of Pediatric Dentistry (AAPD)
recognizes the patient record is an essential component of the
delivery of competent and quality oral health care. It serves
as an information source for the care provider and patient, as
well as any authorized third party. This document will assist
the practitioner in assimilating and maintaining a compre-
hensive, uniform, and organized record addressing patient
care. However, it is not intended to create a standard of care.
Methods
This best practice was developed by the Council on Clinical
Affairs, adopted in 20041, and last revised in 2017.2 This
revision included a new literature search of the PubMed /
MEDLINE database using the terms: dental record, electronic
patient record, problem-oriented dental record, medical history
taking, medical record, record keeping, Health Insurance Port-
ability and Accountability Act (HIPAA), telehealth in dentistry,
data breach, medical necessity, problem-focused record, and
record transfer/sharing of images; fields: all; limits: within the
last five years, humans, and English. See Appendix for the
search strategy. Papers for review were chosen from this list
and from the references within selected articles and dental
textbooks. When data did not appear sufficient or were in-
conclusive, recommendations were based upon expert and/or
consensus opinion by experienced researchers and clinicians.
Background
The patient record provides all privileged parties with the
history and details of patient assessment and communica-
tions between dentist and patient, as well as specific treatment
recommendations, alternatives, risks, and care provided. The
patient record is an important legal document in third-party
relationships. Poor or inadequate documentation of patient
care consistently has been reported as a major contributing
factor in unfavorable legal judgments against dentists.3,4
Therefore, the AAPD recognizes that recommendations on
recordkeeping may provide dentists the information needed
to compile an accurate and complete patient chart that can
be interpreted by a knowledgeable third party. An electronic
® dental record (EDR) is becoming more commonplace and
perhaps will become mandatory.4-7 Health information systems
and electronic health records (EHR) are being implemented as
a means to improve the quality and efficiency of health care.8
Advantages include quality assurance by allowing comparative
analysis of groups of patients or providers, medical and dental
history profiles for demographic data, support for decision
making based on signs and symptoms, administrative man-
agement for patient education and recall, and electronic
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. EDR: Electronic den-
tal record. EHR: Electronic health record. HIPAA: Health Insurance
Portability and Accountability Act. PHI: Protected health information.
TMD: Temporomandibular disorder. TMJ: Temporomandibular joint.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 521

BEST PRACTICES: RECORDKEEPING
data interchange with other professional and third parties. In
addition, EHRs enable quality improvement to be imple-
mented in individual or group practices more readily. Quality
improvement is the process of evaluating clinical practice,
measuring effectiveness, and implementing changes to improve
patient outcomes.9 Quality improvement strategies support and
evaluate care delivery and allow changes to be made in clinical
practice. While most electronic dental billing systems do not
easily allow for entry of diagnostic codes, clinicians can enter
dummy codes to represent diagnoses and outcomes to evaluate
clinical outcomes more easily.9
HIPAA is the Health Insurance Portability and Account-
ability Act.10 Originally passed by Congress in 1996, it has
evolved significantly. Its primary purposes are to provide for
privacy and security of individually-identifiable health infor-
mation, but it also provides for data breech notifications and
additional requirements for covered entities.10 The requirements
of HIPAA are applicable to dental offices, rather numerous,
and complex. The United States Department of Health and Human
Services recommends that dentists and their staff participate
in regular education and training on HIPAA requirements
to maintain familiarity with changing regulations regarding
patient privacy.10
Data security is important in recordkeeping and, with the
widespread use of EHR, security requires evaluation of every
data interface, including data that is stored in the cloud, to
ensure data and patient information protection. 11 A require-
ment of the Security Rule of HIPAA is to perform regular
security risk analyses of electronic systems that store and
transmit protected health information (PHI).12 Daily backup
of the office software system stored in an electronic data base
retrievable by off-site personnel allows for the continuity of
care and business operations in the event that patient records
are lost or damaged. To be compliant with HIPAA, software
systems, including backup hard drives, should be encrypted
in case of a data breach. Correspondence with another care
provider via email, facsimile, and other forms of communi-
cation may be encrypted to protect PHI, and providers should
follow regulations and mandates on this topic. 13 Impermis-
sible use or disclosure of PHI also is considered a data breach
subject to state and federal laws regarding security breach
notification.14 Record access is intended only for those who
require it to perform their duties. If a computer accessing
patient information is placed where people other than the
patient can view the screen, a privacy filter can decrease risk
of compromise. Screen closure after a period of inactivity
will help protect privacy if the computer is left unattended.15
Recommendations
The elements of recordkeeping addressed in this document
are general charting considerations; initial patient record;
components of a patient record; patient medical and dental
histories; comprehensive and limited clinical examinations;
treatment planning and informed consent; progress notes;
correspondence, consultations, and ancillary documents;
522 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
teledentistry; records transfer; record correction and retention;
and accessibility to records. Forms completed by the parent
should be available in languages commonly found in the area
where a treatment facility is located.16
General charting considerations
The dental record must be authentic, accurate, well thought
out, legible, and objective. Each patient should have an
individual dental record. A well-documented record reflects
a patients’ history and care, allowing for continuity of care.17
Chart entries should contain the initials or name of the indi-
vidual making the note. Documentation is the responsibility
of many dental team members, including the dentist, hygienist,
dental assistant, front desk staff, and others.18 Abbreviations
should be standardized for the practice. After data collection,
a list is compiled that includes medical considerations, psycho-
logical/behavioral considerations, and the oral health needs to
be addressed. Problems are listed in order of importance in a
standardized fashion making it less likely that an area might
be overlooked. The plan identifies a general course of treatment
for each problem. This plan can result in the need for addi-
tional information, consultation with other practitioners, patient
education, and preventive strategies. Documentation should
include everything that was accomplished during an appoint-
ment including, but not limited to, discussion of medical
history changes, assessments performed, and discussions with
the parent and/or patient and should be made at the time of
the appointment or soon thereafter.18,19 If a practitioner needs
to add or clarify a note, a separate entry in the chart should
be made.15,18 Templates are widely available; these have shown
to increase compliance when compared to hand-written
notes.20 Clinicians should be aware of accuracy when com-
pleting templates, as incomplete sentences, unpopulated fields
in templates, and conflicting statements have been noted.21
Initial patient record
The parent’s/patient’s initial contact with the dental practice,
usually via telephone or web-based form, allows both parties
an opportunity to address the patient’s primary oral health
needs and to confirm the appropriateness of scheduling an
appointment with that particular practitioner. This conversa-
tion or form may elicit basic patient information such as:
• patient’s name, nickname, and date of birth.
• sex assigned at birth and gender identity.
• name, address, and telephone number of parent.
• name of referring party.
• significant medical history.
• chief complaint.
• availability of medical/dental records (including
radiographs) pertaining to patient’s condition.
• preferred language.
Such information constitutes the initial dental record. At
the first visit to the dental office, additional information would
be obtained and a permanent dental record developed.

Components of a patient record
The dental record must include each of the following specific
components19:
• medical history;
• dental history;
• clinical assessment;
• radiographic or other images obtained, if any, and
their interpretation;
• diagnosis or differential diagnosis;
• treatment recommendations;
• parental consent;
• progress notes; and
• acknowledgment of receipt of Notice of Privacy
Practices/HIPAA consent10.
When applicable, the following should be incorporated
into the patient’s record as well:
• caries-risk assessment;
• periodontal-risk assessment;
• patient assent;
• sedation/general anesthesia records;
• traumatic injury records;
• orthodontic records;
• consultations/referrals;
• laboratory orders;
• test results;
• additional ancillary records; and
• post-treatment instructions and prescriptions.
Medical history22-24
An accurate, comprehensive, and up-to-date medical history is
necessary for correct diagnosis, effective treatment planning,
and patient safety. Familiarity with the patient’s medical
history is essential to decreasing the risk of aggravating a
medical condition while rendering oral health care. Addi-
tionally, a thorough history can aid the diagnosis of dental as
well as medical conditions. The practitioner, or staff under the
supervision of the practitioner, must obtain a medical history
from the parent25 (if the patient is under the age of 18) before
commencing patient care. When the parent cannot provide
adequate details regarding a patient’s medical history, if the
patient is medically compromised, or if the dentist providing
care is unfamiliar with the patient’s medical diagnosis, con-
sultation with the medical health care provider may be
indicated.
Documentation of the patient’s medical history includes
the following elements of information, with elaboration of
positive findings:
• medical conditions and illnesses;
• name and, if available, telephone number of primary
and specialty medical care providers;
• current therapies (e.g., physical, occupational, speech);
• hospitalizations/surgeries;
• anesthetic experiences;
• current medications;
BEST PRACTICES: RECORDKEEPING
• allergies/reactions to medications;
• other allergies/sensitivities;
• immunization status;
• review of systems;
• family history; and
• social history.
The history form should provide the parent additional
space for information regarding positive historical findings, as
well any medical conditions not listed. There should be areas
on the form indicating the date of completion, the signature
of the person providing the history (along with his relationship
to the patient), and the signature of the staff member review-
ing the history with the parent. Records of patients with signifi-
cant medical conditions should be marked ‘medical alert’ in
a conspicuous yet confidential manner. A sample pediatric
medical history form can be found in AAPD’s The Reference
Manual of Pediatric Dentistry.26
Supplemental history for infants/toddlers26,27
The very young patient can present with unique developmental
and social concerns that impact the health status of the oral
cavity. Information regarding these considerations may be
collected via a supplemental history questionnaire for infants/
toddlers. Topics to be discussed may include a history of
prematurity/perinatal complications, developmental considera-
tions, feeding and dietary practices, timing of first tooth
appearance, and tooth brushing initiation and timing as well
as toothpaste use. Assessment of developmental milestones
(e.g., gross/fine motor skills, language, social interactions) is
crucial for early recognition of potential delays and appro-
priate referral to therapeutic services.28 As a majority of infants
and toddlers of employed parents receive childcare on a regular
basis,29 and because the primary caretaker influences the
child’s risk for caries, the questionnaire also should ascertain
childcare arrangements. Data gathered from this questionnaire
will benefit the clinical examination, caries-risk assessment,
preventive homecare plan, and anticipatory guidance counsel-
ing. A sample pediatric medical history form can be found in
AAPD’s The Reference Manual of Pediatric Dentistry.26
Supplemental history for adolescents10,12
The adolescent can present particular psychosocial characteristics
that impact the health status of the oral cavity, care seeking,
and compliance. Integrating positive youth development22
into the practice, the practitioner should obtain additional
information confidentially from teenagers. Topics to be
discussed may include nutritional and dietary considerations,
eating disorders, alcohol and substance misuse, tobacco and
electronic cigarette usage, over-the-counter medications and
supplements, and body art (e.g., intra- and extra-oral pierc-
ings, tattoos), as well as the use of oral contraceptives and
pregnancy for the female adolescent. A sample pediatric
medical history form can be found in AAPD’s The Reference
Manual of Pediatric Dentistry.26
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 523
BEST PRACTICES: RECORDKEEPING
Medical update26
At each patient visit, the history should be consulted and updated.
Recent medical attention for illness or injury, newly diagnosed
medical conditions, allergy, and changes in medications
should be documented. A written update should be obtained
at each recall visit and updated in the EDR.
Dental history 22,26,27,31
A thorough dental history is essential to guide the practitioner’s
clinical assessment, make an accurate diagnosis, and develop
a comprehensive preventive and therapeutic program for each
patient. The dental history should address the following:
• chief complaint;
• previous dental experience;
• date of last dental visit/radiographs;
• oral hygiene practices;
• fluoride use/exposure history;
• dietary habits (including breastfeeding, bottle/no-spill
training cup use in young children);
• oral habits;
• sports activities;
• previous orofacial trauma;
• temporomandibular joint (TMJ) history;
• family history of caries; and
• social development.
A sample pediatric medical history form can be found in
AAPD’s The Reference Manual of Pediatric Dentistry.26
Comprehensive clinical examination22,32,33
A visual examination should precede other diagnostic pro-
cedures. Components of a comprehensive clinical examination
include:
• general health/growth assessment (e.g., height, weight,
body mass index calculation, vital signs);
• pain assessment;
• extraoral soft tissue examination;
• TMJ assessment;
• intraoral soft tissue examination;
• oral hygiene and periodontal health assessment;
• assessment of the developing occlusion;
• intraoral hard tissue examination;
• radiographic assessment, if indicated34,35;
• caries-risk assessment36; and
• assessment of cooperative potential/ behavior of child.37
The dentist may employ additional diagnostic tools to
complete the oral health assessment. Such diagnostic aids may
include electric or thermal pulp testing, percussion, transillu-
mination, caries detection devices, salivary tests, photographs,
computed tomography (CBCT), laboratory tests, and study
casts. Speech, in children who are able to talk, may be evaluated
and provide additional diagnostic information.
To enhance patient diagnosis and treatment documentation,
the practitioner should consider including photographs of
524 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
the child’s oral condition in the dental record. Photographs
may be indicated to:
• facilitate diagnosis.
• verify presence or characteristics of a condition (e.g.
decalcification, molar-incisor hypomineralization) that
may not be documented adequately by other means
(e.g., radiographs).
• monitor a finding for clinical changes.
• document acute traumatic injuries, particularly if
abuse may be suspected.
• facilitate education and treatment planning.
• document teledentistry consultation.
• facilitate determination of medical necessity by third
party payors.
Permission to obtain photographs to facilitate treatment
should be addressed within a general consent for care. 38 If
images containing PMI are intended for other use (e.g., publi-
cation, presentation), specific written authorization is
required.38 Although photographs without identifiable PHI
may be exempt from HIPAA regulations, 38 practitioners
should consult HIPAA rule and state regulations prior to
dissemination of images. Photographs, along with adequate
diagnostic radiographs, can enhance the documentation of
medical necessity of treatment.
Examinations of a limited nature
If a patient is seen for limited care, a consultation, an emer-
gency, or a second opinion, a medical and dental history must
be obtained, along with a hard and soft tissue examination as
deemed necessary by the practitioner. Documentation should
clearly state the limited scope of the evaluation. The parent
should be informed of the limited nature of the treatment
and counseled to seek routine comprehensive care after
resolution of the acute issue. AAPD’s Acute Traumatic Injuries:
Assessment and Documentation39 provides greater details on
diagnostic procedures and documentation for emergent
traumatic injury care.
Treatment recommendations and informed consent40
Once the clinician has obtained the medical, dental, and social
histories and evaluated the information obtained during the
diagnostic procedures, the diagnoses should be derived and a
sequential prioritized treatment plan developed. The treatment
plan would include specific information regarding the teeth
and surfaces to be treated, selected procedures/materials to be
used, number of appointments/time frame needed to accom-
plish this care, behavior guidance techniques beyond basic
communicative techniques that may be employed, and fee for
proposed procedures. The dentist is obligated to educate the
parent on the need for and benefits of the recommended care,
as well as risks, alternatives, and expectations if no intervention
is provided. When deemed appropriate, the patient should
be included in these discussions.40,41 Information should be
provided to the patient in an age-appropriate manner, and

practitioners should seek assent (agreement) from the patient
whenever possible.40 The dentist should not attempt to decide
what the parent will accept or can afford. After the treatment
options are presented, the parent should have the opportu-
nity to ask questions regarding the proposed care and have
concerns satisfied prior to giving informed consent. Informed
consent may include various forms and be procedure specific.40
For adult patients with special health care needs, determining
who legally can provide consent for treatment is essential.40
The practitioner should document interpreters or translation
services used to aid communication (e.g., in person, by
telephone). Documentation should include that questions
were encouraged and answered and the parent appeared
to understand and accepted the proposed procedures. Any
special restrictions or concerns voiced by the parent should
be documented. The people who were present during the dis-
cussion may be documented. If the parent refuses treatment
and a treatment refusal form is signed, it should be retained
in the record.18 A signed dental informed consent for sedation
and general anesthesia should be maintained in the record. A
signed informed consent form should not preclude or replace
a detailed discussion regarding recommended treatment and
treatment modalities.
Progress notes
An entry must be made in the patient’s record that accurately
and objectively summarizes each visit. The entry must mini-
mally contain the following information:
• date of visit;
• reason for visit/chief complaint;
• radiographic exposures and interpretation, if any;
• treatment rendered including, but not limited to:
– teeth restored and materials used,
– the type and dosage of anesthetic agents42,
– medications, and/or nitrous oxide/oxygen43,
– type/duration of protective stabilization44,
– treatment complications, and
– adverse outcomes; and
• post-operative instructions and prescriptions as
needed.
In addition, the entry generally should document:
• changes in the medical history, if any;
• adult accompanying child;
• presence of the accompanying adult in the operatory,
if applicable;
• significant conversations with the parent regarding
limitations, prognosis, behavior challenges, or other
issues that might be out of the ordinary;
• verification of compliance with preoperative
instructions;
• reference to supplemental documents;
• patient behavior guidance; and
• planned treatment for next visit.
BEST PRACTICES: RECORDKEEPING
A standardized format may provide the practitioner a way
to record the essential aspects of care on a consistent basis.
One example of documentation is the SOAP note.45 SOAP is
an acronym for subjective (S) or what the patient says or
reports, objective (O) or the observations of the clinician or
test results, assessment (A) or diagnosis/differential diagnosis
of the problem, and plans (P) for what and how treatment
will be provided. The signature or initials of the office staff
member documenting the visit should be entered. The dentist
has the ultimate responsibility for all entries made in the
chart and may countersign all treatment progress note entries.
When sedation or general anesthesia is employed, addi-
tional documentation on a time-based record is required, as
discussed in AAPD’s Guideline for Monitoring and Manage-
ment of Pediatric Patients Before, During and After Sedation
for Diagnostic and Therapeutic Procedures.46 A sample sedation
record form can be found in AAPD’s The Reference Manual of
Pediatric Dentistry.47
Progress notes should document telephone conversations
and email and text correspondence regarding the patient’s
care. Information including complications from treatment and
questions/concerns regarding planned treatment should be
documented. Appointment history (i.e., cancellations, failures,
tardiness, rescheduled visits) may be retained in the record.18
Documentation also should include noncompliance with
treatment recommendations as well as educational materials
utilized (both video and written). Any referrals made should
be included, along with identification of the staff member
making the entry in the dental record.
Teledentistry48
Dentists are encouraged to understand their state’s regulations
regarding documentation and consent requirements for tele-
dentistry. Documentation of a teledentistry patient visit should
include a thorough description of the encounter in accordance
with state regulations as part of the patient record. Security
measures and privacy of protected patient information should
be maintained in compliance with state and federal laws.48
Orthodontic treatment
AAPD’s Management of the Developing Dentition and Occlusion
in Pediatric Dentistry 49 provides general recommendations on
the documentation of orthodontic care. Signs and
symptoms of TMJ disorders should be recorded when they
occur before, during, or after orthodontic treatment.50 During
orthodontic treatment, progress notes should include defi-
ciencies in oral hygiene, loose bands and brackets, patient
complaints, caries lesions, decalcification/caries, root resorption,
and appointment cancellations and failures.
Correspondence, consultations, and ancillary documents
The primary care dentist often consults with other health care
providers in the course of delivery of comprehensive oral health
care, especially for patients with special health care needs or
complex oral conditions. Communications with medical care
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 525
BEST PRACTICES: RECORDKEEPING
providers or dental specialists should be incorporated into the
dental record. Written referrals to other care providers should
include the specific nature of the referral, as well as pertinent
patient history and clinical findings. Reports received from
other health care providers should be incorporated into the
patient’s chart. A progress note should be made noting corre-
spondence sent or received regarding a referral, indicating
documentation filed elsewhere in the patient’s chart. Copies
of test results, prescriptions, laboratory work orders, and
other ancillary documents should be maintained as part of the
dental record.
Record transfer
If a parent requests a record transfer to another office, this
request as well as what was sent should be documented in
the chart. An sample transfer form can be found in AAPD’s
The Reference Manual of Pediatric Dentistry.51
Correction of records and records retention
For all dental records, whether electronic or paper, adherence
to general guidelines helps avoid problems from a medicolegal
standpoint. An individual should never allow others to use his
password to access electronic files. Changes to a record should
not be made after a patient complaint or a practitioner learns
of pending legal action related to patient care. When changes
must be made in a paper dental record, corrections should be
clearly identified by drawing a single line through the error
and placing one’s initials/signature and date after the changes.
If an electronic record is used, corrections should be noted
by a separate clarifying/correcting entry in the chart.17
The length of time for retention of records of child patients
varies greatly by jurisdiction. The clinician should be aware
of his specific jurisdiction’s requirements and keep the records
safely secured for the specified time. When the time of
retention is completed, the records must be securely destroyed,
so that all personal information is protected.18
Accessibility to records (Cures Act 2020)
In 2020, new federal rules implemented the bipartisan 21st
Century Cures Act that, in part, “promotes patient access to
their electronic health information, supports provider needs,
advances innovation, and addresses industry-wide information
blocking practices”52. The rules forbid health care organiza-
tions, information technology vendors, and others from
restricting patients’ access to their electronic health care data
(i.e., information blocking). Although HIPAA gave patients
the legal right to review their medical records, the new ruling
goes further by giving them the right to access their electronic
health records rapidly and conveniently via secure online
portals. Providers must share not only test results, medication
lists, and referral information but also notes written by clini-
cians.53 The effects on most dentists in the short term remains
unclear.54
526 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Appendix—Search strategy
(“Record keeping” OR “clinical documentation” OR “clini-
cian documentation” OR “clinician compliance” OR
“Documentation/standards”[MeSH Major Topic] OR
“Telemedicine/standards”[MeSH Major Topic] OR “Forms
and Records Control”[MeSH Major Topic] OR “record
transfer” OR “image sharing” OR “Health Information
Exchange”[MeSH Major Topic] OR “Health Services Needs
and Demand”[MeSH Major Topic] OR “medical necessity”
OR “data breach” OR Telemedicine OR “telemedicine”[MeSH
Major Topic] OR Telehealth OR “dental telehealth” OR
“quality assurance” OR “Health Insurance Portability and
Accountability Act”[MeSH Major Topic] OR “Health Insurance
Portability and Accountability Act” OR “Medical History
Taking”[MeSH Major Topic] OR “medical history taking” OR
“medical history taking” OR “problem-oriented dental record”)
AND (“Electronic Health Records”[MeSH Major Topic] OR
“electronic health record” OR “electronic health records” OR
“medical record” OR “medical records” OR “medical recording”
OR “medical records”[MeSH Major Topic] OR “patient record”
OR “patient records” OR “electronic patient record” OR
“Dental Records”[MeSH Major Topic] OR “dental records”
OR “dental record”) AND ((y_5[Filter]) AND (english[Filter]))
AND ((y_5[Filter]) AND (english[Filter])) AND ((y_5[Filter])
AND (english[Filter])) AND ((y_5[Filter]) AND (humans
[Filter]) AND (english[Filter])) AND ((y_5[Filter]) AND
(humans[Filter]) AND (english[Filter])) AND ((y_5[Filter])
AND (humans[Filter]) AND (english[Filter])) AND ((y_5
[Filter]) AND (humans[Filter]) AND (english[Filter])) AND
((y_5[Filter]) AND (humans[Filter]) AND (english[Filter]))
AND ((y_5[Filter]) AND (humans[Filter]) AND (english
[Filter]))
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focused policies that empower patients and support pro-
viders. Health IT Buzz Blog. 9 March 2020. Available
at: “https://www.healthit.gov/buzz-blog/21st-century
-cures-act/the-cures-final-rule”. Accessed September 27,
2021.
53. Blease C, Walker J, DesRoches CM, Delbanco T. New
US law mandates access to clinical notes: Implications
for patients and clinicians. Ann Intern Med 2021;174
(1):101-2.
54. Burger D. ADA leads the charge to foster interoperability.
ADA News, September 29, 2020. Available at: ‘https://
www.ada.org/en/publications/ada-news/2020-archive/
september/ada-standards-committee-on-dental-informatics
-leads-charge-to-foster-interoperability”. Accessed
September 27, 2021.
Endorsements
IADT Guidelines for the Management of
Traumatic Dental Injuries:
– General Introduction
– 1. Fractures and Luxations
– 2. Avulsion of Permanent Teeth
– 3. Injuries in the Primary Dentition
Policy on the Management of Patients with Cleft
Lip/Palate & Other Craniofacial Anomalies
 ENDORSEMENTS: GENERAL INTRODUCTION

International Association of Dental Traumatology

Guidelines for the Management of Traumatic Dental
Injuries: General Introduction
Endorsed by the American Academy
of Pediatric Dentistry
 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(4):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(4):309-313; doi: 10.1111/edt.12574) Received May 19, 2020 | Accepted May 19, 2020
KEYWORDS: AVULSION, LUXATION, PREVENTION, TOOTH FRACTURE, TRAUMA

1 | INTRODUCTION
Traumatic dental injuries (TDIs) occur frequently in children and young
adults, comprising 5% of all injuries. Twenty-five percent of all school children
experience dental trauma and 33% of adults have experienced trauma to
the permanent dentition, with the majority of the injuries occurring before
age 19. Luxation injuries are the most common TDIs in the primary dentition,
whereas crown fractures are more commonly reported for the permanent
1
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 2School of
Dentistry at the University of Leeds, Community Dental Service, Bradford District Care NHS
Trust, Leeds, UK. 3Division of Endodontics, University of Maryland School of Dentistry, UMB,
Baltimore, MD, USA. 4Paediatric Dentistry, Dublin Dental University Hospital, Trinity College
Dublin, The University of Dublin, Dublin, Ireland 5Adams School of Dentistry, University of
North Carolina, Chapel Hill, NC, USA. 6Private Practice, Paris, France. 7UWA Dental School,
University of Western Australia, Perth, WA, Australia.
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,
5th Floor, Edmonton, AB T6G 1C9, Canada.
Email: liran@ualberta.ca
teeth. Proper diagnosis, treatment planning and follow up are important to
assure a favorable outcome.
These updates of the International Association of Dental Traumatology’s
(IADT) Guidelines include a review of the current dental literature using
EMBASE, MEDLINE, PUBMED, and Scopus 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
and urgent care of TDIs. It is understood that some of the subsequent treat-
ment may require secondary and tertiary interventions involving specialists
with experience in dental trauma.
The IADT published its first set of guidelines in 2001 and updated them
in 2007. A further update was published in Dental Traumatology in 2012. As
with previous guidelines, the current working group included experienced
investigators and clinicians from various dental specialties and general prac-
tice. The current revision represents the best evidence based on the available
literature and expert professional judgment. In cases where the data were
not conclusive, recommendations were based on the consensus opinion of
the working group, then reviewed and approved by the members of the
IADT Board of Directors.

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):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.

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ENDORSEMENTS: GENERAL INTRODUCTION

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):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.

532 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 ENDORSEMENTS: GENERAL INTRODUCTION

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 533

ENDORSEMENTS: GENERAL INTRODUCTION
It is understood that guidelines are to be applied with evaluation of the
specific clinical circumstances, clinicians’ judgment and patients’ characteris-
tics, including but not limited to the probability of compliance, finances and
an understanding of the immediate and long-term outcomes of treatment
options vs non-treatment. The IADT does not, and cannot, guarantee favor-
able outcomes from adherence to the Guidelines, but the IADT believes that
their application can maximize the chances of a favorable outcome.
These Guidelines offer recommendations for the diagnosis and treat-
ment of specific TDIs. However, they provide neither the comprehensive nor
the detailed information found in textbooks, the scientific literature, or the
Dental Trauma Guide (DTG). The DTG can be accessed at http://www.
dentaltraumaguide.org. In addition, the IADT website http://www.iadt-
dentaltrauma.org provides connection to the journal Dental Traumatology
and other dental trauma information.
2 | GENERAL RECOMMENDATIONS
2 .1 | Special considerations for trauma to primary teeth
A young child is often difficult to examine and treat due to lack of coopera-
tion and because of fear. This situation is distressing for both the child and
the parents. It is important to keep in mind that there is a close relationship
between the root apex of the injured primary tooth and the underlying
permanent tooth germ. Tooth malformation, impacted teeth and eruption
disturbances in the developing permanent dentition are some of the con-
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
situation, the time for shedding of the injured tooth, and the occlusion are
all important factors that influence treatment. Multiple traumatic episodes
are also common in children and this may affect the outcomes following
trauma to a tooth.
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):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.
534 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
2.2 | Immature vs mature permanent teeth
Every effort should be made to preserve the pulp in the immature perma-
nent tooth to ensure continued root development. A large majority of TDIs
occur in children and teenagers where loss of a tooth has lifetime conse-
quences. The immature permanent tooth has considerable capacity for
healing after traumatic pulp exposure, luxation injury, or root fracture.
2.3 | Avulsion of permanent teeth
The prognosis for avulsed permanent teeth is heavily dependent on the
actions taken at the place of accident. Promotion of public awareness of
first-aid treatment for the avulsed tooth is strongly encouraged. Treatment
choices and prognosis for the avulsed tooth are largely dependent on the
viability of the periodontal ligament (PDL), and the maturity of the root.
See the IADT’s specific Guidelines for managing avulsed teeth.1
2. 4 | Patient/parent instructions
Patient compliance with follow-up visits and home care contributes to better
healing following a TDI. Both the patient and the parents of a young patient
should be advised regarding care of the injured tooth or teeth for optimal
healing, preventing further injury, employing meticulous oral hygiene, and
rinsing with an antibacterial agent such as alcohol-free chlorhexidine
gluconate 0.12% for 1-2 weeks. Alternatively, with a young child, it is desirable
to apply the chlorhexidine to the affected area with a cotton swab.
2.5 | Summary tables for follow up, splinting duration and core outcomes
To help summarise activities for the follow-up appointment and splinting
regimes, Tables 1-3 are presented for different injuries in the primary and
permanent dentitions. The core outcome variables, explained in the next
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.
 ENDORSEMENTS: GENERAL INTRODUCTION

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.

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):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.

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ENDORSEMENTS: FRACTURES AND LUXATIONS

International Association of Dental Traumatology

Guidelines for the Management of Traumatic Dental
Injuries: 1. Fractures and Luxations
Endorsed by the American Academy
of Pediatric Dentistry
 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(4):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(4):314-330; doi: 10.1111/edt.12578) Received May 19, 2020 | Accepted May 19, 2020.
KEYWORDS: AVULSION, LUXATION, PREVENTION, TOOTH FRACTURE, TRAUMA

1
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
Diseases, Copenhagen University Hospital, Copenhagen, Denmark. 4Department of Pediatric
Dentistry, Faculty of Dentistry, Universidad de Valparaíso, Valparaíso, Chile. 5Paediatric Dentis-
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-
trict Care NHS Trust, Leeds, UK. 7Division of Orthodontics and Pediatric Dentistry, Department
of Dental Medicine, Karolinska Institutet, Huddinge, Sweden. 8Center for Pediatric Oral Health
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.
11
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,
University Hospital in Copenhagen (Rigshospitalet), Copenhagen, Denmark. 13Department of
Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. 14Faculty of
Medicine and Health, The University of Sydney, Sydney, NSW, Australia. 15School of Dentistry,
The University of Queensland, St Lucia, Qld, Australia. 16Faculty of Dentistry, College of Health
Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. 17Specialist Private Practice, Bremen,
Germany. 18Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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,
5th Floor, Edmonton, AB T6G 1C9, Canada. Email: liran@ualberta.ca
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
these younger age groups may be different than in adults, mainly due to
immature teeth and pubertal facial growth. The purpose of these Guidelines
is to improve management of injured teeth and minimize complications
resulting from trauma.
2 | CLINICAL EXAMINATION
Trauma involving the dento-alveolar region is a frequent occurrence which
can result in the fracture and displacement of teeth, crushing, and/or fracturing
of bone, and soft tissue injuries including contusions, abrasions, and lacera-
tions. Available current literature provides protocols, methods, and documen-
tation for the clinical assessment of traumatic dental injuries (TDI), trauma
first aid, patient examination, factors that affect treatment planning decisions,
and the importance of communicating treatment options and prognosis to
traumatized patients.1–3
The combination of two different types of injuries occurring concurrently
to the same tooth will be more detrimental than a single injury, creating a
negative synergistic effect. Concurrent crown fractures significantly increase
the risk of pulp necrosis and infection in teeth with concussion or sublux-
ation injuries and mature root development.4 Similarly, crown fractures with

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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 ENDORSEMENTS: FRACTURES AND LUXATIONS

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.

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

538 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

540 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

542 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

544 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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 ENDORSEMENTS: FRACTURES AND LUXATIONS

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: FRACTURES AND LUXATIONS
4 | PHOTOGRAPHIC DOCUMENTATION
The use of clinical photographs is strongly recommended for the initial
documentation of the injury and for follow-up examinations. Photographic
documentation allows monitoring of soft tissue healing, assessment of tooth
discoloration, the re-eruption of an intruded tooth, and the development of
infra-positioning of an ankylosed tooth. In addition, photographs provide
medico-legal documentation that could be used in litigation cases.
5 | PULP STATUS EVALUATION: SENSIBILITY AND VITALITY TESTING
5.1 | Sensibility tests
Sensibility testing refers to tests (cold test and electric pulp test) used to
determine the condition of the pulp. It is important to understand that
sensibility testing assesses neural activity and not vascular supply. Thus, this
testing might be unreliable due to a transient lack of neural response or
undifferentiation of A-delta nerve fibers in young teeth.12–14 The temporary
loss of sensibility is a frequent finding during post-traumatic pulp healing,
especially after luxation injuries.15 Thus, the lack of a response to pulp sensi-
bility testing is not conclusive for pulp necrosis in traumatized teeth.16–19
Despite this limitation, pulp sensibility testing should be performed initially
and at each follow-up appointment in order to determine if changes occur
over time. It is generally accepted that pulp sensibility testing should be
done as soon as practical to establish a baseline for future comparison
testing and follow up. Initial testing is also a good predictor for the long-term
prognosis of the pulp.12–15,20
5.2 | Vitality tests
The use of pulse oximetry, which measures actual blood flow rather than the
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
The current use of pulse oximetry is limited due to the lack of sensors speci-
fically designed to fit dental dimensions and the lack of power to penetrate
through hard dental tissues.
Laser and ultrasound Doppler flowmetry are promising technologies to
monitor pulp vitality.
6 | STABILIZATION/SPLINTING: TYPE AND DURATION
Current evidence supports short-term, passive, and flexible splints for splint-
ing of luxated, avulsed, and root-fractured teeth. In the case of alveolar bone
fractures, splinting of the teeth may be used for bone segment immobili-
zation. When using wire-composite splints, physiological stabilization can
be obtained with stainless steel wire up to 0.4 mm in diameter.22 Splinting
is considered best practice in order to maintain the repositioned tooth in
its correct position and to favor initial healing while providing comfort and
controlled function.23–25 It is critically important to keep composite and
bonding agents away from the gingiva and proximal areas to avoid plaque
retention and secondary infection. This allows better healing of the marginal
gingiva and bone. Splinting time (duration) will depend on the injury type.
Please see the recommendations for each injury type (Tables 1-13).
7 | USE OF ANTIBIOTICS
There is limited evidence for the use of systemic antibiotics in the emergency
management of luxation injuries and no evidence that antibiotics improve
the outcomes for root-fractured teeth. Antibiotic use remains at the dis-
cretion of the clinician as TDIs are often accompanied by soft tissue and
other associated injuries, which may require other surgical intervention. In
addition, the patient’s medical status may warrant antibiotic coverage.26,27
8 | PATIENT INSTRUCTIONS
Patient compliance with follow-up visits and home care contribute to better
healing following a TDI. Both patients and parents or guardians should be
advised regarding care of the injured tooth/teeth and tissues for optimal
healing, prevention of further injury by avoidance of participation in contact
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
548 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
sports, meticulous oral hygiene, and rinsing with an antibacterial agent such
as chlorhexidine gluconate 0.12%.
9 | FOLLOW UPS AND DETECTION OF POST-TRAUMATIC COMPLICATIONS
Follow ups are mandatory after traumatic injuries. Each follow up should
include questioning of the patient about any signs or symptoms, plus clini-
cal and radiographic examinations and pulp sensibility testing. Photographic
documentation is strongly recommended. The main post-traumatic compli-
cations are as follows: pulp necrosis and infection, pulp space obliteration,
several types of root resorption, breakdown of marginal gingiva and bone.
Early detection and management of complications improves prognosis.
1 0 | STAGE OF ROOT DEVELOPMENT—IMMATURE (OPEN APEX) VS
MATURE (CLOSED APEX) PERMANENT TEETH
Every effort should be made to preserve the pulp, in both mature and im-
mature teeth. In immature permanent teeth, this is of utmost importance
in order to allow continued root development and apex formation. The vast
majority of TDIs occur in children and teenagers, where loss of a tooth has
lifetime consequences. The pulp of an immature permanent tooth has con-
siderable capacity for healing after a traumatic pulp exposure, luxation injury,
or root fracture. Pulp exposures secondary to TDIs are amenable to con-
servative pulp therapies, such as pulp capping, partial pulpotomy, shallow
or partial pulpotomy, and cervical pulpotomy, which aim to maintain the
pulp and allow for continued root development.28–31 In addition, emerging
therapies have demonstrated the ability to revascularize/revitalize teeth by
attempting to create conditions allowing for tissue in-growth into the root
canals of immature permanent teeth with necrotic pulps.32–37
1 1 | COMBINED INJURIES
Teeth frequently sustain a combination of several injuries. Studies have
demonstrated that crown-fractured teeth, with or without pulp exposure and
with a concomitant luxation injury, experience a greater frequency of pulp
necrosis and infection.38 Mature permanent teeth that sustain a severe TDI
after which pulp necrosis and infection is anticipated are amenable to
preventive endodontic treatment.
Since prognosis is worse in combined injuries, the more frequent follow-
up regimen for luxation injuries prevails over the less frequent regime for
fractures.
12 | PULP CANAL OBLITERATION
Pulp canal obliteration (PCO) occurs more frequently in teeth with open
apices which have suffered a severe luxation injury. It usually indicates the
presence of viable tissue within the root canal. Extrusion, intrusion, and
lateral luxation injuries have high rates of PCO.39,40 Subluxated and crown-
fractured teeth also may exhibit PCO, although with lower frequency.41
Additionally, PCO is a common occurrence following root fractures.42,43
1 3 | ENDODONTIC CONSIDER ATIONS FOR LUXATED AND FRACTURED
TEETH
13.1 | Fully developed teeth (mature teeth with closed apex)
The pulp may survive after the trauma, but early endodontic treatment is
typically advisable for fully developed teeth that have been intruded, severe-
ly extruded, or laterally luxated. Calcium hydroxide is recommended as an
intra-canal medicament to be placed 1-2 weeks after trauma for up to 1
month followed by root canal filling.44 Alternately, a corticosteroid/antibiotic
paste can be used as an anti-inflammatory and anti-resorptive intra-canal
medicament to prevent external inflammatory (infection-related) resorption.
If such a paste is used, it should be placed immediately (or as soon as
possible) following repositioning of the tooth and then left in situ for at least
6 weeks.45–48 Medicaments should be carefully applied within the root canal
system while avoiding contact with the access cavity walls due to possible
discoloration of the crown.48

13.2 | Incompletely developed teeth (immature teeth with open apex)
The pulp of fractured and luxated immature teeth may survive and heal, or
there may be spontaneous pulp revascularization following luxation. Thus,
root canal treatment should be avoided unless there is clinical or radiographic
evidence of pulp necrosis or periapical infection on follow-up examinations.
The risk of infection-related (inflammatory) root resorption should be
weighed against thechances of obtaining pulp space revascularization. Such
resorption is very rapid in children. Hence, regular follow ups are manda-
tory so root canal treatment can be commenced as soon as this type of re-
sorption is detected (see below). Incompletely developed teeth that have
been intruded and also have a crown fracture (combined traumatic injuries)
are at higher risk of pulp necrosis and infection and, therefore, immediate
or early root canal treatment might be considered in these cases. Other
endodontic treatment of teeth with incompletely developed roots may in-
volve apexification or pulp space revascularization/revitalization techniques.
13.3 | Endodontic treatment for external inflammatory (infection-related)
root resorption
Whenever there is evidence of infection-related (inflammatory) external
resorption, root canal treatment should be initiated immediately. The canal
should be medicated with calcium hydroxide.49 The calcium hydroxide should
be placed for 3 weeks and replaced every 3 months until the radiolucencies
of the resorptive lesions disappear. Final obturation of the root canal can be
performed when bone repair is visible radiographically.
13.4 | Dental dam field isolation during endodontic treatment
Endodontic treatment should always be undertaken under dental dam isola-
tion. The dental dam retainer can be applied on one or more neighboring
teeth to avoid further trauma to the injured tooth/teeth and to prevent the
risk of fracturing an immature tooth. Dental floss or other stabilizing cords
may also be used instead of metal retainers.
1 4 | CORE OUTCOME SET
The International Association for Dental Traumatology (IADT) recently devel-
oped a core outcome set (COS) for traumatic dental injuries (TDIs) in children
and adults.7 This is one of the first COS developed in dentistry and is under-
pinned by a systematic review of the outcomes used in the trauma literature
and follows a robust consensus methodology. Some outcomes were iden-
tified as recurring throughout the different injury types. These outcomes
were then identified as “generic” (ie, relevant to all TDIs). Injury-specific
outcomes were also determined as those outcomes related only to one or
more individual TDIs. Additionally, the study established what, how, when,
and by whom these outcomes should be measured. Table 2 in the General
Introduction section66 of the Guidelines shows the generic and injury-
specific outcomes to be recorded at the follow-up review appointments
recommended for the different traumatic injuries. Further information for
each outcome is described in the original article.7
1 5 | ADDITIONAL RESOURCES
Besides the general recommendations above, clinicians are encouraged to
access the IADT’s official publication, the journal Dental Traumatology, the
IADT website (www.iadt-dentaltrauma.org), the free ToothSOS app and the
Dental Trauma Guide (www.dentaltraumaguide.org).
CONFLICT OF INTEREST
The authors declare there are no competing interests for the above manu-
script. No funding was received for the presented work. Images Courtesy of
the Dental Trauma Guide.
ETHICAL STATEMENT
No ethic approval was required for this paper.
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
ENDORSEMENTS: FRACTURES AND LUXATIONS
ORCID
Cecilia Bourguignon https://orcid.org/0000-0003-2753-649X
Nestor Cohenca https://orcid.org/0000-0002-0603-5437
Eva Lauridsen https://orcid.org/0000-0003-0859-7262
Marie Therese Flores https://orcid.org/0000-0003-2412-190X
Anne C. O’Connell https://orcid.org/0000-0002-1495-3983
Peter F. Day https://orcid.org/0000-0001-9711-9638
Georgios Tsilingaridis https://orcid.org/0000-0001-5361-5840
Paul V. Abbott https://orcid.org/0000-0001-5727-4211
Ashraf F. Fouad https://orcid.org/0000-0001-6368-1665
Bill Kahler https://orcid.org/0000-0002-4181-3871
Liran Levin https://orcid.org/0000-0002-8123-7936
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Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):314-330. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12578”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 551

ENDORSEMENTS: AVULSION OF PERMANENT TEETH

International Association of Dental Traumatology

Guidelines for the Management of Traumatic Dental
Injuries: 2. Avulsion of Permanent Teeth
Endorsed by the American Academy
of Pediatric Dentistry
 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(4):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(4):331-342; doi: 10.1111/edt.12573) Received May 19, 2020 | Accepted May 19 2020.
KEYWORDS: AVULSION, LUXATION, PREVENTION, TOOTH FRACTURE, TRAUMA

1
Adams School of Dentistry, University of North Carolina, Chapel Hill, NC, USA. 2UWA Dental
School, University of Western Australia, Crawley, WA, Australia. 3Division of Orthodontics and
Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden.
4
Center for Pediatric Oral Health Research, Stockholm, Sweden. 5Department of Pediatric Den-
tistry, University of Washington and Seattle Children’s Hospital, Seattle, WA, Australia. 6Resource
Center for Rare Oral Diseases, Copenhagen University Hospital, Copenhagen, Denmark. 7Private
Practice, Paris, France. 8Paediatric Dentistry, Dublin Dental University Hospital, Trinity College
Dublin, The University of Dublin, Dublin, Ireland. 9Department of Pediatric Dentistry, Faculty of
Dentistry, Universidad de Valparaíso, Valparaíso, Chile. 10School of Dentistry, Community Dental
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
Maxillofacial Surgery, Resource Centre for Rare Oral Diseases, University Hospital in Copenhagen
(Rigshospitalet), Copenhagen, Denmark. 13Department of Pediatric Dentistry, Faculty of Dentistry,
Hacettepe University, Ankara, Turkey. 14Faculty of Medicine and Health, The University of Sydney,
Sydney, NSW, Australia. 15School of Dentistry, The University of Queensland, St Lucia, QLD, Austra-
lia. 16Faculty of Dentistry, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
17
Specialist Private Practice, Bremen, Germany. 18Faculty of Medicine and Dentistry, University of
Alberta, Edmonton, AB, Canada.
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,
5th Floor, Edmonton, AB T6G 1C9, Canada.
Email: liran@ualberta.ca
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
Replantation is, in most situations, the treatment of choice but cannot
always be carried out immediately. Appropriate emergency management
and a treatment plan are important for a good prognosis. There are also
individual situations when replantation is not indicated (eg, severe caries or
periodontal disease, an uncooperative patient, severe cognitive impairment
requiring sedation, severe medical conditions such as immunosuppression,
and severe cardiac conditions) which must be dealt with individually. Al-
though replantation may save the tooth, it is important to realize that some
of the replanted teeth have low probability of long-term survival and may
be lost or condemned to extraction at a later stage. However, not replanting
a tooth is an irreversible decision and therefore saving it should be attempted.
In this regard, a recent study has shown that replanted teeth have higher
chances of long-term survival after following the IADT treatment guidelines,
compared to previous studies.18
Guidelines for the emergency management of dental traumatic injuries
are useful for delivering the best possible care in an efficient manner. The
International Association of Dental Traumatology (IADT) has developed a
consensus statement after an update of the dental literature and discussions
among expert groups. Experienced international researchers and clinicians

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

552 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY


from various specialties and general dentistry were included in the groups.
In cases where the data did not appear conclusive, recommendations were
based on best available evidence, consensus opinion, and in some situa-
tions majority decisions among IADT Board members. The guidelines should
therefore be seen as the current best evidence and practice based on litera-
ture research and professional opinion.
Guidelines should assist dentists, other healthcare professionals, and
patients in decision-making. Also, they should be clear, readily understand-
able, and practical with the aim of delivering appropriate care as effectively
and efficiently as possible. Guidelines are to be applied with the clinician’s
judgment of the specific clinical circumstances and patient characteristics,
including but not limited to compliance, finances, and understanding of
the immediate and longterm outcomes of treatment alternatives vs non-
treatment. The IADT cannot and does not guarantee favorable outcomes
from strict adherence to the Guidelines, but believes that their application
can maximize the chances of a favorable outcome. Guidelines undergo
periodic updates. The following guidelines by the International Association of
Dental Traumatology (IADT) represent a revision and update of the previous
guidelines that were published in 2012.19-21
In these IADT Guidelines for management of avulsed permanent teeth,
the literature has been searched using Medline and Scopus databases utiliz-
ing the search words: avulsion, exarticulation and replantation. The task group
discussed treatment in detail and reached consensus as to what to recom-
mend as the current best practice for emergency management. This text
aims to provide concise and necessary advice for treatment in the emergency
situation.
The final decision regarding patient care remains primarily with the
treating dentist. However, the consent to implement the final decision rests
with the patient, parent, or guardian. For ethical reasons, it is important that
the dentist provides the patient and guardian with pertinent information
relating to treatment to ensure they are maximally involved in the decision-
making process.
2 | FIRST AID FOR AVULSED TEETH AT THE PLACE OF ACCIDENT
Dentists should be prepared to give appropriate advice to the public about
first aid for avulsed teeth.2,11,22-27 An avulsed permanent tooth is one of the
few real emergency situations in dentistry. In addition to increasing the
public awareness by mass media campaigns or other means of communi-
cation, parents, guardians and teachers should receive information on how
to proceed following these severe and unexpected injuries. Also, instructions
may be given by telephone to people at the emergency site. Immediate
replantation of the avulsed tooth is the best treatment at the place of the
accident. If for some reason this cannot be carried out, there are alternatives
such as using different types of storage media.
If a tooth is avulsed, make sure it is a permanent tooth (primary teeth
should not be replanted) and follow these recommended instructions:
1. Keep the patient calm.
2. Find the tooth and pick it up by the crown (the white part). Avoid
touching the root. Attempt to place it back immediately into the jaw.
3. If the tooth is dirty, rinse it gently in milk, saline or in the patient’s saliva
and replant or return it to its original position in the jaw.28,29
4. It is important to encourage the patient/guardian/teacher/other person
to replant the tooth immediately at the emergency site.
5. Once the tooth has been returned to its original position in the jaw, the
patient should bite on gauze, a handkerchief or a napkin to hold it in
place.
6. If replantation at the accident site is not possible, or for other reasons
when replantation of the avulsed tooth is not feasible (eg, an unconscious
patient), place the tooth, as soon as possible, in a storage or transport
medium that is immediately available at the emergency site. This should
be done quickly to avoid dehydration of the root surface, which starts to
happen in a matter of a few minutes. In descending order of preference,
milk, HBSS, saliva (after spitting into a glass for instance), or saline are
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
ENDORSEMENTS: AVULSION OF PERMANENT TEETH
suitable and convenient storage mediums. Although water is a poor
medium, it is better than leaving the tooth to air-dry.28,29
7. The tooth can then be brought with the patient to the emergency clinic.
8. See a dentist or dental professional immediately.
The poster “Save a Tooth” is available in multiple languages: Arabic,
Basque, Bosnian, Bulgarian, Catalan, Czech, Chinese, Dutch, English, Estonian,
French, Georgian, German, Greek, Hausa, Hebrew, Hindi (India), Hungarian,
Icelandic, Indonesian Bahasa, Italian, Kannada (India), Korean, Latvian,
Marathi (India), Persian, Polish, Portuguese, Russian, Sinhalese, Slovenian,
Spanish, Tamil (India), Thai, Turkish, Ukrainian, and Vietnamese. This educa-
tional resource can be obtained at the IADT website: http://www.iadt-dental
trauma.org
The IADT’s free app, “ToothSOS” for mobile phones, is another useful
source of information for patients, providing instructions on what to do in
an emergency situation after a dental injury, including avulsion of a perma-
nent tooth.
3 | TREATMENT GUIDELINES FOR AVULSED PERMANENT TEETH
The choice of treatment is related to the maturity of the root (open or
closed apex) and the condition of the periodontal ligament (PDL) cells. The
condition of the PDL cells is dependent on the time out of the mouth and
on the storage medium in which the avulsed tooth was kept. Minimizing
the dry time is critical for survival of the PDL cells. After an extra-alveolar
dry time of 30 minutes, most PDL cells are non-viable.30,31 For this reason,
information regarding the dry time of the tooth prior to replantation or prior
to being placed in a storage medium is very important to obtain as part
of the history. From a clinical point of view, it is important for the clinician
to assess the condition of the PDL cells by classifying the avulsed tooth
into one of the following three groups before commencing treatment:
1. The PDL cells are most likely viable. The tooth has been replanted im-
mediately or within a very short time (about 15 minutes) at the place
of accident.
2. The PDL cells may be viable but compromised. The tooth has been kept
in a storage medium (eg, milk, HBSS (Save-a-Tooth or similar product),
saliva, or saline, and the total extra-oral dry time has been <60 minutes).
3. The PDL cells are likely to be non-viable. The total extra-oral dry time
has been more than 60 minutes, regardless of the tooth having been
stored in a medium or not.
These three groups provide guidance to the dentist on the prognosis of
the tooth. Although exceptions to the prognosis do occur, the treatment
will not change, but may guide the dentist’s treatment decisions.
3.1 | Treatment guidelines for avulsed permanent teeth with a closed
apex
3.1.1 | T he tooth has been replanted at the site of injury or before the
patient’s arrival at the dental clinic
1. Clean the injured area with water, saline, or chlorhexidine.
2. Verify the correct position of the replanted tooth both clinically and
radiographically.
3. Leave the tooth/teeth in place (except where the tooth is malpositioned;
the malpositioning needs to be corrected using slight digital pressure)
4. Administer local anesthesia, if necessary, and preferably with no vaso-
constrictor.
5. If the tooth or teeth were replanted in the wrong socket or rotated, con-
sider repositioning the tooth/teeth into the proper location up to 48
hours after the traumatic incident.
6. Stabilize the tooth for 2 weeks using a passive flexible splint such as
wire of a diameter up to 0.016” or 0.4 mm32 bonded to the tooth and
adjacent teeth. Keep the composite and bonding agents away from the
gingival tissues and proximal areas. Alternatively, nylon fishing line (0.13-
0.25 mm) can be used to create a flexible splint, using composite to bond
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 553
ENDORSEMENTS: AVULSION OF PERMANENT TEETH
it to the teeth. Nylon (fishing line) splints are not recommended for
children when there are only a few permanent teeth for stabilization of
the traumatized tooth. This stage of development may result in loosening
or loss of the splint.33 In cases of associated alveolar or jawbone fracture,
a more rigid splint is indicated and should be left in place for about 4
weeks.
7. Suture gingival lacerations, if present.
8. Initiate root canal treatment within 2 weeks after replantation (refer to
Endodontic Considerations).
9. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
10. Check tetanus status.36 (see: “Tetanus”)
1 1. Provide post-operative instructions. (see: “Patient instructions”)
12. Follow up. (see: “Follow-up procedures”)
3.1.2 | The tooth has been kept in a physiologic storage medium or stored
in non-physiologic conditions, with the extra-oral dry time less than 60
minutes
Physiologic storage media include tissue culture media and cell transport
media. Examples of osmolality-balanced media are milk and Hanks’ Balanced
Salt Solution (HBSS).
1. If there is visible contamination, rinse the root surface with a stream of
saline or osmolality-balanced media to remove gross debris.
2. Check the avulsed tooth for surface debris. Remove any debris by gently
agitating it in the storage medium. Alternatively, a stream of saline can
be used to briefly rinse its surface.
3. Put or leave the tooth in a storage medium while taking a history, exam-
ining the patient clinically and radiographically, and preparing the patient
for the replantation.
4. Administer local anesthesia, preferably without a vasoconstrictor.37
5. Irrigate the socket with sterile saline.
6. Examine the alveolar socket. If there is a fracture of the socket wall, re-
position the fractured fragment into its original position with a suitable
instrument.
7. Removal of the coagulum with a saline stream may allow better reposi-
tioning of the tooth.
8. Replant the tooth slowly with slight digital pressure. Excessive force
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-
graphically.
10. Stabilize the tooth for 2 weeks using a passive, flexible wire of a diameter
up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents away
from the gingival tissues and proximal areas. Alternatively, nylon fishing
line (0.13-0.25 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 children when there are only a few permanent teeth as stabilization
of the traumatized tooth may not be guaranteed. In cases of associated
alveolar or jawbone fracture, a more rigid splint is indicated and should
be left in place for about 4 weeks.
11. Suture gingival lacerations, if present.
12. Initiate root canal treatment within 2 weeks after replantation (refer to
“Endodontic Considerations”).38,39
13. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
14. Check tetanus status.36 (see: “Tetanus”)
15. Provide post-operative instructions. (see: “Post-operative instructions”)
16. Follow up. (see: “Follow-up procedures”)
3.1.3 | Extra-oral dry time longer than 60 minutes
1. Remove loose debris and visible contamination by agitating the tooth in
physiologic storage medium, or with gauze soaked in saline. Tooth may be
left in storage medium while taking a history, examining the patient clini-
cally and radiographically, and preparing the patient for the replantation.
2. Administer local anesthesia, preferably without vasoconstrictor.
3. Irrigate the socket with sterile saline.
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
554 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
4. Examine the alveolar socket. Remove coagulum if necessary. If there is
a fracture of the socket wall, reposition the fractured fragment with a
suitable instrument.
5. Replant the tooth slowly with slight digital pressure. The tooth should
not be forced back to place.
6. Verify the correct position of the replanted tooth both clinically and
radiographically.
7. Stabilize the tooth for 2 weeks40 using a passive flexible wire of a diameter
up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents away
from the gingival tissues and proximal areas. Alternatively, nylon fishing
line (0.13-0.25 mm) can be used to create a flexible splint, with composite
to bond it to the teeth. A more rigid splint is indicated in cases of alveolar
or jawbone fracture and should be left in place for about 4 weeks.
8. Suture gingival lacerations, if present.
9. Root canal treatment should be carried out within 2 weeks (refer to
Endodontic Considerations).
10. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
11. Check tetanus status.36 (see: “Tetanus”)
12. Provide post-operative instructions. (see: “Post-operative instructions”)
13. Follow up. (see: “Follow-up procedures”)
Delayed replantation has a poor long-term prognosis.41 The periodontal
ligament becomes necrotic and is not expected to regenerate. The expected
outcome is ankylosis-related (replacement) root resorption. The goal of
replantation in these cases is to restore, at least temporarily, esthetics and
function while maintaining alveolar bone contour, width, and height. Therefore,
the decision to replant a permanent tooth is almost always the correct deci-
sion even if the extra-oral dry time is more than 60 minutes. Replantation
will keep future treatment options open. The tooth can always be extracted,
if needed, and at the appropriate point following prompt inter-disciplinary
assessment. Parents of pediatric patients should be informed that decoro-
nation or other procedures such as autotransplantation might be necessary
later if the replanted tooth becomes ankylosed and infra-positioned, de-
pending on the patient’s growth rate41-46 and the likelihood of eventual
tooth loss. The rate of ankylosis and resorption varies considerably and can
be unpredictable.
3.2 | Treatment guidelines for avulsed permanent teeth with an open apex
3.2.1 | The tooth has been replanted before the patient’s arrival at the
clinic
1. Clean the area with water, saline, or chlorhexidine.
2. Verify the correct position of the replanted tooth both clinically and radio-
graphically.
3. Leave the tooth in the jaw (except where the tooth is malpositioned;
the malpositioning needs to be corrected using slight digital pressure).
4. Administer local anesthesia, if necessary, and preferably with no vasocon-
strictor.
5. If the tooth or teeth were replanted in the wrong socket or rotated, con-
sider repositioning the tooth/teeth into the proper location for up to 48
hours after the trauma.
6. Stabilize the tooth for 2 weeks using a passive and flexible wire of a
diameter up to 0.016” or 0.4 mm.32 Short immature teeth may require a
longer splinting time.47 Keep the composite and bonding agents away
from the gingival tissues and proximal areas. Alternatively, nylon fishing
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
fracture, a more rigid splint is indicated and should be left in place for 4
weeks.
7. Suture gingival lacerations, if present.
8. Pulp revascularization, which can lead to further root development, is
the goal when replanting immature teeth in children. The risk of external
infection-related (inflammatory) root resorption should be weighed
against the chances of revascularization. Such resorption is very rapid in

children. If spontaneous revascularization does not occur, apexification,
pulp revitalization/ revascularization,48,49 or root canal treatment should
be initiated as soon as pulp necrosis and infection is identified (refer to
Endodontic Considerations).
9. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
10. Check tetanus status.36 (see: “Tetanus”)
11. Provide post-operative instructions. (see: “Post-operative instructions”)
12. Follow up. (see: “Follow-up procedures”)
In immature teeth with open apices, there is a potential for spontaneous
healing to occur in the form of new connective tissue with a vascular supply.
This allows continued root development and maturation. Hence, endodontic
treatment should not be initiated unless there are definite signs of pulp
necrosis and infection of the root canal system at follow-up appointments.
3.2.2 | The tooth has been kept in a physiologic storage medium or
stored in non-physiologic conditions, and the extra-oral time has been
less than 60 minutes
Examples of physiologic or osmolality-balanced media are milk and HBSS.
1. Check the avulsed tooth and remove debris from its surface by gently
agitating it in the storage medium. Alternatively, a stream of sterile saline
or a physiologic medium can be used to rinse its surface.
2. Place or leave the tooth in a storage medium while taking the history,
examining the patient clinically and radiographically and preparing the
patient for the replantation.
3. Administer local anesthesia, preferably without vasoconstrictor.
4. Irrigate the socket with sterile saline.
5. Examine the alveolar socket. Remove coagulum, if necessary. If there is
a fracture of the socket wall, reposition the fractured segment with a
suitable instrument.
6. Replant the tooth slowly with slight digital pressure.
7. Verify the correct position of the replanted tooth both clinically and
radiographically.
8. Stabilize the tooth for 2 weeks using a passive and flexible wire of a di-
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, nylon
fishing line (0.13-0.25 mm) can be used to create a flexible splint, with
composite to bond it to the teeth. In cases of associated alveolar or jaw-
bone fracture, a more rigid splint is indicated and should be left for
about 4 weeks.
9. Suture gingival lacerations, if present.
10. Revascularization of the pulp space, which can lead to further root dev-
elopment, is the goal when replanting immature teeth in children. The
risk of external infection-related (inflammatory) root resorption should
be weighed against the chances of revascularization. Such resorption is
very rapid in children. If spontaneous revascularization does not occur,
apexification, pulp revitalization/revascularization,48,49 or root canal treat-
ment should be initiated as soon as pulp necrosis and infection is
identified (refer to Endodontic Considerations).
11. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
12. Check tetanus status.36 (see: “Tetanus”)
13. Provide post-operative instructions. (see: “Post-operative instructions”)
14. Follow up. (see: “Follow-up procedures”)
3.2.3 | Extra-oral time longer than 60 minutes
1. Check the avulsed tooth and remove debris from its surface by gently
agitating it in the storage medium. Alternatively, a stream of saline can
be used to rinse its surface.
2. Place or leave the tooth in a storage medium while taking the history,
examining the patient clinically and radiographically and preparing the
patient for the replantation.
3. Administer local anesthesia, preferably with no vasoconstrictor.
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
ENDORSEMENTS: AVULSION OF PERMANENT TEETH
4. Irrigate the socket with sterile saline.
5. Examine the alveolar socket. If there is a fracture of the socket wall,
reposition the fractured segment with a suitable instrument.
6. Replant the tooth slowly with slight digital pressure.
7. Verify the correct position of the replanted tooth both clinically and
radiographically.
8. Stabilize the tooth for 2 weeks using a passive and flexible wire of a di-
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,
nylon fishing line (0.13-0.25 mm) can be used to create a flexible splint,
with composite to bond it to the teeth. In cases of associated alveolar or
jawbone fracture, a more rigid splint is indicated and should be left for
about 4 weeks.
9. Suture gingival lacerations, if present.
10. Revascularization of the pulp space, which can lead to further root devel-
opment and maturation, is the goal when replanting immature teeth in
children. The risk of external infection-related (inflammatory) root resorp-
tion should be weighed against the chances of revascularization. Such
resorption is very rapid in children. If spontaneous revascularization does
not occur, apexification, pulp revitalization/revascularization, or root canal
treatment should be initiated as soon as pulp necrosis and infection is
identified (refer to Endodontic Considerations).
11. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
12. Check tetanus status.36 (see: “Tetanus”)
13. Provide post-operative instructions. (see: “Post-operative instructions”)
14. Follow up. (see: “Follow-up procedures”)
Delayed replantation has a poor long-term prognosis.41 The periodontal
ligament becomes necrotic and is not expected to regenerate. The expected
outcome is ankylosis-related (replacement) root resorption. The goal of re-
plantation in these cases is to restore esthetics and function, at least tem-
porarily, while maintaining alveolar bone contour, width and height.
Therefore, the decision to replant a tooth is almost always the correct decision
even if the extraoral time is more than 60 minutes. Replantation will keep
future treatment options open. The tooth can always be extracted later if
needed, and at the appropriate point following a prompt inter-disciplinary
assessment. Parents should be informed that decoronation or other pro-
cedures such as autotransplantation might be necessary if the replanted
tooth becomes ankylosed and infra-positioned depending on the patient’s
growth41-46 and the likelihood of tooth loss. The rate of ankylosis and re-
sorption varies considerably and can be unpredictable.
4 | ANESTHETICS
The best treatment for an avulsed tooth is immediate replantation at the
site of the accident, which is usually not painful. While local anesthesia is
not available when teeth are replanted at the site of injury, once the patient
arrives at a dental or medical facility, pain control by means of local anes-
thesia is always recommended.50-55 There are concerns as to whether there
are risks of compromising healing by using a vasoconstrictor in the anesthetic
solution. However, there is little evidence to support omitting a vasocon-
strictor in the oral and maxillofacial region. Regional anesthesia (eg, infra-
orbital nerve block) may be considered as an alternative to infiltration
anesthesia in more severe injury cases and must be determined by the
clinician’s experience of providing such block injections.51,52
5 | SYSTEMIC ANTIBIOTICS
Even though the value of systemic administration of antibiotics is highly
questionable, the periodontal ligament of an avulsed tooth often becomes
contaminated by bacteria from the oral cavity, the storage medium, or the
environment in which the avulsion occurred. Therefore, the use of systemic
antibiotics after avulsion and replantation has been recommended to prevent
infection-related reactions and to decrease the occurrence of inflammatory
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 555
ENDORSEMENTS: AVULSION OF PERMANENT TEETH
root resorption.34,35 Additionally, the patient’s medical status or concomitant
injuries may warrant antibiotic coverage. In all cases, appropriate dosage
for the patient’s age and weight should be calculated. Amoxicillin or peni-
cillin remain the first choices due to their effectiveness on oral flora and
low incidence of side effects. Alternative antibiotics should be considered
for patients with an allergy to penicillin. The effectiveness of tetracycline
administered immediately after avulsion and replantation has been demon-
strated in animal models.35 Specifically, doxycycline is an appropriate
antibiotic to use because of its antimicrobial, anti-inflammatory and anti-
resorptive effects. However, the risk of discoloration of permanent teeth
must be considered before systemic administration of a tetracycline in
young patients. Tetracycline or doxycycline are generally not recommended
for patients under 12 years of age.56
6 | TOPICAL ANTIBIOTICS
The effect of topical antibiotics placed on the root surface prior to replanta-
tion with respect to pulp revascularization remains controversial.8,57,58 While
animal studies have shown great potential,59-61 human studies have failed
to demonstrate improved pulp revascularization when teeth are soaked in
topical antibiotics.62 Therefore, a specific antibiotic, duration of use, or
methods of application cannot be recommended based on human studies
(see future areas of research).
7 | TETANUS
Although most people receive tetanus immunization and boosters, it can-
not be assumed that this is always the case.36,63,64 Refer the patient to a
physician for evaluation of the need for a tetanus booster.
8 | STABILIZATION OF REPLANTED TEETH (SPLINTING)
Avulsed teeth always require stabilization to maintain the replanted tooth
in its correct position, provide patient comfort and improve function.32,47,65-72
Current evidence supports short-term, passive and flexible splints for stabi-
lization of replanted teeth. Studies have shown that periodontal and pulp
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”
or 0.4 mm32 or with nylon fishing line (0.13-0.25 mm), and bonded to the
teeth with composite resin. Replanted permanent teeth should be stabilized
for a period of 2 weeks depending on the length and degree of maturation
of the root. An animal study has shown that more than 60% of the mecha-
nical properties of the injured PDL return within 2 weeks following injury.69
However, the likelihood of successful periodontal healing after replantation
is not likely to be affected by splinting duration.47
Wire (or nylon line) and composite stabilization should be placed on the
labial surfaces to avoid occlusal interference and to enable palatal/lingual
access for endodontic procedures. Various types of wire (or nylon line) and
acid etch bonded stabilization have been used to stabilize avulsed teeth
as they allow good oral hygiene and they are well tolerated by patients.72 It
is critically important to keep the composite and bonding agents away from
the marginal gingiva and interproximal areas to avoid plaque retention and
secondary infection, and to allow relatively easy cleaning by the patient.
The patient and parent should be advised that on removal of the splint, the
injured tooth may be mobile. An additional week of splinting is appropriate
only if excessive trauma from the opposing dentition might further trau-
matize the tooth or if the avulsed tooth is unable to remain in the correct
position. An assessment of this should be made after the splint is removed
and the occlusion checked.
9 | PATIENT INSTRUCTIONS
Patient compliance with follow-up visits and home care contributes to
satisfactory healing following an injury.2,24,25,27,29 Both patients and parents
or guardians of young patients should be advised regarding care of the
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
556 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
replanted tooth for optimal healing and prevention of further injury. They
should be advised to:
1. Avoid participation in contact sports.
2. Maintain a soft diet for up to 2 weeks, according to the tolerance of the
patient.65
3. Brush their teeth with a soft toothbrush after each meal.
4. Use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks.
10 | ENDODONTIC CONSIDERATIONS
When endodontic treatment is indicated (teeth with closed apex),17,73-81 treat-
ments hould be initiated within 2 weeks postreplantation. Endodontic treat-
ment should always be undertaken after isolation with the dental dam. This
may be achieved by placing the dental dam retainer on neighboring uninjured
teeth to avoid further trauma to the injured tooth/teeth. Calcium hydroxide
is recommended as an intracanal medicament for up to 1 month followed
by root canal filling.82,83 If a corticosteroid or corticosteroid/antibiotic mixture
is chosen to be used as an anti-inflammatory and anti-resorptive intracanal
medicament, it should be placed immediately or shortly after replantation
and left in situ for at least 6 weeks.76,78,84 Medicaments should be carefully
applied to the root canal system with care to avoid placement in the crown
of the tooth. Some medicaments have been shown to discolor teeth, leading
to patient dissatisfaction.77
In teeth with open apices, spontaneous pulp space revascularization
may occur. Thus, root canal treatment should be avoided unless there is
clinical or radiographic evidence of pulp necrosis and infection of the root
canal system on follow-up examinations. The risk of infection-related (inflam-
matory) root resorption should be weighed against the chances of obtain-
ing pulp space revascularization. Such resorption is very rapid in children.
In cases where pulp necrosis and infection of the root canal system are
diagnosed, root canal treatment, apexification or pulp space revascularization/
revitalization should be performed. In cases where ankylosis is expected and
decoronation is anticipated, proper consideration of the intracanal materials
used and their duration is indicated.
11 | FOLLOW-UP PROCEDURES
11.1 | Clinical control
Replanted teeth should be monitored clinically and radiographically at 2
weeks (when the splint is removed), 4 weeks, 3 months, 6 months, one year,
and yearly thereafter for at least five years.2,6-9,25,26,85 Clinical and radiographic
examination will provide information to determine the outcome. Evaluation
may include the findings described below.
For open apex teeth where spontaneous pulp space revascularization is
possible, clinical and radiographic reviews should be more frequent owing
to the risk of infection-related (inflammatory) resorption and the rapid loss
of the tooth and supporting bone when this is not identified quickly. Evi-
dence of root and/or bone resorption anywhere around the circumference
of the root should be interpreted as infection-related (inflammatory) resorp-
tion. Radiographic absence of periodontal ligament space, the replacement
of root structure by bone, together with a metallic sound to percussion,
should be interpreted as ankylosis-related (replacement) resorption. It is
worth noting that the two types of resorption may occur concurrently. For
these reasons, replanted teeth with an open apex should be monitored
clinically and radiographically at 2 weeks (when the splint is removed), 1, 2,
3, 6 months, one year, and yearly thereafter for at least five years.2,6-9,25,26,85
1 1.2 | Favorable outcomes
1 1.2.1 | Closed apex
Asymptomatic, functional, normal mobility, no sensitivity to percussion, and
normal percussion sound. No radiolucencies and no radiographic evidence
of root resorption. The lamina dura appears normal.

11.2.2 | Open apex
Asymptomatic, functional, normal mobility, no sensitivity to percussion, and
normal percussion sound. Radiographic evidence of continued root form-
ation and tooth eruption. Pulp canal obliteration is expected and can be
recognized radiographically sometime during the first year after the trauma.
It is considered to be the mechanism by which the “pulp” heals after
replantation of avulsed immature permanent teeth.86
11.3 | Unfavorable outcomes
11.3.1 | Closed apex
Patient may or may not have symptoms; presence of swelling or sinus tract;
the tooth may have excessive mobility or no mobility (ankylosis) with high-
pitched (metallic) percussion sound. Presence of radiolucencies. Radiographic
evidence of infection-related (inflammatory) resorption, ankylosis-related
(replacement) resorption, or both. When ankylosis occurs in a growing
patient, infra-position of the tooth is highly likely to create disturbances in
alveolar and facial growth over the short, medium and long term.
11.3.2 | Open apex
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
high-pitched percussion sound. In the case of ankylosis, the tooth may
gradually become infra-positioned. Presence of radiolucencies. Radiographic
evidence of infection-related (inflammatory) resorption, ankylosis-related
(replacement) resorption, or absence of continued root formation. When
ankylosis occurs in a growing patient, infra-position of the tooth is highly
likely to create disturbances of alveolar and facial growth over the short,
medium and long term.
12 | LONG-TERM FOLLOW-UP CARE (LOSS OF TOOTH OR INFRA-OCCLUSION)
Follow-up care requires good coordination between the initial provider of
treatment and specialists in secondary care services (eg, an inter-disciplinary
team such as an orthodontist and pediatric dentist and/or endodontist)
with the appropriate experience and training in the holistic management of
complex dento-alveolar trauma. The team will benefit from other specialists
who will provide longer-term care such as a bonded bridge, a transplant, or
an implant. In situations where access to an inter-disciplinary team may not
be possible, dentists can only be expected to provide follow-up care and
treatment within their experience, training and competence.
Patients or parents and children need to be fully informed of the prog-
nosis of an avulsed tooth as soon as possible. They should be fully engaged
in the decision-making process. Furthermore, the potential costs of and
time required for different treatment options should be openly discussed.
In cases where teeth are lost in the emergency phase after trauma, or
will likely be lost later, discussions with appropriate colleagues who have
expertise with managing these cases are prudent, especially in growing
patients. Ideally, these discussions should take place before the tooth shows
signs of infra-position. Appropriate treatment options may include decor-
onation, autotransplantation, a resin-retained bridge, a removable partial
denture or orthodontic space closure with or without composite resin modi-
fication. Treatment decisions are based on a full discussion with the patient
or the child and parents and the clinician’s expertise with the aim to keep
all options open until maturity is reached. The decision to perform decor-
onation is made when the ankylosed tooth shows evidence of infra-occlusion
that is deemed esthetically unacceptable and cannot be corrected by
simple restorative treatment.41,45 After growth is completed, implant treatment
can be considered. Readers are referred to relevant textbooks and journal
articles for further reading regarding these procedures.
13 | CORE OUTCOME SET
The IADT recently developed a core outcome set (COS) for traumatic dental
injuries (TDI) in children and adults.87 This is one of the first COS developed
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
ENDORSEMENTS: AVULSION OF PERMANENT TEETH
in dentistry and follows a robust consensus methodology and is underpinned
by a systematic review of the outcomes used in the trauma literature.88 A
number of outcomes were identified as recurring throughout the different
injury types. These outcomes were then included as “generic”—that is re-
levant 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. Further information for each outcome is described in the original
paper.87
Generic outcomes:
1. Periodontal healing
2. Pulp space healing (for open apex teeth)
3. Pain
4. Discoloration
5. Tooth loss
6. Quality of life
7. Esthetics (patient perception)
8. Trauma-related dental anxiety
9. Number of clinic visits
Injury-specific outcomes:
1. Infra-occlusion
14 | FUTURE ARE AS OF RESEARCH—TOPICS DISCUSSED BUT NOT
INCLUDED AS RECOMMENDATIONS IN THESE GUIDELINES
Several promising treatment procedures for avulsed teeth have been dis-
cussed in the consensus group. Some of these treatment suggestions have
certain experimental evidence, and some are used in clinical practice. Accord-
ing to the working group members, there is currently insufficient weight or
quality of clinical and/or experimental evidence for some of these methods
to be recommended in these Guidelines. The group advocates further research
and documentation for the following:
• Revascularization of the pulp space—see guidelines published by the
American Association of Endodontists (AAE)89 and the European Society
of Endodontology (ESE).90
• Optimal splint types and length of time relative to periodontal and pulp
healing.
• Effect on healing when a local anesthetic containing vasoconstrictors is
used.
• Effects of topical and systemic antibiotics on healing and root resorption.
• Effect of intracanal corticosteroids on healing and root resorption.
• Long-term development or establishment of the alveolar crest following
replantation and decoronation.
• Effect of periodontal regeneration on the restoration of normal function.
• Periodontal healing following tooth replantation.
• Home care following tooth replantation.
CONFLICT OF INTEREST
The authors confirm that they have no conflict of interest.
ETHICAL APPROVAL
No ethic approval was required for this paper.
DISCLAIMER
These guidelines are intended to provide information for healthcare provid-
ers caring for patients with dental injuries. They represent the current best
evidence based on literature research and professional opinion. As is true for
all guidelines, the healthcare provider must use clinical judgment dictated
by the conditions present in any given traumatic situation. The IADT does
not guarantee favorable outcomes from following the Guidelines, but using
the recommended procedures can maximize the chances of success.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 557
ENDORSEMENTS: AVULSION OF PERMANENT TEETH
ORCID
Ashraf F. Fouad https://orcid.org/0000-0001-6368-1665
Paul V. Abbott https://orcid.org/0000-0001-5727-4211
Georgios Tsilingaridis https://orcid.org/0000-0001-5361-5840
Nestor Cohenca https://orcid.org/0000-0002-0603-5437
Eva Lauridsen https://orcid.org/0000-0003-0859-7262
Anne O’Connel https://orcid.org/0000-0002-1495-3983
Marie Therese Flores https://orcid.org/0000-0003-2412-190X
Peter F. Day https://orcid.org/0000-0001-9711-9638
Bill Kahler https://orcid.org/0000-0002-4181-3871
Liran Levin https://orcid.org/0000-0002-8123-7936
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89. American Association of Endodontists. Regenrative Endodontics. Avail-
able from https://www.aae.org/specialty/clinical-resources/regenerative-
endodontics/. Accessed June 2, 2020.
90. Galler KM, Krastl G, Simon S, Van Gorp G, Meschi N, Vahedi B, et al.
European Society of Endodontology position statement: revitalization
procedures. Int Endod J. 2016;49:717–23.

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© 2020 The Authors. Dental Traumatology 2020;36(4):331-342. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12573”.
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 ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

International Association of Dental Traumatology

Guidelines for the Management of Traumatic Dental
Injuries: 3. Injuries in the Primary Dentition
Endorsed by the American Academy
of Pediatric Dentistry
 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(4):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(4):343-359; doi: 10.1111/edt.12576)
Received May 19, 2020 | Accepted May 19 2020.
KEYWORDS: AVULSION, LUXATION, PREVENTION, TOOTH FRACTURE, TRAUMA

1
School of Dentistry, University of Leeds and Community Dental Service Bradford District Care
NHS Trust, Leeds, UK. 2Department of Pediatric Dentistry, Faculty of Dentistry, Universidad de
Valparaíso, Valparaíso, Chile. 3Paediatric Dentistry, Dublin Dental University Hospital, Trinity
College Dublin, The University of Dublin, Dublin, Ireland. 4UWA Dental School, University of
Western Australia, Nedlands, WA, Australia. 5Division of Orthodontics and Pediatric Dentistry,
Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden. 6Center for Pediatric
Oral Health Research, Stockholm, Sweden. 7Adams School of Dentistry, University of North
Carolina, Chapel Hill, NC, USA. 8Department of Pediatric Dentistry, University of Washington
and Seattle Children’s Hospital, Seattle, WA, USA. 9Resource Center for Rare Oral Diseases, Co-
penhagen University Hospital, Copenhagen, Denmark. 10Specialist Private Practice, Paris, France.
11
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,
University Hospital in Copenhagen (Rigshospitalet), Copenhagen, Denmark. 13Department of
Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. 14Faculty of
Medicine and Health, The University of Sydney, Sydney, NSW, Australia. 15School of Dentistry,
The University of Queensland, St Lucia, Qld, Australia. 16Faculty of Dentistry, College of Health
Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. 17Specialist Private Practice, Bremen,
Germany. 18Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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,
5th Floor, Edmonton, AB T6G 1C9, Canada.
Email: liran@ualberta.ca
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
common area of the body to be injured.2 A recent meta-analysis on trau-
matic dental injuries (TDIs) reveals a world prevalence of 22.7% affecting the
primary teeth.3 Repeated TDIs are also frequently seen in children.4
Unintentional falls, collisions, and leisure activities are the most common
reasons for TDIs, especially as children learn to crawl, walk, run, and embrace
their physical environment.5 They most commonly occur between 2 and
6 years of age4–7 with injuries to periodontal tissues occurring most fre-
quently.6,8 Children with these injuries present to many healthcare settings,
including general dental practitioners, emergency medical services, pharma-
cists, community dental clinics, and specialist dental services. Consequently,
each service provider needs to have the appropriate knowledge, skills, and
training in how to care for children with TDIs to their primary dentition.
The primary teeth Guidelines contain recommendations for the diagnosis
and management of traumatic injuries to the primary dentition, assuming
the child is medically healthy with a sound and caries-free primary dentition.
Management strategies may change where multiple teeth are injured. Many
articles have contributed to the content of these Guidelines and the treat-
ment tables (1-12) and these articles are not mentioned elsewhere in this
introductory text.9–15

Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
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1.1 | Initial presentation and minimizing anxiety to the child and parent
Management of TDIs in children is distressing for both the child and the
parents. It can also be challenging for the dental team. A TDI in the primary
dentition often may be the reason for the child’s first visit to the dentist.
Minimizing anxiety for the child and parents, or other caregivers, during the
initial visit is essential. At this young age, the child may resist co-operating for
an extensive examination, radiographs, and treatment. Knee-to-knee exami-
nation can be helpful in examining a young child. Information about how
to undertake an examination of a child with a TDI involving their primary
dentition can be found in current textbooks16–18 or can be viewed in the fol-
lowing video (https://tinyurl.com/kneetokneeexamination). Wherever possible,
the acute and follow-up dental care should be provided by a child-
oriented team that has experience and expertise in the management of
pediatric oral injuries. These teams are best placed to access specialist diag-
nostic and treatment services, including sedation and general anesthesia,
and pain management for the prevention or minimization of suffering.19
1.2 | A structured approach
It is essential that clinicians adopt a structured approach to managing trau-
matic dental injuries. This includes history taking, undertaking the clinical
examination, collecting test results, and how this information is recorded.
The literature shows that the use of a structured history at the initial consul-
tation leads to a significant improvement in the quality of the trauma records
involving the permanent dentition5,20. There are a variety of structured his-
tories available in current textbooks16–18 or used at different specialist cen-
ters.21,22 Extra-oral and intra-oral photographs act as a permanent record of
the injuries sustained and are strongly recommended.
1.3 | Initial assessment
Elicit a careful medical, social (including those who attend with the child),
dental, and accident history. Thoroughly examine the head and neck and
intra-orally for both bony and soft tissue injuries.17,18 Be alert to concomitant
injuries including head injury, facial fractures, missing tooth fragments, or
lacerations. Seek a medical examination if necessary.
1.4 | Soft tissue injuries
It is essential to identify, record, and diagnose extra-oral and intraoral soft
tissue injuries.18,23 The lips, oral mucosa, attached and free gingivae, and the
frenula should be checked for lacerations and hematomas. The lips should
be examined for possible embedded tooth fragments. The presence of a
soft tissue injury is strongly associated with the pursuit of immediate care.
Such injuries are most commonly found in the 0- to 3-year age group.24
Management of soft tissues, beyond just first aid, should be provided by a
child-oriented team with experience in pediatric oral injuries. Parental en-
gagement with the homecare for soft tissue injuries to the gingivae is criti-
cal and will influence the outcomes for healing of the teeth and soft tissues.
Parental homecare instructions for intra-oral soft tissue injuries are described
later in these Guidelines.
1.5 | Tests, crown discoloration, and radiographs
Extra-oral and intra-oral photographs are strongly recommended.
Pulp sensibility tests are unreliable in primary teeth and are therefore
not recommended.
Tooth mobility, color, tenderness to manual pressure, and the position or
displacement should be recorded.
The color of injured and uninjured teeth should be recorded at each clinic
visit. Discoloration is a common complication following luxation injuries.8,25–27
This discoloration may fade, and the tooth may regain its original shade over
a period of weeks or months.8,28–30 Teeth with persistent dark discoloration
may remain asymptomatic clinically and radiographically normal, or they
may develop apical periodontitis (with or without symptoms).31,32 Root canal
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
562 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
treatment is not indicated for discolored teeth unless there are clinical or
radiographic signs of infection of the root canal system.18,33
Every effort has been made in these Guidelines to reduce the number
of radiographs needed for accurate diagnosis, thus minimizing a child’s ex-
posure to radiation. For essential radiographs, radiation protection includes
the use of a thyroid collar where the thyroid is in the path of the primary X-ray
beam and a lead apron for when parents are holding the child. Radiation-
associated risks for children are a concern as they are substantially more
susceptible to the effects of radiation exposure for the development of most
cancers than adults. This is due to their longer life expectancy and the acute
radiosensitivity of some developing organs and tissues.34,35 Therefore, clini-
cians should question each radiograph they take and cognitively ask whether
additional radiographs will positively affect the diagnosis or treatment pro-
vided for the child. Clinicians must work within the ALARA (As Low As
Reasonably Achievable) principles to minimize the radiation dose. The use of
CBCT following TDI in young children is rarely indicated.36
1.6 | Diagnosis
A careful and systematic approach to diagnosis is essential. Clinicians should
identify all injuries to each tooth including both hard tissues injuries (eg,
fractures) and periodontal injuries (eg, luxations). When concomitant injuries
occur in the primary dentition following extrusion and lateral luxation in-
juries, they have a detrimental impact on pulp survival.27 The accompanying
tables (1-12) and the trauma pathfinder diagram (www.dentaltraumaguide.org)
help clinicians identify all possible injuries for each injured tooth.
1.7 | Intentional (non-accidental) injuries
Dental and facial trauma can occur in cases of intentional injuries. Clinicians
should check whether the history of the accident and the injuries sustained
are consistent or match. In situations where there is suspicion of abuse,
prompt referral for a full physical examination and investigation of the
incident should be arranged. Referral should follow local protocols, which is
beyond the scope of these Guidelines.
1.8 | Impact of orofacial and primary tooth trauma on the permanent
dentition
There is a close spatial relationship between the apex of the primary tooth
root and the underlying permanent tooth germ. Tooth malformation, im-
pacted teeth, and eruption disturbances in the developing permanent den-
tition are some of the consequences that can occur following injuries to
primary teeth and the alveolar bone.37–43 Intrusion and avulsion injuries are
most commonly associated with the development of anomalies in the per-
manent dentition.37–42
For intrusive and lateral luxation injuries, previous Guidelines have recom-
mended the immediate extraction of the traumatized primary tooth if the
direction of displacement of the root is toward the permanent tooth germ.
This action is no longer advised due to (a) evidence of spontaneous re-
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
lack of evidence that immediate extraction will minimize further damage to
the permanent tooth germ.
It is very important to document that parents have been informed
about possible complications to the development of the permanent teeth,
especially following intrusion, avulsion, and alveolar fractures.
1.9 | Management strategy for injuries to the primary dentition
In general, there is limited evidence to support many of the treatment options
in the primary dentition. Observation is often the most appropriate option in
the emergency situation unless there is risk of aspiration, ingestion, or inter-
ference with the occlusion. This conservative approach may reduce additional
suffering for the child18 and the risk of further damage to the permanent
dentition.18,46,47
 ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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 ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
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 ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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 ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

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© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.

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A summary of the management of TDIs in the primary dentition in-
cludes the following:
• A child’s maturity and ability to cope with the emergency situation, the
time for shedding of the injured tooth, and the occlusion are all important
factors that influence treatment.
• It is critical that parents are given appropriate advice on how best to man-
age the acute symptoms to avoid further distress.48,49 Luxation injuries,
such as intrusion and lateral luxation, and root fractures may cause severe
pain. The use of analgesics such as ibuprofen and/or acetaminophen
(paracetamol) is recommended when pain is anticipated.
• Minimizing dental anxiety is essential. Provision of dental treatment de-
pends on the child’s maturity and ability to cope. Various behavioral
approaches are available50–51 and have been shown to be effective for
managing acute procedures in an emergency situation.52,53 TDIs and their
treatment have the potential to lead to both post-traumatic stress
disorder and dental anxiety. The development of these conditions in
young children is a complex issue54,55 with little research specifically
examining either condition following TDIs in the primary dentition.
However, evidence from the wider dental literature suggests that the
multi-factorial nature of dental anxiety, its fluctuating nature, and the
role of dental extractions are exacerbating factors.56–58 Where possible,
avoidance of dental extractions, especially at the acute or initial visit, is
a reasonable strategy.
• Where appropriate and the child’s cooperation allows, options that main-
tain the child’s primary dentition should be the priority.59 Discussions
with parents about the different treatment options should include the
potential for further treatment visits and consideration for how best
to minimize the impact of the injury on the developing permanent
dentition.60
• For crown and crown-root fractures involving the pulp, root fractures,
and luxation injuries, rapid referral within several days to a child-oriented
team that has experience and expertise in the management of dental
injuries in children is essential.
• Splinting is used for alveolar bone fractures40,61 and occasionally may be
needed in cases of root fractures62 and lateral luxations.62
1.10 | Avulsed primary teeth
An avulsed primary tooth should not be replanted. Reasons include a signifi-
cant treatment burden (including replantation, splint placement and removal,
root canal treatment) for a young child as well as the potential of causing
further damage to the permanent tooth or to its eruption.40,41,63,64 However,
the most important reason is to avoid a medical emergency resulting from
aspiration of the tooth. Careful follow up is required to monitor the develop-
ment and eruption of the permanent tooth. Refer to the accompanying
table () for specific guidance.
1.11 | Antibiotics and Tetanus
There is no evidence for recommending the use of systemic antibiotics in
the management of luxation injuries in the primary dentition. However,
antibiotic use does remain at the discretion of the clinician when TDIs are
accompanied by soft tissue and other associated injuries or significant
surgical intervention is required. Finally, the child’s medical status may
warrant antibiotic coverage. The child’s pediatrician should be contacted
where questions arise in these situations.
A tetanus booster may be required if environmental contamination of
the injury has occurred. If in doubt, refer to a medical practitioner within
48 hours.
1.12 | Parental instructions for homecare
Successful healing following an injury to the teeth and oral tissues depends
on good oral hygiene. To optimize healing, parents or caregivers should
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
ENDORSEMENTS: INJURIES IN PRIMARY DENTITION
be advised regarding care of the injured tooth/teeth and the prevention of
further injury by supervising potentially hazardous activities. Clean the
affected area with a soft brush or cotton swab and use alcohol-free chlor-
hexidine gluconate 0.12% mouth rinse applied topically twice a day for one
week to prevent accumulation of plaque and debris and to reduce the
bacterial load. Care should be taken when eating not to further traumatize
the injured teeth while encouraging a return to normal function as soon as
possible.
Parents or caregivers should be advised about possible complications
that may occur, such as swelling, increased mobility, or a sinus tract. Children
may not complain about pain, but infection may be present. Parents or care-
givers should watch for signs of infection such as swelling of the gums. If
present, they should take the child to a dentist for treatment. Examples of
unfavorable outcomes are found in the table for each injury (Tables 1-12).
1.13 | Training, skills, and experience for teams managing the follow-up
care
During the follow-up phase of treatment, dental teams caring for children
with complex injuries to the primary dentition should have specialist train-
ing, experience, and skills. These attributes enable the members of the team
to respond appropriately to the medical, physical, emotional, and devel-
opmental needs of children and their families. In addition, skills within the
team should also encompass health promotion and access to specialist
diagnostic and treatment services including sedation, general anesthesia, and
overall pain management for the prevention or minimization of suffering.19
1.14 | Prognosis
Factors relating to the injury and subsequent treatment may influence pulp
and periodontal outcomes, and they should be carefully recorded. These
prognostic factors need to be carefully collected at both the initial consulta-
tion and follow-up visits. This is most likely achieved using the structured
history form described previously. The dental literature and appropriate
websites (eg, www.dentaltraumaguide.org) provide clinicians with useful in-
formation on the probable pulp and periodontal prognosis. These sources of
information can be invaluable when having conversations with the parents
or caregivers and the child.
1.15 | Core outcome set
The International Association for Dental Traumatology (IADT) recently devel-
oped a core outcome set (COS) for traumatic dental injuries (TDIs) in children
and adults.65 This is one of the first COS developed in dentistry and is under-
pinned by a systematic review of the outcomes used in the trauma literature
and follows a robust consensus methodology.66 Some outcomes were iden-
tified as recurring throughout the different injury types. These outcomes
were then identified as “generic” (ie, relevant to all TDIs). Injury-specific
outcomes were also determined as those outcomes related only to one or
more individual TDIs. Additionally, the study established what, how, when,
and by whom these outcomes should be measured. Table 1 in the General
Introduction section67 of the Guidelines shows the generic and injury-
specific outcomes to be recorded at the follow-up review appointments
recommended for the different traumatic injuries. Further information for
each outcome is described in the original article.65
CONFLICT OF INTEREST
The authors declare there is no competing interest for the above manuscript.
Images courtesy of the Dental Trauma Guide.
ETHICAL STATEMENT
No ethics approval was required for this paper
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ORCID
Peter F. Day https://orcid.org/0000-0001-9711-9638
Marie Therese Flores https://orcid.org/0000-0003-2412-190X
Anne C. O’Connell https://orcid.org/0000-0002-1495-3983
Paul V. Abbott https://orcid.org/0000-0001-5727-4211
Georgios Tsilingaridis https://orcid.org/0000-0001-5361-5840
Ashraf F. Fouad https://orcid.org/0000-0001-6368-1665
Nestor Cohenca https://orcid.org/0000-0002-0603-5437
Eva Lauridsen https://orcid.org/0000-0003-0859-7262
Cecilia Bourguignon https://orcid.org/0000-0003-2753-649X
Bill Kahler https://orcid.org/0000-0002-4181-3871
Liran Levin https://orcid.org/0000-0002-8123-7936
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Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
574 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
the teeth, 5th edn. Copenhagen, Denmark: Wiley Blackwell; 2019. p.
295–326.
18. Flores MT, Holan G, Andreasen JO, Lauridsen E. Injuries to the primary
dentition. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook
and color atlas of traumatic injuries to the teeth, 5th edn. Copenhagen,
Denmark: Wiley Blackwell; 2019. p. 556–88.
19. World Medical Association. Declaration of Ottawa on Child Health.
2009; https://www.wma.net/policies-post/wma-declaration-of-ottawa-on-
child-health/. Accessed June 4, 2020.
20. Day PF, Duggal MS. A multicentre investigation into the role of struc-
tured histories for patients with tooth avulsion at their initial visit to
a dental hospital. Dent Traumatol. 2003;19:243–7.
21. Day PF, Duggal MS. The role for ‘reminders’ in dental traumatology: 1.
Current practices in the UK and Ireland. Dent Traumatol. 2006;22:247–51.
22. Andreasen JO. Appendix 1 and 2. In: Andreasen JO, Andreasen FM,
Andersson L, eds. Textbook and color atlas of traumatic injuries to the
teeth, 5th edn. Copenhagen, Denmark: Wiley Blackwell, 2019; p. 1020–3.
23. Andersson L, Andreasen JO. Soft tissue injuries. In: Andreasen JO,
Andreasen FM, Andersson L, editors. Textbook and color atlas of trau-
matic injuries to the teeth, 5th edn. Copenhagen, Denmark: Wiley
Blackwell; 2019. p. 626–44.
24. Soares TR, Barbosa AC, Oliveira SN, Oliveira EM, Risso Pde A, Maia LC.
Prevalence of soft tissue injuries in pediatric patients and its relation-
ship with the quest for treatment. Dent Traumatol. 2016;32:48–51.
25. Lauridsen E, Blanche P, Amaloo C, Andreasen JO. The risk of healing
complications in primary teeth with concussion or subluxation injury - a
retrospective cohort study. Dent Traumatol. 2017;33:337–44.
26. Lauridsen E, Blanche P, Yousaf N, Andreasen JO. The risk of healing
complications in primary teeth with intrusive luxation: A retrospective
cohort study. Dent Traumatol. 2017;33:329–36.
27. Lauridsen E, Blanche P, Yousaf N, Andreasen JO. The risk of healing com-
plications in primary teeth with extrusive or lateral luxation - A retro-
spective cohort study. Dent Traumatol. 2017;33:307–16.
28. Auslander WP. Discoloration, a traumatic sequela. NY State Dent J.
1967;33:534–8.
29. Jacobsen I, Sangnes G. Traumatized primary anterior teeth. Prognosis
related to calcific reactions in the pulp cavity. Acta Odontol Scand.
1978;36:199–204.
30. Fried I, Erickson P, Schwartz S, Keenan K. Subluxation injuries of maxillary
primary anterior teeth: epidemiology and prognosis of 207 traumatized
teeth. Pediatr Dent. 1996;18:145–51.
31. Holan G, Fuks AB. The diagnostic value of coronal dark-gray discolor-
ation in primary teeth following traumatic injuries. Pediatr Dent. 1996;
18:224–7.
32. Holan G. Development of clinical and radiographic signs associated
with dark discolored primary incisors following traumatic injuries: a pro-
spective controlled study. Dent Traumatol. 2004;20:276–87.
33. Holan G. Long-term effect of different treatment modalities for trau-
matized primary incisors presenting dark coronal discoloration with no
other signs of injury. Dent Traumatol. 2006;22:14–7.
34. Law CS, Douglass JM, Farman AG, White SC, Zeller GG, Lurie AG, et al.
The image gently in dentistry campaign: partnering with parents to
promote the responsible use of x-rays in pediatric dentistry. Pediatr
Dent. 2014;36:458–9.
35. White SC, Scarfe WC, Schulze RK, Lurie AG, Douglass JM, Farman AG.
The Image Gently in Dentistry campaign: promotion of responsible use
of maxillofacial radiology in dentistry for children. Oral Surg Oral Med
Oral Pathol Oral Radiol. 2014;118:257–61.
36. Sodhi KS, Krishna S, Saxena AK, Sinha A, Khandelwal N, Lee EY. Clinical
application of ‘Justification’ and ‘Optimization’ principle of ALARA in
pediatric CT imaging: “How many children can be protected from un-
necessary radiation?”. Eur J Radiol. 2015;84:1752–7.

37. Andreasen JO, Flores MT, Lauridsen E. Injuries to developing teeth. In:
Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color
atlas of traumatic injuries to the teeth, 5th edn. Copenhagen, Denmark:
Wiley Blackwell; 2019. p. 589–625.
38. Andreasen JO, Ravn JJ. The effect of traumatic injuries to primary teeth
on their permanent successors. II. A clinical and radiographic follow-up
study of 213 teeth. Scand J Dent Res. 1971;79:284–94.
39. Da Silva Assuncao LR, Ferelle A, Iwakura ML, Cunha RF. Effects on per-
manent teeth after luxation injuries to the primary predecessors: a
study in children assisted at an emergency service. Dent Traumatol.
2009;25:165–70.
40. Flores MT, Onetto JE. How does orofacial trauma in children affect the
developing dentition? Long-term treatment and associated complica-
tions. Dent Traumatol. 2019;35:312–23.
41. Lenzi MM, da Silva Fidalgo TK, Luiz RR, Maia LC. Trauma in primary
teeth and its effect on the development of permanent successors: a
controlled study. Acta Odontol Scand. 2018;22:1–6.
42. Lenzi MM, Alexandria AK, Ferreira DM, Maia LC. Does trauma in the
primary dentition cause sequelae in permanent successors? A system-
atic review. Dent Traumatol. 2015;31:79–88.
43. Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intrusion of primary
teeth and its effects on the permanent successors: a clinical follow-up
study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:
493–8.
44. Spinas E, Melis A, Savasta A. Therapeutic approach to intrusive luxation
injuries in primary dentition. A clinical follow-up study. Eur J Paed Dent.
2006;7:179–86.
45. Colak I, Markovic D, Petrovic B, Peric T, Milenkovic A. A retrospective
study of intrusive injuries in primary dentition. Dent Traumatol. 2009;
25:605–10.
46. Flores MT. Traumatic injuries in the primary dentition. Dent Traumatol.
2002;18:287–98.
47. Cunha RF, Pugliesi DM, Percinoto C. Treatment of traumatized primary
teeth: a conservative approach. Dent Traumatol. 2007;23:360–3.
48. Martens LC, Rajasekharan S, Jacquet W, Vandenbulcke JD, Van Acker
JWG, Cauwels RGEC. Paediatric dental emergencies: a retrospective
study and a proposal for definition and guidelines including pain man-
agement. Eur Arch Paediat Dent. 2018;19:245–53.
49. Whiston C, Ali S, Wright B, Wonnacott D, Stang AS, Thompson GC, et al.
Is caregiver refusal of analgesics a barrier to pediatric emergency pain
management? A cross-sectional study in two Canadian centres. CJEM.
2018;20:892–902.
50. Roberts JF, Curzon ME, Koch G, Martens LC. Review: behaviour manage-
ment techniques in paediatric dentistry. Eur Arch Paediat Dent. 2010;
11:166–74.
51. American Academy of Pediatric Dentistry. Behaviour guidance for the
pediatric dental patient. Pediatr Dent. 2015;40:254–67.
52. Ali S, McGrath T, Drendel AL. An evidence-based approach to minimi-
zing acute procedural pain in the emergency department and beyond.
Pediatr Emerg Care. 2016;32:36–42.
Reprinted with permission of John Wiley and Sons.
© 2020 The Authors. Dental Traumatology 2020;36(4):343-359. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12576”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.
ENDORSEMENTS: INJURIES IN PRIMARY DENTITION
53. Pancekauskaite G, Jankauskaite L. Paediatric pain medicine: pain differ-
ences, recognition and coping acute procedural pain in paediatric
emergency room. Medicina. 2018;54(6):94.
54. De Young AC, Kenardy JA, Cobham VE. Trauma in early childhood: a
neglected population. Clin Child Fam Psychol Rev. 2011;14:231–50.
55. Stoddard FJ Jr. Outcomes of traumatic exposure. Child Adolesc Psychiatr
Clin N Am. 2014;23:243–56.
56. Tickle M, Jones C, Buchannan K, Milsom KM, Blinkhorn AS, Humphris
GM. A prospective study of dental anxiety in a cohort of children fol-
lowed from 5 to 9 years of age. Int J Paediatr Dent. 2009;19:225–32.
57. Milsom KM, Tickle M, Humphris GM, Blinkhorn AS. The relationship
between anxiety and dental treatment experience in 5-yearold chil-
dren. Br Dent J. 2003;194:503–6.
58. Soares FC, Lima RA, de Barros MVG, Dahllöf G, Colares V. Development
of dental anxiety in schoolchildren: a 2-year prospective study. Com-
munity Dent Oral Epidemiol. 2017;45:281–8.
59. Holan G, Needleman HL. Premature loss of primary anterior teeth due
to trauma–potential short- and long-term sequelae. Dent Traumatol.
2014;30:100–6.
60. Holan G, Topf J, Fuks AB. Effect of root canal infection and treatment
of traumatized primary incisors on their permanent successors. Dent
Traumatol. 1992;8:12–5.
61. Akin A, Uysal S, Cehreli ZC. Segmental alveolar process fracture involv-
ing primary incisors: treatment and 24-month follow up. Dent
Traumatol. 2011;27:63–6.
62. Cho WC, Nam OH, Kim MS, Lee HS, Choi SC. A retrospective study of
traumatic dental injuries in primary dentition: treatment outcomes of
splinting. Acta Odontol Scand. 2018;76:253–6.
63. Tewari N, Mathur VP, Singh N, Singh S, Pandey RK. Long-term effects
of traumatic dental injuries of primary dentition on permanent succes-
sors: a retrospective study of 596 teeth. Dent Traumatol. 2018;34:
129–34.
64. de Amorim LF, da Costa LR, Estrela C. Retrospective study of traumatic
dental injuries in primary teeth in a Brazilian specialized pediatric prac-
tice. Dent Traumatol. 2011;27:368–73.
65. Kenny KP, Day PF, Sharif MO, Parashos P, Lauridsen E, Feldens CA. What
are the important outcomes in traumatic dental injuries? An interna-
tional approach to the development of a core outcome set. Dent
Traumatol. 2018;34:4–11.
66. 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.
67. Levin L, Day PF, Hicks L, O’Connell AC, Fouad AF, Bourguigon C, et al.
International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: General Introduction. Dent
Traumatol. 2020;36:309–13.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 575
ENDORSEMENTS: CLEFT LIP / PALATE / CRANIOFACIAL ANOMALIES
Policy on the Management of Patients with Cleft
Lip / Palate and Other Craniofacial Anomalies
Latest Revision
2019
The American Academy of Pediatric Dentistry (AAPD), in its
efforts to promote optimal health for children with cleft lip/
palate and other craniofacial anomalies, endorses the current
statements of the American Cleft Palate-Craniofacial Associa-
tion (ACPA).1
A child born with cleft lip/palate or other craniofacial
anomalies has multiple and complex problems, including early
feeding and nutritional concerns, middle ear disease, hearing
deficiencies, deviations in speech and resonance, dentofacial
and orthodontic abnormalities, and psychosocial adjustment
problems.
Reports by the United States Surgeon General2,3 on chil-
dren with special needs issued in 1987 and 2005 stressed that
the care of these children should be comprehensive, coordi-
nated, culturally sensitive, specific to the needs of the indiv-
idual, and readily accessible. Recognizing that children with
clefts and other craniofacial anomalies have special needs, the
Maternal and Child Health Bureau in 1991 provided funding
to ACPA to develop parameters of care for these patients
through a series of consensus conferences among a multidis-
ciplinary group of specialists.1 In addition, the ACPA joined
with the Cleft Palate Foundation to create standards for
approval of teams to ensure that care is provided in a coordi-
nated and consistent manner, including an appropriate
sequence of evaluations and treatment for the patient’s
overall developmental, medical, and psychological needs.4
As part of the parameters1 and standards4, several funda-
mental principles were identified as critical to optimal cleft/
craniofacial care. These principles are:
1. Management of patients with craniofacial anomalies
is best provided by an interdisciplinary team of spe-
cialists.1 These teams are composed of qualified health
professionals from medical, surgical, dental, and allied
health fields working together in a coordinated sys-
tem. A designated patient care coordinator should
be included in the team to assist in coordinated care
for patients and their families/caregivers.4
2. Optimal care for patients with craniofacial anomalies
is provided by teams that see sufficient numbers of
these patients each year to maintain clinical expertise
in diagnosis and treatment.
576 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
How to Cite: American Academy of Pediatric Dentistry. Policy on the
management of patients with cleft lip/palate and other craniofacial
anomalies. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:576-7.
3. The optimal time for the first evaluation is within
the first few weeks of life and, whenever possible,
within the first few days. However, referral for team
evaluation and management is appropriate for patients
of any age.1
4. From the time of first contact with the child and
family, every effort must be made to assist the family
in adjusting to the birth of a child with a craniofacial
anomaly and the consequent demands and stress
placed upon that family.1
5. Parents/caregivers must be given information about
recommended treatment procedures, options, risk fac-
tors, benefits, and costs to assist them in: (1) making
informed decisions on the child’s behalf, and (2) pre-
paring the child and themselves for all recommended
procedures. The team should actively solicit family
participation and collaboration in treatment plan-
ning.1,4 When the child is mature enough to do so, he
or she should also participate in treatment decisions.1
6. Treatment plans should be developed and imple-
mented on the basis of team recommendations.1
7. Care should be coordinated by the team, but should
be provided at the local level whenever possible; how-
ever, complex diagnostic or surgical procedures should
be restricted to major centers with appropriate treat-
ment facilities and experienced care providers.
8. It is the responsibility of each team to be sensitive to
linguistic, cultural, ethnic, psychosocial, economic, and
physical factors that affect the dynamic relationship
between the team, the patient, and his/her family.1
9. It is the responsibility of the team to monitor both
short-term and long-term outcomes. Thus, longitu-
dinal follow up of patients, including appropriate
documentation and record-keeping, is essential.1
10. Evaluation of treatment outcomes must take into
account the satisfaction and psychosocial well-being
of the patient, as well as effects on growth, function,
and appearance.1
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ACPA: American Cleft
Palate-Craniofacial Association.

Patients with craniofacial anomalies require dental care
throughtout life as a direct result of their condition and as an
integral part of the treatment process. A dental home should
be established within six months of eruption of the first tooth
and no later than 12 months of age.5 It includes oral health
examinations, caries control, and preventive, restorative, and
prosthetic dental treatment as needed. Patients should be
closely monitored for periodontal disease and anomalies in
dentition and eruption. The condition of the developing
dentition and supporting tissues, with counseling regarding
early oral hygiene and prevention of early childhood caries,
is essential. Prosthetic appliances such as an obturator may
help to close a fistula or aid in speech. Orthodontic treatment
is also an integral part of the habilitative process and often
takes place in phases. The skeletal and dental components
should be regularly evaluated. When indicated, orthodontic
treatment prepares a child for alveolar bone grafting of the
cleft maxilla, correcting malocclusions, and jaw surgery.1 As
members of the interdisciplinary team of physicians, dentists,
speech-language pathologists, and other allied health profes-
sionals, pediatric dentists should provide dental services in
close cooperation with their orthodontic, oral and maxillofacial
surgery, and prosthodontic colleagues.1,4 All dental specialists
should ensure1:
1. Consultation with an appropriate dental specialist
should be made for cleft lip taping and or pre-
surgical orthopedics including, but not limited to,
nasal alveolar molding. A craniofacial orthodontist
(or appropriately-trained clinician) who can discuss
with the family the types of infant orthopedic services
available and the rationale for using infant ortho-
pedics prior to initial cleft lip repair is necessary.
2. Dental radiographs, cephalometric radiographs, and
other imaging modalities as indicated should be
utilized to evaluate and monitor dental and facial
growth and development.
3. Diagnostic records, including properly occluded den-
tal study models, should be collected at appropriate
intervals for patients at risk for developing maloc-
clusion or maxillary-mandibular discrepancies.
4. As the primary dentition erupts, the team evaluation
should include a dental examination and, if such
services are not already being provided, referral to
appropriate providers for caries control, preventive
measures, restorative care, and space management.
5. Before the primary dentition has completed eruption,
the skeletal and dental components should be evalu-
ated to determine if a malocclusion is present or
developing.
6. Depending upon the specific goals to be accomplished
and also upon the age at which the patient is initially
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: CLEFT LIP / PALATE / CRANIOFACIAL ANOMALIES
7. While continuous active orthodontic treatment from
early mixed dentition to permanent dentition should
be avoided, each stage of orthodontic therapy may
be followed by retention and regular observation.
Orthodontic retention for the permanent dentition
may extend into adulthood.
8. For some patients with craniofacial anomalies, func-
tional orthodontic appliances may be indicated.
9. For patients with craniofacial anomalies, orthodontic
treatment may be needed in conjunction with sur-
gical correction (and/or distraction osteogenesis) of
the facial deformity.
10. Congenitally missing teeth may be replaced with a
removable appliance, fixed restorative bridgework, or
osseointegrated implants.
11. Patients should be closely monitored for dental and
periodontal disease.
12. Prosthetic obturation of palatal fistulae may be
necessary in some patients.
13. A prosthetic speech device may be used to treat
velopharyngeal inadequacy in some patients.
References
1. American Cleft Palate-Craniofacial Association. Param-
eters for Evaluation and Treatment of Patients with Cleft
Lip/Palate or Other Craniofacial Differences. Chapel Hill,
N.C.: The Maternal and Child Health Bureau, Health
Resources and Services Administration, U.S. Public
Health Service, DHHS; January 2018. Grant # MCJ-
425074. Available at: “https://acpa-cpf.org/team-care/
standardscat/parameters-of-care/”. Accessed October 11,
2019.
2. U.S. Department of Health and Human Services. A
Report of the Surgeon General: Children with Special
Health Care Needs. Rockville, Md.: Office of Maternal
and Child Health, U.S. Department of Health and
Human Services; 1987.
3. U.S. Department of Health and Human Services. The
Surgeon General’s Call to Action to Improve the Health
and Wellness of Persons with Disabilities. Rockville,
Md.: U.S. Department of Health and Human Services,
Office of the Surgeon General; 2005.
4. American Cleft Palate-Craniofacial Association Commis-
sion on Approval of Teams. Standards for Approval of
Cleft Palate and Craniofacial Teams. American Cleft
Palate-Craniofacial Association; 2016. Available at:
“https://acpa-cpf.org/wp-content/uploads/2017/06/
standards.pdf ”. Accessed October 11, 2019.
5. American Academy of Pediatric Dentistry. Policy on
dental home. Pediatr Dent 2018;40(6):29-30.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 577
Check out AAPD's TWO Podcasts

7+(%,*$87+25,7<21/,77/(7((7+

Pedo Teeth Talk Sponsored by Hu-Friedy

Newly Erupted Sponsored by Elevate Oral Care

Listen on aapd.org, Spotify, iTunes,

Stitcher, Google Podcasts
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.
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.

580 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: GROWTH CHARTS

Growth Charts

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 581

RESOURCES: GROWTH CHARTS

582 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: GROWTH CHARTS

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 583

RESOURCES: GROWTH CHARTS

584 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: GROWTH CHARTS

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 585

RESOURCES: GROWTH CHARTS

586 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: BMI CHARTS

Body Mass Index (BMI) Charts

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 587

RESOURCES: BMI CHARTS

588 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: HEALTHY FOOD PATTERNS

Recommended USDA Food Patterns

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 589

RESOURCES: HEALTHY 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”.

590 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: HEALTHY 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”.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 591

RESOURCES: HEALTHY BEVERAGES

Healthy Beverage Consumption in Early Childhood

These recommendations were developed as part of a collaboration of the Academy of Nutrition and Dietetics, the American
Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association. This cooperative
effort transpired under the leadership of Healthy Eating Research, a leading nutrition research organization, through funding
from the Robert Wood Johnson Foundation. The recommendations outlined on the next pages by age are intended for healthy
children in the United States and do not address medical situations in which specific nutrition guidance is needed to manage a
health condition.
For the complete consensus statement, visit:
– https://healthyeatingresearch.org/wp-content/uploads/2019/09/HER-HealthyBeverage-ConsensusStatement.pdf
For the complete technical report, visit:
– https://healthyeatingresearch.org/research/technical-scientific-report-healthy-beverage-consumption-in-early-childhood-recommen-
dations-from-key-national-health-and-nutrition-organizations/

Table. Summary of Recommendations for Healthy Beverage Consumption, Ages 0-5 Years*

0-6 months 6-12 months 12-24 months 2-5 years Notes

2-3 years 4-5 years

1R $SSUR[LPDWHO\ FXSV FXSV FXSV :KHUH DQ LQGLYLGXDO FKLOG IDOOV
Beverages Recommended as Part of a Healthy Diet

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GULQNLQJ R] GD\ SHUGD\ SHUGD\ SHUGD\ PRQWKV WR  \HDUV ZLOO GHSHQG
Plain ZDWHU LQDFXS%HJLQ RQ WKH DPRXQWV RI RWKHU EHYHU
QHHGHG RIIHULQJGXULQJ DJHVFRQVXPHGGXULQJWKHGD\
drinking
PHDOVRQFH
water VROLGIRRGVDUH
LQWURGXFHG

1RW 1RW FXSV 8SWRFXSV 8SWRFXSV )RU  PRQWKV UHGXFHGIDW

UHFRPPHQGHG UHFRPPHQGHG R] R]  R]   RUORZIDW  PLONPD\EH
SHUGD\ SHUGD\ SHUGD\ FRQVLGHUHG LQ FRQVXOWDWLRQ ZLWK
ZKROHPLON VNLP IDWIUHH  VNLP IDWIUHH  DSHGLDWULFLDQHVSHFLDOO\LIZHLJKW
Plain, or or JDLQ LV H[FHVVLYH RU IDPLO\ KLV
ORZIDW ORZIDW WRU\ LV SRVLWLYH IRU REHVLW\ G\V
pasteurized
 PLON  PLON OLSLGHPLDRURWKHUFDUGLRYDVFXODU
milk GLVHDVHWKHWRWDODPRXQWRIPLON
FRQVXPHG GXULQJ WKLV DJH ZLOO
GHSHQGRQKRZPXFKVROLGIRRG
LVEHLQJHDWHQ
Beverages to Limit

1RW 1RW :KROHIUXLW :KROHIUXLW :KROHIUXLW $PRXQWV OLVWHG IRU DJHV 
UHFRPPHQGHG UHFRPPHQGHG SUHIHUUHG SUHIHUUHG SUHIHUUHG PRQWKV WR  \HDUV DUH XSSHU
OLPLWV QRW PLQLPXP UHTXLUH
100% 1RPRUHWKDQ 1RPRUHWKDQ 1RPRUHWKDQ PHQWV  WKDW PD\ EH FRQVXPHG
juice FXS R]  FXS R]  FXS RQO\LIIUXLWLQWDNHUHFRPPHQGD
SHUGD\ SHUGD\ R] SHUGD\ WLRQV FDQQRW EH PHW ZLWK ZKROH
MXLFH MXLFH MXLFH IUXLW

Note: All amounts listed are per day, unless otherwise noted; 1 cup = 8 fluid ounces.

* 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.

592 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: HEALTHY BEVERAGES

Table. Continued *
0-6 months 6-12 months 12-24 months 2-5 years Notes

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beverages GULQNVIUXLWÀDYRUHGGULQNVIUXLW
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beverages

Note: All amounts listed are per day, unless otherwise noted; 1 cup = 8 fluid ounces.

* 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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 593

RESOURCES: IMMUNIZATION SCHEDULE

Child and Adolescent Immunization Schedule

594 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: IMMUNIZATION SCHEDULE

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 595

RESOURCES: IMMUNIZATION SCHEDULE

596 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: IMMUNIZATION SCHEDULE

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 597

RESOURCES: IMMUNIZATION SCHEDULE

598 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: IMMUNIZATION SCHEDULE

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 599

RESOURCES: IMMUNIZATION SCHEDULE

600 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: IMMUNIZATION SCHEDULE

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 601

RESOURCES: IMMUNIZATION SCHEDULE

602 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: IMMUNIZATION SCHEDULE

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 603

RESOURCES: CHILD SPEECH AND HEARING

Speech and Language Milestones

What should my child be able to do?
Hearing and Understanding Talking

Birth-3 Months Birth-3 Months

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4-6 Months 4-6 Months

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‡1RWLFHVWR\VWKDWPDNHVRXQGV ‡*LJJOHVDQGODXJKV
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7 Months-1 Year 7 Months-1 Year

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‡/RRNVZKHQ\RXSRLQW
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 OLNH cuptruckjuiceDQGdaddy
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 &RPHKHUHDQG:DQWPRUH"
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One to Two Years One to Two Years

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Two to Three Years Two to Three Years

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 ZRUGVDQGVRXQGV

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.

604 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: CHILD SPEECH AND HEARING

What should my child be able to do?

Hearing and Understanding Talking

Three to Four Years Three to Four Years

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playDQG get0D\PDNHVRPHPLVWDNHVOLNH³=DFKJRWV
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<RXUFKLOGPD\XVHVKRUWVHQWHQFHVZLWK\RXQJHUFKLOGUHQ+H
PD\WDONORXGHURXWVLGHWKDQLQVLGH

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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 605

RESOURCES: MEDICAL HISTORY FORM

Pediatric Medical History

Child’s legal name: ________________________________________ Preferred name: _____________________ 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
Have you been told your child needs antibiotics or another medicine before dental treatment? Reason ____________________ ‰ 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 at birth, prematurity, inherited conditions, syndromes, or birth defects (such as cleft lip/palate) ....... ‰ YES ‰ NO
Problems with physical growth or development ………………...……..………...………………………………………....... ‰ YES ‰ NO
Sinusitis, chronic adenoid/tonsil infections ……………………………………………………………….............................. ‰ YES ‰ NO
Sleep apnea, snoring, or mouth breathing ……………………..……………………………………….................................. ‰ 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, bronchitis, 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 or bedwetting ……………………………………..……………………………………..…...... ‰ 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, concussion, epilepsy, or convulsions/seizures …………………………………...…………......... ‰ YES ‰ NO
Autism/autism spectrum disorder or sensory integration 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
Corona virus disease 2019 (COVID-19), cytomegalovirus (CMV), human immunodeficiency virus (HIV)/AIDS, methicillin- ‰ YES ‰ NO
resistant staphylococcus aureus (MRSA), mononucleosis, scarlet fever, sexually-transmitted disease (STD), or tuberculosis (TB)

PROVIDE DETAILS HERE: _________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

Is there any other significant medical history pertaining to this child or the child’s 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 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, how long? __________ Which? ‰ Finger ‰ Thumb ‰ Pacifier ‰ Other_____
How often are your child’s teeth brushed? ________ times per ___________ Does someone help your child brush? ‰ YES ‰ NO
How often are your child’s teeth flossed? ‰ 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
RESOURCES: MEDICAL HISTORY FORM

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 breastfed? ‰ 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
6 months months months months more
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 your child’s teeth? ‰ N/A ‰ before age ‰ 6-11 ‰ 12-17 ‰ 18-23 ‰ 2 years or
6 months months months months more
When did you begin using toothpaste? ‰ N/A ‰ before age ‰ 6-11 ‰ 12-17 ‰ 18-23 ‰ 2 years or
6 months months months months more
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

608 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: SYSTEMIC CONDITIONS AFFECT PERIODONTIUM

Systemic Diseases and Syndromes that Affect

the Periodontium
This chart includes medical conditions known to impact periodontal health and that may be included in a differential diagnosis when
periodontitis is detected in pediatric patients. Individualized at-home and professional preventive oral care interventions must be empha-
sized for these patients. A multidisciplinary approach may be indicated for safe and effective oral health care.

Disorder General Diagnostic Oral findings Treatment

characteristics criteria considerations
Clinical Radiographic

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 &KDUDFWHUL]HGE\UHGXFHG /<67&+6 Premature )RUH[WUDFWLRQVVXUJHULHVFRQVLGHU
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PXVFOHFRQWUDFWXUHVDQG Table continued on the next page.
GHVWUXFWLYHDUWKULWLV

Abbreviations in table: BMI: Body mass index; CDC: Centers for Disease Control and Prevention; CV: cardiovascular; NSAIDs: nonsteroidal anti-inflammatory drugs;
PLS: Papillon Lefèvre syndrome; SRP: Scaling and root planing; WBCs: White blood cells.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 609

RESOURCES: SYSTEMIC CONDITIONS AFFECT PERIODONTIUM
Disorder General
characteristics
Hypophos- 5DUHJHQHWLFPHWDEROLFERQH
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Abbreviations in table: BMI: Body mass index; CDC: Centers for Disease Control and Prevention; CV: cardiovascular; NSAIDs: nonsteroidal anti-inflammatory drugs;
PLS: Papillon Lefèvre syndrome; SRP: Scaling and root planing; WBCs: White blood cells.
610 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Diagnostic Oral findings
criteria
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 RESOURCES: SYSTEMIC CONDITIONS AFFECT PERIODONTIUM

Disorder General Diagnostic Oral findings Treatment

characteristics criteria considerations
Clinical Radiographic

Papillon $XWRVRPDOUHFHVVLYHGLVRUGHU 8ULQDO\VLVIRU  5DSLGO\DGYDQFLQJ *HQHUDOL]HG  7UHDWPHQWRIRUDO

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Abbreviations in table: BMI: Body mass index; CDC: Centers for Disease Control and Prevention; CV: cardiovascular; NSAIDs: nonsteroidal anti-inflammatory drugs;
PLS: Papillon Lefèvre syndrome; SRP: Scaling and root planing; WBCs: White blood cells.

References
1. Thumbigere Math V, Rebouças P, Giovani PA, et al. Periodontitis in Chédiak-Higashi syndrome: An altered immunoinflam-
matory response. JDR Clin Trans Res 2018;3(1):35-46. Available at: “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC573
4460/’. Accessed September 21, 2022.
2. National Organization for Rare Disorders (NORD). Chédiak Higashi Syndrome. Available at: “https://rarediseases.org/rare
-diseases/chediak-higashi-syndrome/”. Accessed September 1, 2022.
3. American Diabetes Association. Diabetes Overview. Understanding A1c. Diagnosis. Available at: “https://diabetes.org/
diabetes/a1c/diagnosis”. Accessed September 21, 2022.
4. Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment
apparatus: Case definitions and diagnostic considerations. J Periodontol 2018;89(Suppl 1):S183-S203.
5. National Organization for Rare Disorders (NORD). Haim-Munk Syndrome. Available at: “https://rarediseases.org/rare-diseases/
haim-munk-syndrome/”. Accessed September 1, 2022.
6. National Organization for Rare Disorders (NORD). Hypophosphatasia. Available at: “https://rarediseases.org/rare-diseases/
hypophosphatasia/”. Accessed September 1, 2022.
7. Okawa R, Kokomoto K, Nakano K. Dental effects of enzyme replacement therapy in case of childhood-type hypophosphatasia.
BMC Oral Health 2021;21(1):323.
8. National Organization for Rare Disorders (NORD). Langerhans Cell Histiocytosis. Available at: “https://rarediseases.org/rare-
diseases/papillon-lefevre-syndrome/”. Accessed September 1, 2022.
9. National Organization for Rare Disorders (NORD). Leukocyte Adhesion Deficiency Syndromes. Available at: “https://rare
diseases.org/rare-diseases/leukocyte-adhesion-deficiency-syndromes/”. Accessed September 1, 2022.
10. National Collaborative on Childhood Obesity Research. A Guide to Methods for Assessing Childhood Obesity: Overview of
Body Composition and Measuring Adiposity. Available at: “https://www.nccor.org/tools-assessingobesity-guide/overview-of-
body-composition-and-measuring-adiposity/#two-c”. Accessed August 24, 2022.
11. National Organization for Rare Disorders (NORD). Papillon Lefèvre Syndrome. Available at: “https://rarediseases.org/rare-
diseases/papillon-lefevre-syndrome/”. Accessed August 24, 2022.
12. Kapferer-Seebacher I, van Dijk FS, Zschocke J. Periodontal Ehlers-Danlos Syndrome. In: Adam MP, Everman DB, Mirzaa
®
GM, et al., eds. GeneReviews [Internet]. Seattle, Wash.: University of Washington, Seattle; 2021:1993-2022. Available at:
“https://www.ncbi.nlm.nih.gov/books/NBK572429/#.” Accessed August 24, 2022.
13. Rinner A, Zschocke J, Schossig A, Gröbner R, Strobl H, Kapferer-Seebacher I. High risk of peri-implant disease in periodontal
Ehlers-Danlos Syndrome. A case series. Clin Oral Implants Res 2018;29:1101-6.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 611

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 ages two through five 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
Case selection for application of silver diamine fluoride
Patients who may benefit from SDF include those:
• with high caries risk who have active cavitated caries
lesions in anterior or posterior teeth;
• presenting with behavioral or medical management chal-
lenges and cavitated caries lesions;
• with multiple cavitated caries lesions that may not all
be treated in one visit;
• with dental caries lesions that are difficult to treat; and
• without access to or with difficulty accessing dental care.
Criteria for tooth selection include:
• no clinical signs of pulpal inflammation or reports of unsolic-
ited/spontaneous pain.
• cavitated caries lesions that are not encroaching on the
pulp. If possible, radiographs should be taken to assess
depth of caries lesions.
• cavitated caries lesions on any surface as long as they are
accessible with a brush for applying SDF. (Orthodontic
separators may be used to help gain access to proximal
lesions.)
SDF can be used prior to restoration placement and as part
of caries control therapy.4 Informed consent, particularly high-
lighting expected staining of treated lesions, potential staining
of skin and clothes, and need for reapplication for disease
control, is recommended.
Clinical application of silver diamine fluoride
• Remove gross debris from cavitation to allow better SDF
contact with denatured dentin.
• Carious dentin excavation prior to SDF application is not
necessary. As excavation may reduce proportion of arrested
caries lesions that become black, it may be considered for
esthetic purposes.
612 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
SDF-treated lesions with temporary gingival staining
• A protective coating may be applied to the lips and skin
to prevent a temporary henna-appearing tattoo that can
occur if SDF comes into contact with soft tissues.
• Isolate areas to be treated with cotton rolls or other isola-
tion methods. If applying cocoa butter or any other product
to protect surrounding gingival tissues, use care to not
inadvertently coat the surfaces of the caries lesions.
• Caution should be taken when applying SDF on primary
teeth adjacent to permanent anterior teeth that may have
noncavitated (white-spot) lesions to avoid inadvertent
staining.
• Careful application with a microbrush should be adequate
to prevent intraoral and extraoral soft tissue exposure. No
more than one drop of SDF should be used for the entire
appointment.
• Dry lesion with gentle flow of compressed air.
• Bend microsponge brush. Dip brush into SDF and dab
on the side of the plastic dappen dish to remove excess
liquid before application. Apply SDF directly to only the
affected tooth surface. Remove excess SDF with gauze,
cotton roll, or cotton pellet to minimize systemic absorption.
• Application time should be at least one minute if possible.
(Application time likely will be shorter in very young and
difficult to manage patients. When using shorter applica-
tion periods, monitor carefully at postoperative and recall
visits to evaluate arrest and consider reapplication.)
• Apply gentle flow of compressed air until medicament is
dry. Try to keep isolated for as long as three minutes.
• The entire dentition may be treated after SDF treatment
with five percent sodium fluoride varnish to help prevent
caries on the teeth and sites not treated with SDF.
* 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/)

Follow-up
Estimations of SDF effectiveness in arresting dental caries
lesions range from 47 to 90 percent with one-time application
depending on size of the cavity and tooth location.4-7 Anterior
teeth have higher rates of arrest than posterior teeth.5 There-
fore, follow-up for evaluation of caries arrest is advisable.2-3
• Follow-up at two to four weeks after initial treatment to
check the arrest of the lesions treated.
• Reapplication of SDF may be indicated if the treated
lesions do not appear arrested (dark and hard). Addi-
tional SDF can be applied at recall appointments as
needed, based on the color and hardness of the lesion
or evidence of lesion progression.
• Caries lesions can be restored after treatment with SDF.
• When lesions are not restored after SDF therapy, bi-
annual reapplication shows increased caries arrest rate
versus a single application.
References
1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental
caries and sealant prevalence in children and adolescents
in the United States, 2011–2012. NCHS data brief, no
191. Hyattsville, Md.: National Center for Health Stat-
istics. 2015. Available at: “https://www.cdc.gov/nchs/
products/databriefs/db191.htm”. Accessed September 6,
2017.
RESOURCES: SDF CHAIRSIDE GUIDE
2. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries
remineralisation and arresting effect in children by pro-
fessionally applied fluoride treatment – A systematic
review. BMC Oral Health 2016;16:12.
3. Duangthip D, Jiang M, Chu CH, Lo EC. Restorative
approaches to treat dentin caries in preschool children:
Systematic review. Eur J Paediatr Dent 2016;17(2):
113-21.
4. Crystal YO, Niederman R. Silver diamine fluoride treat-
ment considerations in children’s caries management:
Brief communication and commentary. Pediatr Dent
2016;38(7):466-71.
5. Fung M, Duangthip D, Wong M, Lo E, Chu C. Arresting
dentine caries with different concentration and perio-
dicity of silver diamine fluoride. JDR Clin Transl Res
2016;1(2):143-52.
6. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos T,
Morato M. Efficacy of silver diamine fluoride for caries
reduction in primary teeth and first permanent molars
of schoolchildren: 36-month clinical trial. J Dent Res
2005;84(8):721-4.
7. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial
on effectiveness of silver diamine fluoride and glass
ionomer in arresting dentine caries in preschool children.
J Dent 2012;40(11):962-7.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 613
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\ 'HVFULSWLRQ ZKDWZKHUHKRZRFFXUHG 
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 7UDQVSRUWDWLRQPHGLXP______________
/RVVRIFRQVFLRXVQHVV ‰1R‰ Yes 7RRWKVHQVLWLYHWRDLUWKHUPDOFKDQJH ‰1R‰ Yes 2WKHUFRPSODLQWV ‰1R‰ Yes
1HFNSDLQ ‰1R‰ Yes 'LVSODFHGRUORRVHQHGWRRWK ‰1R‰ Yes 3UHYLRXVGHQWDOWUDXPD ‰1R‰ Yes
:KHH]LQJFRXJKLQJJDJJLQJ‰1R‰ Yes )UDFWXUHGWRRWK ‰1R‰ Yes 8VHRIRUDODSSOLDQFH ‰1R‰ Yes
2WKHUERGLO\LQMXULHV ‰1R‰ Yes :DVPLVVLQJIUDJPHQWIRXQG" ‰1R‰ Yes 1RQQXWULWLYHRUDOKDELW ‰1R‰ Yes

Description of positive findings:

EXTRAORAL EXAM

CRANIOFACIAL ASSESSMENT
&UDQLDOQHUYHGHILFLW ‰1R‰ Yes +HPRUUKDJHGUDLQDJH ‰1R‰ Yes /DFHUDWLRQ ‰1R‰ Yes %XUQV ‰1R‰ Yes
6XVSHFWHGIDFLDOIUDFWXUH‰1R‰ Yes 6ZHOOLQJ‰1R‰ Yes $EUDVLRQ‰1R‰ Yes )RUHLJQERG\‰1R‰ Yes
70-GHYLDWLRQDV\PPHWU\‰1R‰ Yes Contusion ‰1R‰ Yes 3XQFWXUH‰1R‰ Yes 2WKHUILQGLQJ‰1R‰ Yes

Description of positive findings:

DIAGRAM OF INJURIES
SOFT TISSUES INJURIES
/LSV ‰1R‰ Yes %XFFDOPXFRVD‰1R‰ Yes 3DODWH‰1R‰ Yes
Frenum ‰1R‰ Yes 7RQJXH ‰1R‰ Yes Other ‰1R‰ Yes
)ORRURIPRXWK‰1R‰ Yes
INTRAORAL EXAMINATION

*LQJLYD‰1R‰ Yes

Description of positive findings:

OCCLUSAL ASSESSMENT
0RODUFODVVLILFDWLRQR______ L______ &URVVELWH ‰1R‰ Yes
&DQLQHFODVVLILFDWLRQR______ L______ 0LGOLQHGHYLDWLRQ ‰1R‰ Yes OTHER COMMENTS
2YHUELWH  BBBBBBBB ,QWHUIHUHQFHV ‰1R‰ Yes
2YHUMHW PP BBBBBBBB $SSOLDQFHSUHVHQW‰1R‰ Yes

Description of positive findings:

614 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: ACUTE INJURIES

TOOTH NUMBERS:
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‰  1R‰ Yes SUMMARY
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6XVSHFWHGRUFRQILUPHGDEXVH" ‰  1R‰ Yes

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INSTRUCTIONS AND DISPOSITION

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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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 615

RESOURCES: AVULSED PERMANENT TOOTH

Acute Management of an Avulsed Permanent

Tooth with an Open ( >1 millimeter) Apex
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; use 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: ?
• Verify the correct position of
the tooth clinically and Replantation:
?

radiographically. • Replant tooth slowly and gently.

• 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
antiresorptive, anti-osteoclastic, anti-inflammatory, and antibacterial effects).
• 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
Pediatric Dentistry; 2022:614-5.
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”.

616 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: AVULSED PERMANENT TOOTH

Acute Management of an Avulsed Permanent

Tooth with an Closed ( < 1 millimeter) Apex
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; use 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: ?
• Verify the correct position of
the tooth clinically and Replantation:
?

radiographically. • Replant tooth slowly and gently.

• 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
antiresorptive, anti-osteoclastic, anti-inflammatory, and antibacterial effects).
• 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
Pediatric Dentistry; 2022:614-5.
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”.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 617

RESOURCES: AIRWAY ASSESSMENT

Pediatric Airway Assessment

This screening form may help identify patients at increased risk for sleep-related breathing disorders (e.g., obstructive sleep
apnea) and/or breathing complications when undergoing sedation or general anesthesia. Such patients may benefit from referral
to a medical professional for further evaluation and management.

Patient name: _______________________________________________________________________ Birthdate: ________/_______/_____________ Gender: ____________

Part I. General history

Was your child born prematurely?
Does your child have a craniofacial syndrome?
Does your child have any history of:
a physical or neurological impairment?
low muscle tone?
respiratory disease/breathing problems?
repeated exposure to smoke?
‰ NO ‰ YES (how many weeks early?): ______________________________
‰ NO ‰ YES (describe): _____________________________________________
‰ NO ‰ YES (describe): ______________________________________________
‰ NO ‰ YES (describe): ______________________________________________
‰ NO ‰ YES (describe): ______________________________________________
‰ NO ‰ YES (describe): ______________________________________________

Part II. Daytime indicators

Does your child often:
tend to breathe through the mouth? ‰ NO ‰ YES ‰ Do not know
wake up with headaches in the morning? ‰ NO ‰ YES ‰ Do not know
seem restless, unable to sit still, or always on the go? ‰ NO ‰ YES ‰ Do not know
interrupt others, have difficulty staying focused, or become easily frustrated? ‰ NO ‰ YES ‰ Do not know
Do you or a teacher notice your child appears sleepy during the day? ‰ NO ‰ YES ‰ Do not know

Part III. Sleep history

How would you rate your child’s sleep? ‰ Good ‰ Fair ‰ Poor
How many hours does your child sleep on average during a 24-hour period?: _________
Does your child:
fall asleep quickly? ‰ NO ‰ YES ‰ Do not know
snore more than half the time while sleeping? ‰ NO ‰ YES ‰ Do not know
snore loudly while sleeping? ‰ NO ‰ YES ‰ Do not know
have trouble breathing or struggle to breathe while asleep? ‰ NO ‰ YES ‰ Do not know
stop breathing during sleep? ‰ NO ‰ YES ‰ Do not know
grind his/her teeth while sleeping? ‰ NO ‰ YES ‰ Do not know
sleep in a seated position or with neck hyperextended? ‰ NO ‰ YES ‰ Do not know
occasionally wet the bed at night? ‰ NO ‰ YES ‰ Do not know
experience excessive sweating while sleeping? ‰ NO ‰ YES ‰ Do not know
Is your child hard to wake up in the morning? ‰ NO ‰ YES ‰ Do not know

________________________________________ _______________________________ ___________________

Signature of parent/guardian Relationship to child Date

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 is 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.

618 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: AIRWAY ASSESSMENT

Part IV: Clinical assessment

Does the patient appear overweight? ‰ NO ‰ YES BMI ___________ Percentile ___________
Does the patient have
limited neck mobility? ‰ NO ‰ YES
micro/retrognathia? ‰ NO ‰ YES
limited oral opening? ‰ NO ‰ YES
lip incompetency? ‰ NO ‰ YES
an anterior open bite? ‰ NO ‰ YES
a narrow maxillary arch with vaulted palate? ‰ NO ‰ YES
a posterior crossbite? ‰ NO ‰ YES
macroglossia? ‰ NO ‰ YES

Which Modified Mallampati Classification1 best describes the patient? ‰ I ‰ II ‰ III ‰ IV

I II III IV

Which tonsillar grade1 (adapted) best describes the patient? ‰ 0 ‰ 1 ‰ 2 ‰ 3 ‰ 4

0 1 2 3 4
Surgically removed Tonsils hidden Tonsils extending Tonsils are beyond Tonsils extend
tonsils within tonsil pillars to the pillars the pillars to midline

Is a medical referral indicated? ‰ NO ‰ YES

Comments: ____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_______________________________________ _________________
Doctor’s signature Date

Reference:
1. Friedman M, Tanyeri H, La Rosa M, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope 1999;109(12):1901-7.

Images reprinted and adapted with permission of John Wiley and Sons.
Copyright © 1999. Friedman M, Tanyeri H, La Rosa M, Landsberg R, et al. Laryngoscope 1999;109(12):1901-7.
Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1097/00005537-199912000-000028”.
Laryngoscope is published for the American Laryngological Rhinological and Otological Society by John Wiley and Sons Ltd.

619
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 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 medications 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, coughing, wheezing, 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.

620 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 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 sedated patients 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 discharge 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 discharged, you should take your child directly home, not to daycare or school. Car restraints should be placed
securely around your child but not restrict your child’s airway and breathing or the ability to be carefully observed.
• 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 either side with the head supported and the chin up. Although
sleepy, your child should be awakened easily. 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 and uncoordinated for the remainder of the day. After the sedation appointment, limit your
child to quiet activities monitored by an adult. Prohibit potentially harmful activities such as bike riding, swimming, using
playground equipment, or climbing stairs and 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 alert, your child may have sips of clear liquids to prevent nausea and dehydration. Small sips taken repeatedly are
preferable to large gulps. Straws should not be used if your child had any extractions. The first meal should be something
light and easily digestible (e.g., apple sauce, soup, gelatin). 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: _______________________________

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 621

RESOURCES: SEDATION RECORD

Procedural 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 (including COVID) ‰ ‰ ________________________________ Limited oral opening ‰ ‰
Previous sedation/general anesthetics ‰ ‰ ________________________________ Macroglossia ‰ ‰
Physical/neurologic impairment ‰ ‰ ________________________________ Brodsky grading scale: ‰1 ‰ 2 ‰ 3 ‰ 4
Snoring, obstructive sleep apnea, mouth breathing ‰ ‰ ________________________________ Mallampati classification: ‰ I ‰ I I ‰ III ‰ IV
Relevant birth, family, or social history ‰ ‰ ________________________________
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
for dental procedures obtained from
Preoperative instructions reviewed with
Postoperative 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 VItal Signs (if unable to obtain, ckeck ‰)

Change in medical hx/ROS ‰ ‰ Clear liquids ____hrs Upper airway clear ‰ ‰ Pulse: _____/min
Change in medications ‰ ‰ Milk, other liquids, Lungs clear ‰ ‰ SpO2: _____%
Recent respiratory illness/COVID ‰ ‰ &/or foods ____hrs Tonsillar obstruction ‰ ‰ (___%) BP: _____/ _____ mmHg
Pregnancy test indicated ‰ ‰ Medications ____hrs Weight: _____kg Height: _____cm Resp: _____/min
Date: _______ Test: ________ Results: _________ BMI: _____ BMI % for age: ______ Temp: _____oF

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
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Safety Checklist ‰ Monitors tested & functioning as intended ‰ Emergency kit, suction, & high-flow oxygen
‰ No contraindication to procedural sedation ‰ Two adults present or extended time for discharge accepted

Drug Dosage Calculations

Sedatives
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg 8_________mg/mL = _________mL
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg 8_________mg/mL = _________mL
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

Patient: __________________________________________________________ DOB _____/_____/________ Date: ___________________________

Intra- and Postoperative Management EMS telephone number: __________________________

Timeout: ‰Caregiver present for timeout ‰Pt ID ‰Agreement on procedure ‰Tooth/surgical site __________________________
Planned level of sedation: ‰Minimal ‰Moderate ‰Deep ‰GA
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 : : : : : : : : : : : : : : : :
Sedatives1
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 (e.g., Start, Completion, Recovery, Discharge)
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 Was all planned treatment completed? ‰ Yes ‰ No
Comments: ____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

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
‰ Postoperative 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/Dentist Chairside Monitoring

Signature: _____________________________ Assistant: _______________________ Personnel Signature: __________________________

Postoperative call
Date: ______________ Time: _________ By: _________ Spoke to: __________________________ Comments: _______________________________
______________________________________________________________________________________________________________________________
RESOURCES: POSTOP INSTRUCTIONS

Postoperative Instructions for Extractions / Oral

Surgery
Patient: __________________________________________________________ Date: _________________________________
Your child had the following procedure performed today: U Biopsy U Extraction U Exposure of unerupted tooth
U Frenectomy/Frenotomy U Gingivectomy U Gingival graft U Wound management 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 noncarbonated liquids but should NOT use a straw. Encourage
fluids to help avoid dehydration. Cold soft foods (e.g., applesauce, diced peaches, watermelon, ice cream, gelatin, 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 ), ibuprofen (Advil , Motrin ), or
®
® ® ®
naproxen (Aleve , Anaprox , Naprosyn ), before the numbness wears off. Do NOT give aspirin to your child. Follow the instruc-
tions on the bottle for dosing based upon your child’s age/weight. If pain is not relieved by one of these medications, you may
alternate acetaminophen and ibuprofen every three hours. Please call our office if pain cannot be controlled with these medications.
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. Ice packs may be used for the first 24 hours
(10 minutes on then 10 minutes off) to decrease swelling and/or bruising. Keep the head elevated; avoid lying flat. 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: __________________________________

624 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 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
Remarkable clinical findings: Radiographic history/date:
‰ Developmental anomalies ‰ Bitewings ________________________________
‰ Soft tissue pathology ‰ Panoramic _______________________________
‰  Fluorosis ‰ Full mouth _______________________________
‰ Caries ( ‰ noncavitated ‰ cavitated ) ‰ Single tooth ______________________________
‰ Malocclusion ‰ Cephalogram _____________________________
‰ Traumatic injury ‰ Other ___________________________________
‰ Other (e.g., habits) __________________________
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 _____________________________________________________________________________
______________________________________________________________________________________
History of caries: ‰ None ‰ Minimal ‰ Moderate ‰ Severe
Therapeutic/surgical interventions: ‰ Silver diamine fluoride ‰ Resin infiltration ‰ Pulp therapy
‰ Interim therapeutic restoration ‰ Other restoration ( ‰ resin ‰ amalgam ‰ crown ‰ __________)
‰ Extraction ‰ Other ________________________
Comments ______________________________________________________________________________
______________________________________________________________________________________
History of trauma: ‰ No ‰ Yes (date:______________) Comments _______________________________
_______________________________________________________________________________________
Behavior: ‰ Cooperative ‰ Previous difficulties ‰ Ongoing considerations
Adjunctive techniques: ‰ Nitrous oxide ‰ Sedation ‰ General anesthesia ‰ Other _______________
Referral for specialty care: ‰ No ‰ Yes _______________________________________________________
Additional considerations: ____________________________________________________________________
_______________________________________________________________________________________
Assessed caries risk: ‰ Low ‰ Moderate ‰ High Assessed periodontal risk: ‰ Low ‰ Moderate ‰ High
Recall frequency: _________________________ Patient due for recall: ________________________
For additional information, please contact (_______) ___________________
__________________________________________ __________________________________________
Signature of person completing form Signature of attending dentist
625
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 nonschool 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.

626 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: COMMON LABS

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 Absolute counts Significance
Neutrophils 1,500-8,000/mm3 Increase in bacterial infections, hemorrhage, diabetic acidosis.
Absolute Neutrophil Count (ANC) < 1,000/mm3: patient at increased risk for infection. Defer elective dental
treatment.
Lymphocytes 1,500-3,000/mm3 Viral and bacterial infections, acute and chronic lymphocytic leukemia, antigen reaction
Eosinophils 50-250/mm3 Increase in parasitic and allergic conditions, blood dyscrasias, pernicious anemia
Basophils 15-50/mm3 Increase in types of blood dyscrasias
3
Monocytes 285-500/mm Hodgkin’s disease, lipid storage disease, recovery from severe infections, monocytic leukemia

Bleeding Screen
Test Normal value Function Significance
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
Test Normal value Function Significance
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

Test Normal value Function Significance

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
Increased in hyperglycemia; pre-diabetes: 5.7-6.4%; diabetes
Hemoglobin A1C (HbA1C) < 5.6 % mellitus: > 6.5%.

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. Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J, eds. Harrison’s Principles of Internal Medicine. 21 ed. New York, N.Y.: McGraw Hill; 2022.
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 American Academy of Pediatric Dentistry 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
Important: 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:2-5
Children < 12 years: 10-15 mg/kg/dose every 4-6 hours as needed (maximum daily dose 75 mg/kg, but not to exceed 4,000 mg/24 hours)

OR ALTERNATIVE DOSING BASED ON AGE OF CHILD 3

Age Weight Dosage
lbs kg mg 3
0-3 months 6-11 2.7-5.3 40
4-11 months 12-17 5.4-8.1 80
1-2 years 18-23 8.2-10.8 120
2-3 years 24-35 10.9-16.3 160
4-5 years 36-47 16.4-21.7 240
6-8 years 48-59 21.8-27.2 320-325
9-10 years 60-71 27.3-32.6 325-400
11 years 72-95 32.7 - 43.2 480-500

Children > 12 years and adults: 325-650 mg every 4-6 hours

OR 1,000 mg 3-4 times daily as needed (maximum daily dose 4,000 mg)

Ibuprofen
Forms: Liquid, tablet, injectable
Usual oral dosage:2-5
Infants and children < 12 years: 4-10 mg/kg/dose every 6-8 hours as needed (maximum single dose 400 mg)

OR ALTERNATIVE DOSING BASED ON AGE OF CHILD 3

Age Weight Dosage
lbs kg mg
6-11 months 12-17 5.4-8.1 50
12-23 months 18-23 8.2-10.8 75-80
2-3 years 24-35 10.9-16.3 100
4-5 years 36-47 16.4-21.7 150
6-8 years 48-59 21.8-27.2 200
9-10 years 60-71 27.3-32.6 200-250
11 years 72-95 32.7 - 43.2 300

Children > 12 years: 200-400 mg every 4-6 hours as needed (maximum daily dose 3,200)
Adults: 200-400 mg/dose every 4-6 hours as needed
OR 600-800 mg every 6-8 hours as needed (maximum daily dose 3,200)

628 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: USEFUL MEDICATIONS

Naproxen
Important: 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.4
Forms: Suspension, tablet
Usual dosage:2-5
Children and adolescents: 5-7 mg/kg every 8-12 hours as needed (maximum daily dose 1,000 mg)
Adults: Initial dose of 500 mg, then 250-500 mg every 12 hours
OR 250 mg every 6-8 hours as needed (maximum daily dose 1,250 mg on day 1, then 1,000 mg/day thereafter)

Moderate/Severe Pain
Important: 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.6 An overview of the benefits and risks of analgesic medications for the management of
acute dental pain has been summarized.7

Systemic Antibiotics
Amoxicillin
Forms: Suspension, chewable tablet, tablet, capsule
Usual oral dosage:2-5
Infants > 3 months, children, and adolescents < 40 kg: 20-40 mg/kg/day in divided doses every 8 hours (maximum single dose 500 mg)
OR 25-45 mg/kg/day in divided doses every 12 hours (maximum single dose 875 mg)
Adolescents and adults: 250-500 mg every 8 hours
OR 500-875 mg every 12 hours
Endocarditis prophylaxis:3,4,8
Infants, children, and adolescents: 50 mg/kg (maximum single dose 2,000 mg) 30-60 minutes before procedure
Adults: 2,000 mg 30-60 minutes before procedure
Periodontal disease treatment for select cases using oral regimen combination of amoxicillin and metronidazole 9
Children and adolescents: Amoxicillin: 25-35 mg/kg/day in divided doses every 8 hours for 7 days (maximum single dose 500 mg)
AND Metronidazole: 10 mg/kg/dose every 8 hours for 7 days (maximum single dose 250 mg)
Adults: Amoxicillin: 375-500 mg every 8 hours for 7 days
AND Metronidazole: 250 mg every 8 hours for 7 days
Caution: For individuals who are allergic to penicillin, see alternative regimens under azithromycin and metronidazole

Amoxicillin clavulanate potassium

Important: Use the lowest dose of clavulanate combined with amoxicillin available to decrease gastrointestinal adverse drug events. The
frequency of dosing is generally based on the ratio of amoxicillin to clavulanate.4
Forms: Suspension, chewable tablet, tablet
Usual oral dosage:2-5 (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;
maximum daily dose 1,750 mg) (prescribe suspension or chewable tablet due to clavulanic
acid component)
Children > 40 kg and adults: 500-875 mg every 12 hours (prescribe tablet)
Examples of formulations and dosing schedule:3,4
4:1 formulations are dosed 3 times daily (amoxicillin 125 mg/clavulanate 31.25 mg; amoxicillin 250 mg/clavulanate 62.5 mg;
amoxicillin 500 mg/clavulanate 125 mg)
7:1 formulations are dosed 2 times daily (amoxicillin 200 mg/clavulanate 28.5 mg; amoxicillin 400 mg/clavulanate 57 mg;
amoxicillin 875 mg/clavulanate 125 mg)

Useful Medications continued on the next page.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 629

RESOURCES: USEFUL MEDICATIONS

Azithromycin
Important: Doses may vary for extended release suspension depending on the reason for prescribing the antibiotic.
This drug is an option 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.3,4
Forms: Tablet, capsule, suspension, injectable
Usual oral dosage:2-5
Children > 6 months up to 16 years: 10-12 mg/kg on day 1, single dose, (maximum 500 mg), 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 (maximum 250 mg) for 2-5 days
Endocarditis prophylaxis:3-5,8
Infants, children, and adolescents: 15 mg/kg (maximum single dose 500 mg) 30-60 minutes before procedure
Adults: 500 mg 30-60 minutes before the procedures
Periodontal disease treatment for select cases using oral regimen of azithromycin only, when allergic to penicillin 9
Children and adolescents: 10-12 mg/kg once daily for 3 days (maximum daily dose 500 mg)
Adults: 500 mg once daily for 3 days (maximum daily dose 500 mg/day)

Cephalexin
Caution: This antibiotic should not be used by an individual who has a history of anaphylaxis, angioedema, or urticaria with penicillin
or ampicillin.3-5
Forms: Suspension, tablet, capsule
Usual oral dosage:2-5
Infants, children and adolescents: Mild to moderate infections: 25-50 mg/kg/day divided every 6-12 hours
(maximum daily dose 2,000 mg)
Severe infections: 75-100 mg/kg/day divided every 6-8 hours
(maximum daily dose 4,000 mg)
OR 500 mg every 12 hours
Adults: 250-1,000 mg every 6 hours (maximum daily dose 4,000 mg)
Endocarditis prophylaxis:3,4,8
Infants, children, and adolescents: 50 mg/kg (maximum single dose 2,000 mg) 30-60 minutes before procedure
Adults: 2,000 mg 30-60 minutes before procedure

Clarithromycin
Important: This drug is an option 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.3,4
Forms: Suspension, tablet
Usual oral dosage:2-5
Infants, children and adolescents: 15 mg/kg/day divided every 12 hours (maximum single dose 500 mg)
Adults: 500 mg every 12 hours
Endocarditis prophylaxis:3,4,8
Infants, children and adolescents: 15 mg/kg (maximum single dose 500 mg) 30-60 minutes before procedure
Adults: 500 mg 30-60 minutes before procedure

Clindamycin
Important: This is an option for patients with Type I allergy 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. However,
Clostridioides difficile colitis is a serious adverse reaction with this antibiotic.3-5
This antibiotic is no longer recommended for endocarditis prophylaxis for dental procedures.8
Forms: Suspension, capsule, injectable
Usual oral dosage:2-5
Infants, children and adolescents: 10-25 mg/kg/day in divided doses every 8 hours (maximum single dose 450 mg)
Adults: 300-450 mg every 6-8 hours (maximum daily dose 1,800 mg)

630 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: USEFUL MEDICATIONS

Doxycycline
Important: Tetracycline may cause permanent tooth discoloration, enamel hypoplasia in developing teeth, and hyperpigmentation of the soft
tissues. Due to these side effects, this drug usually is not recommended for women who are pregnant and children < 8 years old. However,
short-term use of doxycycline (< 21 days) is recommended by the American Academy of Pediatrics for specific infections when necessary
because there is lack of clinical evidence that this form of tetracycline results in discoloration of developing teeth when used for < 21 days.3,4,10
Forms: Suspension, tablet, delayed release tablet, capsule, injectable
Usual oral dosage:2-5
Children > 8 years and adolescents: 2.2 mg/kg/dose every 12 hours (maximum single dose 100 mg/dose)
Adults: 100 to 200 mg/day once a day or divided 2 times daily every 12 hours
Endocarditis prophylaxis:3,4,8
Children > 8 years and adolescents: children < 45 kg, 2.2 mg/kg
children > 45 kg, 100 mg 30-60 minutes before procedure
Adults: 100 mg 30-60 minutes before the procedure

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 or propylene glycol-containing products while taking metronidazole.
There is a warning with the drug because it has been shown to be carcinogenic in mice and rats.3.4
Forms: Tablet, tablet extended release, capsule, injectable
Usual oral dosage:
For anaerobic skin and bone infection:3-5
Children and adolescents: 15-50 mg/kg/day in divided doses 3 times daily (maximum daily dose 2,250 mg)
Adults: 7.5 mg/kg every 6 hours (maximum daily dose 4,000 mg)
For periodontal disease, including necrotizing gingivitis:4,5,9
Children and adolescents who are allergic to penicillin: 10 mg/kg/dose every 8 hours for 7 days (maximum single dose 250 mg)
Adults who are allergic to penicillin: 250-500 mg every 8 hours for 7 days
See amoxicillin and azithromycin above for other periodontal treatment approaches.

Penicillin V Potassium
Important: 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
Forms: Liquid, tablet
Usual oral dosage:2-5
Children and adolescents: 25-50 mg/kg/day in divided doses every 6 hours (maximum daily dose 2,000 mg)
Adults: 250-500 mg every 6-8 hours

Topical Antibacterial/Antimicrobial Agents

Chlorhexidine gluconate
Important: Most brands contain alcohol.
Forms: Dental solution 0.12% (118 mL, 473 mL)
Usual dosage for gingivitis/periodontitis and stomatitis (off label use for stomatitis):2-5
Children • 8 years and adults: Rinse with 15 mL 2 times daily (after breakfast and before bed) for 30 seconds and expectorate.

Mupirocin
Important: For external use only; not for use in patients < 2 months of age.
Forms: Ointment 2%; cream 2%
Usual dosage for localized impetigo or skin infection:2-5
Children and adults: Apply a small amount of ointment to the affected area 3 times daily for 5-10 days. If no clinical response after
5 days, then reevaluate.

Useful Medications continued on the next page.

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RESOURCES: USEFUL MEDICATIONS

Retapamulin
Important: For external use only; limited information on age group < 9 months of age.
Forms: Ointment 1%
Usual dosage for localized impetigo:2-5
Children and adults: Apply a small amount of ointment to the affected area 2 times daily for 5 days.

Antifungal Agents for Candidiasis

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.3,4
Form: Suspension 10 mg/mL, 40 mg/mL; tablet: 50 mg, 100 mg, 150 mg, 200 mg; injectable: 100mg/50 mL, 200 mg/100 mL,
400 mg/200 mL.
Usual dosage:2-5
Infants, children and adolescents: Single dose of 6-12 mg/kg/dose followed by 3 mg/kg/dose once daily for 7-14 days
(maximum single dose 400 mg)
Adults: Single dose of 200 mg on day 1, then 100-200 mg/dose once daily for 7-14 days

Topical or transmucosal agents for oral candidiasis

Clotrimazole
Important: This drug is not for use in patients < 3 years of age.
Form: Lozenge 10 mg
Usual dosage:2-5
Children > 3 years and adults: Dissolve 1 lozenge 5 times daily for 7-14 days. Treatment may extend beyond clinical resolution.

Miconazole
Important: This dosage form contains milk protein concentrate.
Form: Buccal tablet 50 mg
Usual dosage:3,4
Adolescents > 13 years and adults: 1 tablet daily for 14 days; apply to the gum region, just above the upper lateral incisor.

Nystatin
Form: Suspension (100,000 units/mL)
Usual oral dosage:3,4,10
Infants: 200,000 units (2 mL) 4 times daily; ½ of dose placed in each side of mouth. Use for 7-14 days.
Children and adults: Swish 400,000-600,000 units (4-6 mL) 4 times daily for several minutes and swallow; continue at least 48 hours
after symptoms resolve. Use for 7-14 days.

Topical agents for angular cheilitis

Clotrimazole
Form: Cream 1%
Usual dosage:4,11
All ages: Apply a thin layer to the corners of the mouth 2-4 times daily for 7-14 days or until complete healing.

Miconazole nitrate
Forms: Ointment 2%; cream 2%
Usual dosage:4,11
Children > 2 years and adults: Apply a thin layer to the corners of the mouth 2-4 times daily for 7-14 days or until complete healing.

632 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: USEFUL MEDICATIONS

Nystatin
Forms: Ointment, cream (100,000 units/g)
Usual dosage:2,4,11
For all ages: Apply a thin layer to corners of mouth 2-4 times daily for 7-14 days or until complete healing.

Nystatin, triamcinolone acetonide (not Food and Drug Administration [FDA]-approved for this use)
Forms: Ointment, cream (100,000 units nystatin/g and 0.1% triamcinolone acetonide)
Usual dosage:4,11
All ages > 2 months: Apply a thin layer to the corners of the mouth 2 times daily for no longer than 2 weeks. Should be used for the
shortest period of time in children (3-5 days).

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:3-5
Infants, children and adolescents: 20 mg/kg/dose 4 times daily for 5-7 days (maximum single dose 800 mg)
Immunocompromized children: 20 mg/kg/doses 4 times daily for 7-10 days
Immunocompromized adolescents: 400 mg 3 times daily for 5-10 days or until resolution
Adults: 400 mg 3-5 times daily for 5-10 days

Valacyclovir (not FDA-approved for this use)

Forms: Suspension may be compounded by pharmacist; tablets 500 mg, 1,000 mg
Usual dosage:3-5
Infants ≥ 3 months, children and adolescents: 20 mg/kg/dose 2 times daily for 5-7 days (maximum single dose 1,000 mg)
Immunocompromised children and adolescents: 20 mg/kg/dose 2 times daily for 10-14 days
Adults: 1,000 mg 2 times daily for 7-10 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:2-5 (Begin treatment at the earliest signs/symptoms)
Infants and children: 20 mg/kg/dose 4 times daily for 7-10 days or until clinical resolution (maximum single dose 400 mg)
Immunocompromised children: 20 mg/kg/dose 4 times daily for 7-10 days or until clinical resolution
Adolescents and adults: 400 mg 3 times daily for 5-10 days or until clinical resolution

Famciclovir
Form: Tablet 125 mg, 250 mg, 500 mg
Usual dosage: 2-5
Children and adolescents: 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 dose has not been established
for adolescents; maximum daily dose 2,000 mg for adults for one-day regimens or 1,500 mg/ day orally for
multiple-day regimens)
Immunocompromised adolescents and adults: 500 mg 2 times daily for 5-10 days

Valacyclovir
Form: Tablet 500 mg, 1,000 mg
Usual oral dosage:2-5
Children • 12 years and adults: 2,000 mg every 12 hours for 1 day (2 doses); initiate at first signs or symptoms of infection
(maximum daily dose 4,000 mg for one-day regimen)
Immunocompromised adolescents and adults: 1,000 mg every 12 hours for 5-10 days (maximum daily dose 3,000 mg)

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 633

RESOURCES: USEFUL MEDICATIONS

Topical agents for herpes labialis

Docosanol
Form: Cream 10%
Usual dosage:2-5
Children • 12 years and adults: Apply a thin layer on the lesion 5 times daily for up to 10 days.

Acyclovir
Form: Cream 5%
Usual dosage:3-5
Children • 12 years and adults: Apply a thin layer on the lesion 5 times daily for 4 days.

Acyclovir (minimal transmucosal absorption)

Important: This dosage form contains milk protein concentrate.
Form: Buccal tablet 50 mg
Usual dosage:3-5
Children • 12 years and adults: Apply 1 tablet 1 time to the upper gums in area of canine fossa.

Acyclovir with hydrocortisone

Form: Cream (5% acyclovir with 1% hydrocortisone)
Usual dosage:3-5
Children • 6 years and adults: Apply a thin layer on the lesion 5 times daily for 5 days.

Penciclovir
Form: Cream 1%
Usual dosage:2-5
Children • 12 years and adults: Apply a thin layer on the lesion every 2 hours while awake for 4 days.

Topical Corticosteroids
Use for noninfectious ulcers and mucocutaneous lesions, including aphthous ulcers, localized contact allergic reactions, and symptomatic
benign migratory glossitis.

Triamcinolone acetonide (medium potency corticosteroid)

Form: Dental paste or ointment 0.1%
Usual dosage:3,4,11
Children, adolescents and adults: Apply paste to ulcers 2-4 times daily, after meals and at bedtime; not to exceed 14 day course.
Avoid eating or drinking for 30 minutes after application

Fluocinonide (high potency corticosteroid; not FDA-approved for oral application)

Form: Gel, ointment 0.05%
Usual dosage:4,11
Adolescents and adults: Apply thin amount of gel or ointment to ulcers 2-4 times daily; not to exceed 14 day course.

Dexamethasone (high potency corticosteroid; not FDA-approved for oral application)

Form: Elixir, solution 0.5 mg/5 mL (contains alcohol)
Usual dosage:11
Adolescents and adults: Rinse with 5 mL 2-4 times daily for 2 minutes and expectorate; not to exceed 14 day course.

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

Form: Gel, ointment 0.05%
Usual dosage:4,11
Adolescents and adults: Apply thin amount of gel or ointment to ulcers 2-4 times daily, not to exceed 14 day course.

634 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: USEFUL MEDICATIONS

References
1. American Academy of Pediatric Dentistry. Policy on pediatric dental pain management. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:139-41.
2. Jeske AH. Mosby’s Dental Drug Reference. 13th ed. St. Louis, Mo.: Elsevier, Inc.; 2022.
3. Lexicomp Online, Pediatric and Neonatal Lexi-Drugs Online. Hudson, Ohio: Wolters Kluver Clinical Drug Information,
Inc.; 2022. Available at: “http://webstore.lexi.com/Pediatric-Lexi-Drugs”. Accessed September 25, 2022.
4. Lexicomp Online, Lexi-Drugs Online. Hudson, Ohio: Wolters Kluver Clinical Drug Information, Inc.; 2022. Available
at: “http://www.wolterskluwercdi.com/lexicomp-online/”. Accessed September 25, 2022.
5. ClinicalKey Online, Gold Standard Drug Monographs Online. North America: Elsevier, Inc.; 2022. Available at: “http://
www.clinicalkey.com/#!/content/drug_monograph/”. Accessed September 25, 2022.
6. Tobias JD, Green TP, Coté CJ, Section on Anesthesiology and Pain Medicine, American Academy of Pediatrics Committee
on Drugs. Codeine: Time to say “no”. Pediatrics 2016;138(4):e20162396.
7. 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.
8. Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis. A scientific
statement from the American Heart Association. Circulation 2021;143(20):e963-e978. Epub 2021 Apr 15. Available
at: “https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000969”. Erratum in: Circulation 2021;144(9):e192.
Available at: “https://www.ahajournals.org/doi/10.1161/CIR.0000000000001012”. Accessed September 19, 2022.
9. American Academy of Pediatric Dentistry. Risk assessment of periodontal diseases and pathologies in pediatric dental
patients. The Reference Manual of Pediatric Dentistry, Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:
466-84.
10. Committee on Infectious Diseases, American Academy of Pediatrics. Antimicrobial agents and related therapy, Section 4.
In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on
Infectious Diseases. 32nd ed. Itasca, Ill.: American Academy of Pediatrics; 2021:863-1006.
11. Little JW, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 9th ed. St. Louis, Mo.:
Elsevier, Inc.; 2018.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 635

RESOURCES: MEDICAL EMERGENCIES
Management of Medical Emergencies
For all emergencies
1. Discontinue dental treatment
2. Call for assistance / someone to bring oxygen and emergency kit
3. Position patient: ensure open and unobstructed airway
Condition Signs and symptoms
Allergic reaction Hives; itching; edema;
(mild or delayed) erythema–skin,
mucosa conjuctiva
Allergic reaction Urticaria-itching, flushing,
(sudden onset): hives; rhinitis;
anaphylaxis wheezing/difficulty breathing;
bronchospasm; laryngeal
edema; weak pulse; marked
fall in blood pressure; loss of
consciousness
Acute asthmatic Shortness of breath;
attack wheezing; coughing;
tightness in chest;
cyanosis; tachycardia
Local anesthetic Light-headedness; changes
toxicity in vision and/or speech;
metallic taste; changes in
mental status; confusion,
agitation; tinnitis; tremor;
seizure; tachypnea;
bradycardia; unconsciousness;
cardiac arrest
Local anesthetic Anxiety; tachycardia/
reaction: palpitations; restlessness;
vasoconstrictor headache; tachypnea;
chest pain; cardiac arrest
Overdose: Somnolence; confusion;
benzodiazepine diminished reflexes;
respiratory depression;
apnea; respiratory arrest;
cardiac arrest
Abbreviations in table: CPR = cardiopulmonary resuscitation; IM = intramuscular; IN = intranasal; IV = intravenous; kg = kilogram; mg = milligram; mL=
milliliter; SubQ = subcutaneous.
636 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
4. Monitor vital signs
5. Be prepared to support respiration, support circulation, provide CPR, and call
for emergency medical services
Treatment Drug dosage Drug delivery
1. Discontinue all sources of allergy-causing Diphenhydramine: follow Oral
substances manufacturer’s instructions
2. Administer diphenhydramine based on child’s age/weight
This is a true, life-threatening emergency Epinephrine (1 mg/mL): IM or SubQ
1. Call for emergency medical services 0.01 mg/kg every 5 minutes (Auto injector
2. Administer epinephrine until recovery or until available)
3. Administer oxygen help arrives1
4. Monitor vital signs
5. Transport to emergency medical facility
by advanced medical responders
1. Sit patient upright or in a 1. Albuterol (patient’s or Inhale
comfortable position emergency kit inhaler)
2. Administer oxygen 2. Epinephrine (1 mg/mL): IM or SubQ
3. Administer bronchodilator 0.01 mg/kg every
4. If bronchodilator is ineffective, administer 15 minutes as needed1
epinephrine
5. Call for emergency medical services with
transportation for advanced care if
indicated
1. Assess and support airway, breathing, Supplemental oxygen Mask
and circulation (CPR if warranted)
2. Administer oxygen
3. Monitor vital signs
4. Call for emergency medical services with
transportation for advanced care if
indicated
1. Reassure patient Supplemental oxygen Mask
2. Assess and support airway, breathing, and
circulation (CPR if warranted)
3. Administer oxygen
4. Monitor vital signs
5. Call for emergency medical services with
transportation for advanced care if
indicated
1. Assess and support airway, breathing, and Flumazenil 0.01 mg/kg IV (if IV access
circulation (CPR if warranted) (maximum: 0.2 mg); may is not available,
2. Administer oxygen repeat at 1 minute intervals may be given
3. Monitor vital signs not to exceed a cumulative IM)
4. If severe respiratory depression, establish dose of 0.05 mg/kg or
IV access and reverse with flumazenil 1 mg, whichever is less1
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 IV, IM, or SubQ
narcotic respiratory depression; circulation (CPR if warranted) up 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 (5 mg/mL): IV

blinking, or blank stare;
uncontrolled muscle
movements; muscle rigidity;
unconsciousness; postictal
phase–sleepiness, confusion,
amnesia, slow recovery
prevent injury 0.15-0.2 mg/kg per dose;
2. Ensure open airway and maximum 10 mg per dose.
adequate ventilation May repeat dose once1
3. Monitor vital signs
4. If status is epilepticus, give either diazepam OR IM, IN, IV
OR midazolam and call for emergency Midazolam: 0.2 mg/kg
medical services with transportation for (maximum 10 mg)1
advanced care if indicated

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 inhaler
weak; dizziness; hypotension; 4. Administer oxygen
cold extremities; 5. Cold towel on back of neck
unconsciousness 6. Monitor recovery

Abbreviations in table: CPR = cardiopulmonary resuscitation; IM = intramuscular; IN = intranasal; IV = intravenous; kg = kilogram; mg = milligram; mL=
milliliter; SubQ = subcutaneous.

Reference
1. Shenoi RP, Timm N, AAP Committee on Drugs, AAP Committee on Pediatric Emergency Medicine. Drugs used to treat pediatric emergencies.
Pediatrics 2020;145(1):e20193450. Available at: “https://publications.aap.org/pediatrics/article/145/1/e20193450/36970/Drugs-Used-to-Treat-
Pediatric-Emergencies”. Accessed August 24, 2022.

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.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 637

RESOURCES: SARS-CoV-2

Severe Acute Respiratory Syndrome Coronavirus 2 and COVID-19

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 vaccinations and infection control policies, procedures, and practices in health care settings to prevent disease
transmission and strongly encourages dentists to be up to date with all recommended vaccines and boosters against coronavirus disease
2019 (COVID-19). 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 recommenda-
tions to minimize risk of COVID-19.
Because the issues and understanding of SARS-CoV-2 continue to evolve, the AAPD offers two online resource hubs:
• COVID-19 Update/Coronavirus Update (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.
• Beyond Re-emergence Pediatric Dentistry Practice Checklist (https://www.aapd.org/about/about-aapd/news-room/aapd-practice-check
list-resources/) guides 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 COVID-19 Information is a curated website of the latest COVID-19 guidance including government
policy, emerging science, and patient resources (https://www.ada.org/resources/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): COVID-19 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 (COVID-19) pandemic on a global scale
(https://www.who.int/emergencies/diseases/novel-coronavirus-2019).

COVID-19: Vaccines, Infection Control Tools, and Readings

• CDC Vaccines and Immunizations: COVID-19 Vaccination Clinical & Professional Resources (https://www.cdc.gov/vaccines/covid-
19/index.html).
• CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnnel During the COVID-19 Pandemic
(https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html).
• Occupational Safety and Health Administration COVID-19 Control and Prevention: Dentistry Workers and Employers (https://www.
osha.gov/coronavirus/control-prevention/dentistry) and Protecting Workers: Guidance on Mitigating and Preventing the Spread of
COVID-19 in the Workplace (https://www.osha.gov/coronavirus/safework).
• Environmental Protection Agency List N Tool: COVID-19 Disinfectants (https://cfpub.epa.gov/wizards/disinfectants/).
• Organization for Safety, Asepsis and Prevention/CareQuest Institute Best Practices for Infection Control in Dental Clinics During
the COVID-19 Pandemic (https://www.carequest.org/system/files/CareQuest-Institute-OSAP-best-practices-for-infection-control-in-
dental-clinics-during-the-covid-19-pandemic.pdf ).
• Anesthesia Patient Safety Foundation. Novel Coronavirus (COVID-19) Anesthesia Resource Center (https://www.apsf.org/novel-
coronavirus-covid-19-resource-center/).
• CDC Scientific Brief: SARS-CoV-2 Transmission (https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html)
and Testing Overview (https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html).
• Scottish Dental Clinical Effectiveness Programme Rapid Review of Aerosol Generating Procedures in Dentistry (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://onlinelibrary.wiley.com/doi/10.1111/odi.13632”. Accessed August 21, 2022.
2. Harte JA. Standard and transmission-based precautions in dentistry. J Am Dent Assoc 2010;141(5):572-81. Available at: “https://jada.
ada.org/article/S0002-8177(14)61533-6/fulltext”. Accessed August 21, 2022.

638 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 RESOURCES: BLS / CPR CHART

Basic Life Support / Cardiopulmonary Resuscitation

Reprinted with permission

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

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 639

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 help ensure
quality patient care and to protect patients. 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 Commission on Dental Accreditation
(CODA);
• Experience. Reflects the skills of an educationally-qualified, board candidate/board certified pediatric dentist. Scope of practice i
ncludes 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 room, 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, diagnosis of temporomandibular disorders, pulp testing, treatment of common oral
diseases, uncomplicated biopsies and adjunctive diagnostic tests (e.g., exfoliative cytology, microbial culture, Mutans Streptococcus
testing, other laboratory testing), impressions for dental models, risk assessment for caries and periodontal disease/conditions,
and 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, and counseling for tobacco
and substance misuse 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, micro-
abrasion, and esthetic restorations.
• Management of the developing dentition and occlusion/orthodontic procedures. Treatment of nonnutritive 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 conjunction with orthognathic surgery, nonsurgical
management of temporomandibular disorders, and 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; and treatment of chemical
or thermal intraoral injuries.
• Periodontal procedures. Periodontal probing, gingival curettage, scaling, root planing, local or systemic chemotherapy, dental
splinting, frenuloplasty, frenulectomy, and frenulotomy (including correction of ankyloglossia), gingivectomy/gingivoplasty,
and gingival grafts.
• Endodontic procedures. Pulp capping, pulpotomy, lesion sterilization/tissue repair, pulpectomy, and root filling of primary and
permanent teeth; pulp revascularization, apexification, apexogenesis, apicoectomy; and 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; and 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, and removal of minor cysts and foreign bodies.
• Additional or special procedures. List procedures (e.g., laser surgery) and qualifications:

640 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

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