CHAPTER 2: BEHAVIOR GUIDANCE OF THE

PEDIATRIC DENTAL PATIENT

1. Behavior guidance: The processes by which practitioners help patients identify appropriate and
inappropriate behavior, learn problem solving strategies and develop impulse control and self-
esteem.
Behavior guidance is the means by which the dental health team effectively and efficiently
performs treatment for a child and, at the same time, instills a positive dental attitude.

2. Classification of behavior y Wright’s

① Cooperative
A. Children with minimal apprehension and are communicative comprehending and willing
B. Respond well to behavior shaping
② Potentially cooperative
A. Definition: capable of appropriate behaviors but are disruptive in the dental environment.
(a child’s behavior can be modified and the child can become cooperative)
B. Types of potentially cooperative patient
a. Uncontrolled
- Typically 3~6 years old
- Characterized by a tantrum
b. Defiant
- Can be all ages
- Characterized by an “ I don’t’ want to” attitude in young children
- Characterized by passive resistance in adolescents
- Spoiled and stubborn and do not like to be advised by adults
c. Timid
- Typically preschool and younger grade school-age children
- Characterized by shielding behavior and hesitating behaviors.
- For example, children with shielding behavior may stand behind a parent in the
reception area or may keep their hands close to their face and mouth
- They may deteriorate into uncontrolled behaviors, esp. in the absence of
proficient management technique.
d. Tense-cooperative
- Typically older children (>7y)
- These children want to cooperate with the dentist and try to behave in an adult
manner but are very nervous.
- These patients have also been termed “white knuckler” patients because they
grip the arms of the dental chair so tightly.
e. Whining
- Is usually continuous
- Typically there is an absence of tears.
- This behavior is difficult to overcome in one dental visit
③ Lacking cooperative ability
A. Children who are deficient in comprehension or communication skills or both
B. Examples are very young children (typically < 3y) and children with certain disabilities.
C. Special behavior guidance techniques are used for these children.

3. Frankl rating scale

① Common behavioral scale used in pediatric dentistry
② Ratings
A. Rating 1- definitely negative refusal of treatment, forceful crying, fearfulness or any
other overt evidence of extreme negativism
 B. Rating 2: negative resistance: reluctance to accept treatment, uncooperativeness,
some evidence of negative attitude but not pronounced (sullen, withdrawn)
C. Rating 3: positive acceptance of treatment, cautious behavior at times, willingness to
comply with dentist, although with some reservation, but patient follows the dentist’s
direction cooperatively.
D. Rating 4: definitely positive good rapport with the dentist; interest in the dental
procedure; laugher and enjoyment.
③ Positive cooperative behavior can be jotted down as “+” or “+ +” and uncooperative behavior
as “−” or “− −.”
④ For children who are too young to cooperate, the term precooperative is preferred.

4. Jean piaget’s stages of child development: all children progress through the same sequence of
cognitive stages.
① Sensorimotor stage (birth to 24 months)
A. Use senses and motor abilities to understand the world and have little to no meaningful
verbal communication
B. They are hyperaware of people around them as they reach this age and are perceptive
to nonverbal communication.
② Preoperational stage (2~5 years)
A. Begin to use language in similar ways to adults and can form mental symbols and words
to represent objects.
B. Limited logical reasoning skills.
C. Children tend to perceive the world from their own perspective or be “egocentric.
③ Concrete operational stage ( 6~11 years)
A. increased logical reasoning skills and can see the world from different points of view
B. difficulty with abstract ideas and attain benefit from concrete instructions
④ Formal operations (>11years): Children can think about abstractions and hypothetical
concepts and reason analytically

5. Learning theory
① Positive reinforcement is a reward for doing something well.
② Negative reinforcement is a penalty for not doing something, different from punishment
where a person did something that are not supposed to do.
③ AAPD recommends active ignoring of minor infractions, and the dentist may consider
ignoring minor movements or intentional misbehavior

6. Temperament: additional difference in behavior in families with shared environment and genetics.
① Used to describe traits that manifest early in life and are stable and consistent across
different settings.
② 9 temperament categories and formulated 3 constellations of temperament made up of
 various combination of the individual categories that had significance
A. 9 temperament categories
a. Activity level
b. Rhythmicity
c. Approach or withdrawal
d. Adaptability
e. Threshold of responsiveness
f. Intensity of reaction
g. Quality of mood
h. Distractibility
i. Attention span and persistence
B. 3 basic classification
a. Easy temperament: biological regularity, quick adaptability to change, tendency to
approach new situations versus withdraw, predominantly positive mood of mild or
moderate intensity.
b. Difficult temperament: biological irregularity, withdrawal tendencies to the new, slow
adaptability to change, frequent negative emotional expressions of high intensity
c. Slow-to-warm-up temperament: withdrawal tendencies to the new, slow adaptability
to change and frequent negative emotional reactions of low intensity – shy

C. Approximately 65% of infants can be categorized into one of these three categories. The
remainder have a mixture of traits

7. Coping strategies
① Behavioral coping efforts are overt physical or verbal activities, whereas cognitive efforts
involve the conscious manipulation of one’s thoughts or emotions
② Coping skills in patients with dental anxiety can be improved through cognitive behavioral
therapy.
③ Girls have also been reported to use more emotional and comfort-seeking strategies when
faced with a stressful event, but boys use more physical aggression and stalling techniques

8. Factors influencing child behavior

① Demographic
A. Girls exhibited more dental anxiety and dental behavior management problems than did
boys
B. Age: most intense in younger children and decreases as children grow older. Dental
anxiety also decreases as the child grows older, as does needle phobia.
a. 2 year old
- The dentist should use communication techniques such as TellShowDo (TSD)
because the child may have adequate communication skills and may be
cooperative with a normal explanatory, friendly approach
- Parents should be present within the operating room as these children have
 anxiety resulting from separation from the parent.
b. 3~7 years old
- Most often cooperative and willing to comply with dental procedures.
- Proper familiarization techniques and behavior shaping strategies are valuable
tools to influence children’s behaviors positively in this age group
c. 8~
- As children get older, they normally try to control their apprehensions and
anxieties to the best of their ability.
- If procedures prove to be stressful to these children, they may revert to
undesirable behaviors
- Proper familiarization techniques and behaviorshaping strategies are valuable
tools to influence children’s behaviors positively in this age group
② Parental anxiety; significant correlation between maternal anxiety and a child’s cooperative
behavior at the first dental visit.
Although analysis of the scientific data reveals that children of all ages can be affected by
their mothers’ anxieties, the effect is greatest with those younger than four years of age.
③ Toxic stress
A. Stress that continues over a prolonged period and has lifelong effects is termed toxic
stress.
B. Toxic stressors include child abuse/neglect, chronic exposure to drugs or violence tin the
home, economic hardship, and parental depression or mental illness
C. Dubbed dandelion children, are low reactors and exhibit little physiologic change when
presented with toxic stress, but other children, dubbed orchid children, exhibit extreme
physiologic changes (i.e., high reactors).

D. Parenting styles also affect child behavior: positive behavior has been associated with
children of authoritative parents

④ Medical experiences
A. Pinkham classifies fears of dentistry as realistic and theorized fears.
a. Realistic fears are previous bad experiences, fears acquired from siblings and peers
and the fear of the needle
 b. Theorized fears are not real such as electrocuted by the x-ray tube
B. Irregular dental visits and increased length of time since the last dental visit are
significantly associated with increased dental anxiety
C. Patients with chronic medical conditions without dev. delay behave better due to
recurring medical experiences.
D. Pain: The child in pain will almost always exhibit behavior guidance challenges.
a. Introduction to new experiences through the tell-show-do (TSD) technique can
prevent patients from interpreting new sensations as painful
b. Anxiety can upregulate pain perception, many of our behavior management
strategies such as relaxation and distraction can downregulate pain.
E. Previous surgery is correlated with negative behavior at a first visit.
⑤ Awareness of dental problem
A. There is a tendency toward negative behavior at the 1 st dental visit when the child
believes that a dental problem exists.
B. Early, regular dental visits decrease a child’s risk of preventable oral disease, help a
child develop appropriate coping mechanisms, and enhance a positive attitude for future
visits
⑥ General behavior problems
A. Dental fear has been found in most but not all children with behavior management
problems
B. Dental fear and anxiety may also be linked to general behavioral problems, and children
at risk of developing internalizing disorders (i.e., separation anxiety disorder, generalized
anxiety disorder, obsessive-compulsive disorder) are more likely to exhibit dental fear
C. General fears can be important etiologic factors in the development of dental fears

9. Age-related psychosocial traits and skills

① 2nd year
A. Children who observe nonaggressive ways of handling frustration are likely to acquire a
similar approach.
B. Unfortunately, children who witness violent or aggressive behavior consistently are just
as likely to adopt that particular approach.
C. Physical punishment, beyond an attentiongetting technique by a parent (e.g., one
painless thump on the buttocks), is usually contraindicated and can actually make a
misbehaving child behave worse
D. Becoming interested in self-help skills
② 3rd year
A. The period for children between the 2nd and 3rd birthdays has been labeled the “terrible
two”
B. Children in the third year may use the word “no!” anytime they want to display resistanc
C. By the end of the third year, the child is asking “how” and “why” question
D. The child's unique identity is beginning to surface, and he or she can integrate the
standards of others into his or her own life. Because of this and because of increased
communication skills, the 3-year-old child is capable of a variety of social interchanges
with other people.
③ 4th years
A. Participates in small social groups
B. Shows many independent self-help skills
④ 5th years
A. Undergoes a period of consolidation; deliberate
B. Relinquishes comfort objects, such as a blanket or thumb

Anticipatory guidance
  Refers to age-appropriate counseling for patients and their parents focused on prevention
 First dental visit should be by 1 year old
Familiarization: no-treatment dental visit with an emphasis on introducing the dental setting and
common instruments.

10. Functional inquiry: can help the practitioner to understand a child’s potential behavior
① During the inquiry, there are two primary goals
A. To learn about patient and parental concerns
B. To gather information to enable a reliable estimate of the cooperative ability of the child.
② 2 methods of functional inquiries: combination of two will give a best result.
A. By a paper questionnaire:If a parent responds negatively to more than one question, the
chance of encountering a behavior problem rises considerably
B. By direct interview of child and parent

Behavior management technique and strategies

1. 5 domains of pediatric patient management
① Physical domain: papoose board, belt, and tape
② Pharmacological domain: anesthetics, sedatives, NO
③ Reward-oriented domain: reinforcement
④ Aversive domain: punishment
⑤ Linguistic domain: communication

2. Primary objective: is to lead children step by step so that they develop a positive attitude toward
dentistry.

3. Pre-appointment behavior modification

① Refers to anything that is said or done to have a positive influence on the child’s behavior
before the child enters a dental operatory
② This prepares the pediatric patient and eases the introduction to dentistry
③ Method of pre-appointment behavior modification
A. Film or video: Positive previsit imagery: showing children positive images of dentistry
prior to the visit.
 B. Live or videoed patient models such as siblings, other children, or parents.- direct
observation (uses social learning theory and the concept of modeling to improve
behavior by allowing a child to observe a cooperative patient undergoing dental
treatment, modeling refers to learning by observation)
C. Pre-appointment parental education via mailings, prerecorded messages or customized
web pages.
Children seemed better prepared by their mothers, and the dentist saw more
cooperative pediatric patients.

Scheduling: very young children are usually at their best early in the day. Emergent or urgent
treatment should not be delayed
Parents should be informed that natural parent behaviors such as reassurance can contribute to
child distress behavior and should be avoided
The dentist should use caution in determining if siblings should observe an operative visit,
especially one with local anesthesia. Also, it is best to have only one parent in the operatory to
reduce distraction and the occasional disagreement between parents

4. Communication and communicative guidance

① Requests and commands for child are best when they are direct, brief, literal and appropriate
for the child’s level of understanding
Avoid “don't” commands in toddlers and preschoolers as they have less developed language
processing skills
② The communication should be bi-directional, between the dentist and the child, or else it will
confuse the child.
③ Use of euphenisms or word substitutes to explain procedures
5. Basic behavior guidance
① Voice control
A. Voice control is a means of obtaining compliance from a child patient, with the dentist
modulating tone and/or volume to gain the patient's attention and cooperation
B. Typically the practitioner of voice control will make a request in a normal tone. If this
request is not honored, the dentist can rephrase it in a firmer tone
C. This technique is most acceptable to the child, dentist, and parent when it is followed by
positive reinforcement for improved behavior and the previously positive tenor of the
appointment is reestablished
D. Young children tend to respond to the tone of voice rather than the actual words.
E. Voice control has been shown to decrease disruptive behaviors without producing long-
term negative effects however, it may not be acceptable to all parents or clinician
F. The technique is useful for inattentive but communicative children. However, it is not
appropriate for children too young to understand or with intellectual or emotional
impairment
G. Loud voice was most effective at minimizing disruptiveness. Furthermore, the children
reported a more positive experience when loud voice control was used
② Non-verbal behavior guidance
A. Nonverbal communication is the reinforcement and guidance of behavior through
appropriate contact, posture, facial expressions, and body language
B. Nonverbal cues are important for the young child, and smiles and a friendly pat on the
arm may help the toddler with limited verbal skills feel more comfortable
C. Children between the ages of 7 and 10 years who were patted on the upper arm or
shoulder displayed less fidgeting behavior than their counterparts who did not receive
this touch; they also reported greater enjoyment of the visit
D. Leveling: Sitting and speaking at eye level allow for friendlier and less authoritative
communications.
③ Tell-show-do: one of the most intuitive and yet essential behavior management technique
A. The technique involves verbal explanation of procedures in phrases appropriate to the
developmental level of the patient (tell); Next the child is shown what will happen or what
will be used, and allowed to see, touch, or smell the material or instrument, or watch a
demonstration of the procedure; finally the child experiences the procedure, instrument
or material.
B. Almost universally acceptable to children, parents and dentists.
C. One way to avoid anxiety over seeing the instruments is to cover all of the tools with the
patient napkin, except nonthreatening items like the mirror and a toothbrush
 D. It is best to apply TSD to one procedure at a time and work through the various steps of
the procedure
E. TSD is the foundation for a new technique known as ask-tell-ask
a. The patient is asked about feelings toward planned procedures and informed about
the procedure using appropriate language
b. After this TSD component is completed, the patient is once again asked how he or
she feels about the procedure. If the patient continues to have concerns, the dentist
should attempt to address them or reconsider his or her behavior guidance plan
④ Behavior shaping and positive reinforcement
A. It Is a procedure which very slowly develops behavior by reinforcing successive
apporximations of the desired behavior until the desired behavior occurs
B. Base on the stimulus-response theory.
C. Explain the necessity for the procedure. A child who understands the reason is more
likely to cooperate
D. Give all explanations at a child’s level of understanding. Use euphemisms appropriately
E. This is most easily achieved by positive reinforcement
a. Positive reinforcement is a way to recognize the cooperation of the child patient and
promote future positive behavior through rewards.
b. May be verbal or nonverbal, nonverbal reinforcement may consist of a pat on the
shoulder, a smile or a wink.
c. Reinforcement should be immediate and specific to the desirable behavior.
⑤ Distraction
A. Of all the pediatric behavior guidance techniques, distraction has the most research to
support its efficacy
B. Parental distraction exhibited better behavior and less fear than the parental
reassurance.
C. The most basic form of distraction is conversation with the dentist such as storytelling.
⑥ Memory restructuring
A. If a parent reminds the child of an unpleasant dental experience, memories of the visit
can become more negative.
B. Memory restructuring has been suggested as a tool to prevent dental fear after an
aversive experience
C. It has 4 specific elements
a. First: Visual reminder such as picture
b. Second, the child is asked if the parent was told how brave the child was during the
dental visit
c. Third: the dentist praises the child with specific, concrete examples of the
cooperative behavior.
d. Finally, the child is asked to demonstrate the behaviors again to satisfy the sense of
accomplishment
⑦ Aversive conditioning also known as hand over mouth exercise (HOME)
A. Its purpose is to gain the attention of a highly oppositional child so that communication
can be established and cooperation obtained for a safe course of treatment.
B. Handovermouth exercise (HOME) is a technique in which the dentist places fingers or
a hand over the patient’s mouth in an effort to gain the attention of an uncontrolled
patient
C. Purpose
a. To gain the attention of a highly oppositional child so that communication can be
established and cooperation obtained for a safe course of tx.
b. Eventually make the dental experience a pleasant one.
D. Aversive conditioning should not be used routinely but as a method of last resort, and it
should always followed by positive reinforcement or praise for improved behaviors.
 Informed consent should be obtained before doing the aversive conditioning, since it
may expose the dentist to liability
E. Indication: usually with children from 3~6 years of age who have appropriate
communicative abilities.
F. Contraindication
a. Who lack cooperative ability
b. Younger than 3 years old
c. Timid children
d. Tense-cooperative children.
G. Currently removed from the AAPD’s clinical practice guidelines.
⑧ Parental presence/absence
A. If a child is behaving poorly, then the dentist can request that the parent leave until the
child becomes cooperative. This is an effective way to encourage communication for the
child unwilling to interact with the dentist.
B. When the child cooperates, the dentist should offer praise, and the parent should return
promptly

6. Alternative communicative techniques

① Escape
A. Take a break from the demands of the dental visit. Typically escape is the cessation of
activity in the mouth, not getting up from the chair.
B. 2 different types of escape
a. Contingent
- Given when a patient complies with a request or exhibits cooperative behavior
- Advantage: Nonaersive nature and it generally takes no more time than other
behavior guidance technique.
b. Noncontingent
- Given regardless of behavior
- It is granted a t a predetermined interval
C. Both escape are effective, Practically, noncontingent escape is difficult to carry out
consistently, but the concept of breaks is very effective with children.
② Desensitization to dental setting and procedures
A. It is an exposure to fear-invoking stimuli in a progressive manner, beginning with the
least disturbing.
B. Indications: Use with patients who have experienced fearinvoking stimuli, anxiety, and/or
neurodevelopmental disorders (e.g., autism spectrum disorder)
③ Deferred treatment
A. When behavior is an obstacle to safe, high-quality care, and treatment needs are not
urgent, deferring treatment is an alternative to advanced behavior guidance.
B. Parents must be aware that ideal treatment is being deferred because of patient
behavior, and they must understand the potential consequences.
C. There must also be a designated plan of observation so that treatment can be
implemented if the condition worsens. This is often termed “active surveillance

7. The use of mouth prop

① Mouth prop are routinely used in dentistry and can help prevent fatigue from the mouth
staying open during long visits, as well as accidental patient closing that may cause trauma
or moisture contamination of the area being treated.
② Use of a mouth prop on a compliant child is not considered stabilization, however for
uncooperative child it is interpreted as protective stabilization that requires informed consent.
③ Multiple types of mouth props
A. McKesson style mouth prop is a rubber, wedge-shaped device and generally well
 accepted by patient.
a. Uncooperative patients may easily dislodge this device, and it is not adjustable.
Also, these devices typically occlude half of the mouth and can make the approach
for an inferior alveolar block difficult.
b. Although unlikely, aspiration of these mouth props is a possibility, and they should
be tied with 18 inches of floss and secured extraorally
B. Molt adjustable mouth props:Rapid opening of the mouth prop on anterior teeth can
luxate or avulse them.

C. Soft foam mouth props

a. May be used on children with special needs
b. Less rigid and easier to place in a patient who refuses to open and are less likely to
damage anterior teeth than rigid
c. It is advisable to replace these mouth props with McKesson rubber props once
adequate opening is obtained, to avoid breaking a mirror or injuring a patient with an
instrument
④ Loose primary teeth can be dislodged and possibly swallowed or aspirated with any type of
mouth prop. It is advisable to check the dentition as a precaution before using any mouth
prop.

8. Advanced behavior guidance techniques: For some children, basic behavior guidance is
inadequate to permit safe, high-quality dental care. This may be due to the young age of the
child, special health care needs, extreme defiance, or fearfulness
① Protective stabilization
A. Definition: 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.
B. May be classified as either active or passive.
a. Active stabilization,
- The parent, dentist, or assistant helps stabilize the patient;
- Typically this is carried out only for a very short period of time or in times of
unexpected, physically uncooperative behavior.
- This type of stabilization is less effective in preventing untoward movement and
has been associated with more injuries compared with passive immobilization in
adult patients with intellectual disability
b. Passive stabilization
- Use of device to restrict patient movement for patient safety.
- Papoose boards or rainbow wraps
- Protective stabilization may also be used during a sedation appointment to
prevent untoward movements by the sedated child
 C. The risks of protective stabilization are physical or psychological harm, loss of dignity,
and violation of patient's rights
a. It is one of the most controversial of behavior guidance techniques
b. As with all advanced techniques, the clinician must be trained in its use (beyond the
predoctoral dental school curriculum) and specific informed consent should be
obtained, documented, and reviewed at each appointment.
D. Indication
a. 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;
b. 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;
c. 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;
d. an uncooperative patient who requires limited (e.g., quadrant) treatment and
sedation or general anesthesia is not an option
e. a patient with SHCN exhibits uncontrolled movements that would be harmful or
significantly interfere with the quality of care.3
E. Contraindications include patients
a. Who cannot be immobilized safely due to medical, psychological, or physical
condition
b. Cooperative patients
c. A patient with a history of physical or psychological trauma,
② Sedation and general anesthesia
Children under sedation should be arousable, interactive, and benefit from communicative
behavior guidance techniques. Children with no coping skills, such as those who are very
young or who have medical or developmental disabilities, may benefit from general
anesthesia.
Over the last two decades, aggressive physical management techniques, specifically hand-over-
mouth and passive restraint, have decreased in acceptability, and pharmacologic techniques
have increased in acceptability

9. Putting it all together

① Behavior guidance for the infant/toddler
A. Children less than 30month of age can usually only respond to simple commands
B. Typical fears of the 2-year-old child are strangers, loud sounds, sudden movement, and
falling. Having the parents involved is critical because children in this group are typically
 very attached to parents
C. Examination of children at this age typically takes place on the parent’s lap in the “knee-
to-knee” position using gentle active restraint from the dentist and parent.
D. Caries should be stabilized with interim restorative techniques or silver diamine fluoride
treatment if possible until behavior improves. If severe caries are present, then
advanced behavior guidance techniques are indicated
② For preschooler (3~5y)
A. By age 4 years, all children should be competent in the domain of language, unless an
abnormality is present in their psychological development
B. Musselman describes these children as “great talkers,” and they take pride in their
clothes and activities.
C. An undemanding, introductory appointment with emphasis on TSD is especially
beneficial.
D. Children in this age group are increasingly seeking to establish independence, and they
take pride in their accomplishments
③ For the school-aged child
A. Nash suggests three skills that can be used for effective communication with children
a. Reflective listening
b. Self-disclosing assertiveness (i.e., “I cannot see the teeth when the mouth is
closed”)
c. Descriptive praise.
B. Playing games and telling jokes can be useful to build rapport and make the visit more
enjoyable
④ For adolescent
A. Adolescents still have fears of dental procedures and should be managed in a
compassionate manner.
B. Listening with empathy is the most effective behavior guidance technique with
adolescent patients.
C. Physical techniques such as muscle relaxation, deep breathing, and progressive
exposure have been shown to be successful in the treatment of phobic adolescents
⑤ for child with previous negative dental experiences
A. The previous experience should not be brought up again. The practitioner should not
jump to advanced behavior techniques based solely on a previous bad experience at
another office
B. Sometimes the child can be treated successfully by a compassionate dentist using
communicative techniques in a new environment, and nitrous oxide can be a helpful
adjunct in retraining fearful patient
⑥ For child with special needs
A. Protective stabilization is often used in the treatment of children with special needs to
prevent untoward movements. Some children with cerebral palsy find this comforting
because it helps them control their movements. Children with ASD also found more
comfort and cooperation in the security and weight of an immobilization device.
B. ADHD
a. ADHD involves two sets of symptoms: inattention and a combination of hyperactive
and impulsive behaviors.
b. Usually manifests between the age of 3~5 but manifestation varies widely.(more
common in boys)
c. Common medication
- Methylphenidate (Ritalin) : adverse effect include nausea, hypertension.
- Atomoxetine (Scattera): adverse effect: hypertension, dry mouth, nausea.
- Amphetamine/ dextroamphetamine (Adderall): adverse effect includes
hypertension, headache, nausea, dry mouth.
 d. Treatment modification depends on age and severity
- Shorter appointment
- Step-by-step verbal reinforcement
e. Parenting style and the ability of the dental team to communicate well with children
are much more imp. in determining the child’s reaction to the dental env.
C. Autism
a. Condition related to brain development that impacts how a person perceives and
socializes with others
b. Wide range of symptoms (spectrum)
c. Repetitive behavior (repeated body movement), heightened sense to light and
sound

10. Practical considerations

① Scheduling
A. Morning appointment times have been suggested for children. It is a practice that has
guided scheduling in many dental offices because children are more alert and the dental
team is fresher in the morning.
B. A policy regarding scheduling should be formulated by the dentist, and scheduling
should not be left to chance
② Appointment length
A. Generally, a long visit is defined as any period in excess of half an hour
B. Appointment duration should not be extended beyond a patient’s tolerance level solely
for the practice’s convenience

PHARMACOLOGIC BEHAVIOR MANAGEMENT

1. Pharmacologic management is further divided into 2 subcategories sedation and GA

2. Minimal to moderate sedation (also known as conscious sedation- this term is misleading and
should not be used.)
① When sedation is administered to children, respiratory depression and loss of protective
reflexes may occur rapidly and unexpectedly,
② The continuum of anesthesia and sedation
A. Minimal sedation:
 a. A minimally depressed level of consciousness where the patient retains the ability to
maintain an airway independently and continuously and respond normally to tactile
stimulation and verbal commands
b. Ventilator and CVS functions are unaffected. \
c. The appropriate initial dosing of a single enteral drug is no more than the MRD of a
drug that can be prescribed for unmonitored home use.
B. Moderate sedation
a. a drug induced depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied by light tactile
stimulation
b. no intervention are required to maintain a patent airway, and spontaneous ventilation
is adequate
c. CVS is usually maintained
A patient whose only response is reflex withdrawal from a painful stimulus is not considered to be
in a state of minimal or moderate sedation.
C. Deep sedation
a. Conscious depression during which patients can’t be easily aroused but respond
purposefully following repeated or painful stimulus
b. Require assistance in maintaining a patent airway, and spontaneous ventilation may
be inadequate. The ability to maintain ventialltory function independently may be
impaired.
c. CVS is maintained.
D. GA
a. Not arousable even by painful stimulus
b. The ability to maintain ventilatory function independently is often impaired. Patients
often require assistance in maintaining a patent airway, and positive pressure
ventilation may be required because of depressed spontaneous ventilation
c. CVS function may be impaired

③ The term “rescue” is often used to describe the steps taken to return the patient to the
initially desired level of sedation.

3. Anatomic and physiologic differences: Physiologic systems grow and develop at different rates,
particularly in children under the age of 8 years.
① The relatively narrow nasal passages, large tongues, and large tonsils and adenoids
contribute to the tendency of the upper airway to be blocked by secretions or edema As a
general rule, patients with tonsillar tissue that occupies more than 50% of the pharyngeal
space are not good candidates for pharmacologic management
② Increased adiposity may affect the ability of a sedated child to maintain a patent airway and
complicate airway management.
Dose calculations for certain sedative drugs may need to be adjusted to avoid inadvertent
 oversedation
③ Basal metabolic activity is greater in children.
④ Children have higher respiratory rate, higher heart rate with lower BP, heart rate has a
greater effect on BP in children
⑤ Higher risk of desaturation in children because of less capability to expand on inspiration
and less oxygen reserve

4. Routes of administration
① Inhalational
A. Equilibrium is quickly established among the partial pressure of the drug in the alveolar
gas space, serum, and target tissues in the brain.
B. Inhaled anesthetic gases are easily titrated by adjustment of the amount of inhaled gas,
provided the rate and depth of ventilation are adequately controlled
② Enteral
A. Because high sympathetic nervous system tone inhibits gastric emptying time, anxious
patients may demonstrate a longer time to the onset of sedation than predicted
B. As a general rule, most clinically useful agents will display an onset approximately 30
minutes after administration, with peak effect noted by 60 minutes.
C. The practice of having parents administer oral medications to children prior to arrival at
the office should be avoided.
③ Intramuscular
A. Moderately rapid onset of action usually within 510 minutes.
B. As with enteral techniques, practitioners are limited to a single dose of medication;
however, the onset of sedation is more predictable than is the onset of oral techniques.
C. For pediatric dental sedation, injections are typically performed in the vastus lateralis or
deltoid muscle.
D. Care should be taken to prepare the solution in a volume that is appropriate for the size
of the injected muscle because excessive volume may cause pain and/or tissue damage
and hinder absorption
E. Once the medication has been injected, if the desired effect is not achieved within 25 to
30 minutes, termination should be considered.
④ IV
A. Onset within 20~40s.
B. Recovery from intravenously administered drugs is often more rapid than that from
drugs delivered through the oral or intramuscular route
C. But requires the most training and experience to perform because drug –related
complication often arise very rapidly, with increased potential for severe consequences.
 D. Because pediatric patient can be easily go to GA state instead of wanted moderate
sedation it is hard to sustain moderate sedation

5. Patient selection and preparation

① Pre-op evaluation
A. Review of medical history
B. Physical status classification
a. ASA 1: appropriate for minimal, moderate or deep
b. ASA 2: consultation of an anesthesiologist or appropriate medical specialist is often
desired.
c. ASA 3 and 4: children with special needs, and those with anatomic airway
abnormalities or extreme tonsillar hypertrophy require additional medical
consultation as part of the preoperative evaluation, and are often better managed by
a physician anesthesiologist or dentist anesthesiologist
C. The physical evaluation should include
a. Height and weight
b. Vital signs
c. Evaluation of airway patency anatomic abnormalities that may increase the risk of
airway obstruction (e.g.,mandibular hypoplasia, large, short neck, limited mandibular
range of motion).
d. Physical abnormalities or conditions that may affect routine intraoperative monitoring
(e.g., recent orthopedic injuries to arms or legs, active skin rashes)
② Instruction to parents
A. Pre-operative dietary instructions
a. Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, or
black coffee up to 2h before the procedures.
b. Breast milk up to 4 hours before the procedure.
c. Infant formula up to 6 hours before the procedure. 4. Nonhuman milk up to 6 hours
before the procedure.
d. A light meal up to 6 hours before the procedure. A light meal typically consists of
toast and clear liquids. Meals that include fried or fatty foods or meat may prolong
gastric emptying times and should be avoided.
e. It is permissible for routine necessary medications to be taken with a sip of water on
the day of the procedure
B. The reason for these recommendation are twofold
a. Emesis during or immediately after a sedative procedure is a potential complication
that can result in the aspiration of stomach contents, leading to laryngosmpsm or
severe airway obstruction.
b. Uptake of sedative agents administered by the oral route is maximized when the
stomach is empty
C. Post op instructions
a. Many pediatric dentists recommend that children first be offered clear liquids after
sedation and advance to solid foods as tolerated.
b. Once solids are tolerated, there are no dietary restrictions other than those imposed
as a result of the dental procedure performed
c. This is based on concern that premature feeding may contribute to nausea, thus
prolonging the reintroduction of solid foods.

6. Drugs and agents used for sedation

① N2O – most frequently used pediatric sedation technique
A. Chemical properties
a. Noninflammable but will support combustion
 b. Small molecular size and low solubility allow for rapid alveolar uptake and
distribution through the arterial circulation to the brain.
c. Within 3~5minutes, equilibrium is reached among the concentrations in the alveolar
gas, blood and target sites in the brain.
B. Excretion occurs almost entirely through the lungs; only very small amounts may be
excreted in body fluids and intestinal gas
C. MAC
a. N2O is the weakest of all inhalational agent with a minimum alveolar concentration
of 105.
b. The MAC of an inhalational agent is a measure of its anesthetic potency; it is
defined as the concentration required to produce immobility in 50% of patients
c. Most commonly used inhalational GA have c1~6% MAC
d. MAC between 30~50% will produce minimal sedation The concentration of nitrous
oxide should not routinely exceed 50% in clinical dental practice because
concentrations in this range increase the likelihood of nausea, vomiting, and
disorientation
D. The most common adverse effect is nausea and vomiting, incidence of adverse effects
increases with concentrations in excess of 50%, length of procedures.
E. Contraindication
a. N2O reduces the ventilator response to hypoxemia but has minimal effect on the
hypercapnic respiratory when delivered < 50%, however it should be avoided in
patients who rely on hypoxia-driven ventilation
b. N2O become entrapped in gas-filled spaces, thus middle ear pressure will increase,
this makes little sig. in a patient with normal patency of Eustachian tubes, however
patients with acute otitis media will exp. pain.
c. Patients with drug dependencies.
d. Methylenetetrahydrofolate reductase deficiency
e. Severe behavioral problems and emotional illness, uncooperativeness,
claustrophobia, maxillofacial deformities that prevent nasal hood placement, COPD,
pregnancy and situation in which high oxygenation is inadvisable such as
bleomycin therapy.
F. Occupational exposure to N2O
a. Chronic exposure to N2O can produce neurotoxicity, sexual and reproductive
problems, hepatotoxicity, and renal dysfunction
b. Leakage from open nitrous oxide delivery systems, such as those used in the
dental office, should be reduced as much as possible
c. Use scavenging systems that remove N2O during patient’s exhalation. The double-
mask type is the most efficient type of scavenger.
d. Wear dosimetry badge when using N2O
N2O is not contraindicated for asthma since it does not cause bronchospasm.
G. Objectives
a. Reducing or eliminating anxiety
b. Reducing untoward movement and reaction to dental treatment
c. Enhancing communication and patient cooperation
d. Raising the pain threshold
e. Increasing tolerance for longer appointments
f. Aiding in the treatment of a patient with mental and/or physical disabilities or a
medically compromised patient
g. Reducing gagging
h. Potentiating the effects of sedative
H. Disadvantages
a. Lack of potency
 b. Dependence on psychological reassurance
c. Interference of the nasal hood with injection to the anterior maxillary region
d. Need for the patient to be able to breathe through the nose
e. Nitrous oxide pollution and potential occupational exposure health hazards
I. 4 plateaus in the first stage of anesthesia with N2O
a. Paresthesia Plateau: Tingling sensation in the fingers and toes. Sometimes
sensations extend through whole body.
b. Vasomotor Plateau: Warm or flushed sensations over whole body.
c. Drift Plateau: A generalized feeling of euphoria and sensations of drifting or floating.
Patients' pupils are centrally fixed and face is void of expression. (Staring ahead
with a "far away" look.)
d. Dream Plateau: Patients' eyes are generally closed and there is difficulty in
speaking, jaw sags open.
The paresthesia and vasomotor plateaus are of short duration whereas the drift and
dream plateaus can be maintained for several hours until nitrous oxide inhalation is
terminated. Children in the drift or dream plateau usually respond to questions by
moving their head rather than talking. Their facial features as well as arms and legs
are noticeably relaxed. The drift and dream plateaus are the desired level of
N2O/O2 sedation. These plateaus are usually in the 30 to 40 % range
J. Technique
a. Preparation
- Use TSD to explain the procedure.
- Patient in reclined position
b. Technique basics
- The bag is filled with 100% oxygen and delivered to the patient for 1 or 2
minutes at an appropriate flow rate, typically between 4 and 6 L/min.
- Once the proper flow rate is achieved, the nitrous oxide can be introduced by
slowly increasing the concentration in increments of 10% to 20% until the
desired level is achieved
- The dentist should encourage the patient to breathe through nose with mouth
closed.
- The appearance of ptosis (sagging of the eyelids) is used by many as an
objective marker of when local anesthetic should be administered.
- The maintenance dose is 30% N2O/ 70%O2
- Nitrous oxide levels should be reduced periodically during a procedure,
especially after 30 minutes’ duration to reduce the adverse effect such as
vomiting.
- Recovery can be achieved quickly by reverse titration. Once the flow of nitrous
oxide is reduced to zero, the patient should be allowed to breathe 100% oxygen
for 3 to 5 minutes. The patient should be allowed to remain in the sitting position
for a brief period to ensure against dizziness upon standing
K. Diffusion hypoxia
a. When high concentrations of nitrous oxide is abruptly discontinued, resulting in the
quick reversal of the nitrous oxide concentration gradient between the gases in the
lung and alveolar circulation.
b. Under these conditions, nitrous oxide rapidly dilutes the oxygen in the alveoli,
creating the conditions for hypoxemia.
c. To prevent this 100% O2 is given to the patient for few minutes
L. Significant effect on reducing mild to moderately anxious and uncooperative child
behavior and does facilitate coping at subsequent visits, even if it is not used at those
visits.
M. It is important to understand that the use of N2O/O2 is only effective if accompanied by
 communicative behavior management technique
N. The child must have some coping skills and an appropriate temperament to be
receptive to nitrous oxide sedation
② Antihistamines
A. Hydroxyzine (Atarax, VIstaril)
a. Weak sedative antihistamines, anticholinergic and antiemetic properties
b. Produce sedation by inhibiting the H-1 histamine receptors involved in governing the
sleep-wake cycle in humans.
c. Onset: 15~30minutes. Peak levels occur at 2 hours, half-life is 3 hours.
d. Preparation: tablets, elixir.
e. Dosage: 0.5~~1.0mg/kg.
f. Side effects: prolonged drowsiness, ataxia, dry mouth, in children paradoxical
reactions may occur at sedative doses.
B. Promethazine (Phenergan)
a. Phenothiazines are most commonly used as antipsychotics, antiemetics, and
sedatives. Promethazine lacks antipsychotic effects, but has strong anticholinergic,
antiemetic, and antihistaminic effects.
b. It is generally replaced by newer sedative agents with better pharmacokinetic
properties.
c. Onset of action: 20 minutes, and peak effect occurring within 2~3 hours. Serum half-
life of 7~14 hours.
d. The long half-life may be seen as beneficial in terms of its antiemetic effects but may
also contribute to prolonged drowsiness, particularly when used in combination with
other sedative drug
e. Promethazine has been associated with an enhanced risk of sudden infant death
syndrome (SIDS) and worsening of sleep apnea.
f. Preparation: tablets, rectal suppository
g. Dosage: 0.5~1mg/kg to a maximum single dose of 50mg.
h. Side effect: blurred vision, prolonged drowsiness, ataxia
C. Diphenhydramine (Benadryl)
a. Along with hydroxyzine, diphenhydramine is the most commonly used antihistamine
for procedural sedation and antiemetic therapy in children
b. It is used for over-the counter use as a sleep aid and therapeutic for motion
sickness.
c. The peak clinical effect occurs at approximately 1 hour. The half-life of
diphenhydramine ranges from 2 to 8 hours.
d. Preparation: tablets, elixir, capsules, injectable
e. Dosage: oral, IM or IV – 1.0~1.5mg/kg. maximum single dose is 50mg.
③ Benzodiazepine agonists and antagonisits
A. Most commonly used drugs for procedural sedation. The popularity of this class of drugs
is due to its wide therapeutic index, shallow dose-response curve, and its specific effects
on the GABAnergic neurons of the central nervous system
B. Benzodiazepines have five major clinical effects: anxiolysis, hypnosis, amnesia, muscle
relaxation, and anticonvulsant activity
C. Diazepam (Valium)
a. Peak serum level in 15~30minutes in children
b. It is metabolized into two principal metabolites, desmethyldiazepam and oxazepam.
Desmethyldiazepam is only slightly less potent than its parent compound diazepam
and is believed to be the chief cause of secondary drowsiness, or resedation, which
may happen hours after the initial dose.
c. The prolonged recovery period poses a potential for resedation and airway
obstruction in the postprocedural phases of treatment, especially in obese children
 and in cases where opioid agents had been coadministered during the procedure.
d. Side effect: ataxia and prolonged sedation
e. Dosage: 0.2~0.5mg/Kg to a maximum single dose of 10mg; intravenous 0.25mg/kg.
f. Supplied
- Tablets: 2, 5, and 10mg
- Suspension: 5mg/ml.
D. Midazolam
a. First water soluble benzodiazepine.
b. Onset of sedation occurs within 20~ 30minutes, and allowing 30 minutes of working
time for the dentist.
c. The elimination half-time of midazolam is 1 to 4 hours, which is significantly shorter
than that of diazepam.
d. Midazolam is much more potent than diazepam, as predicted by its greater affinity to
bind benzodiazepine receptors in the brain. (2~5x more potent)
e. Midazolam produces more consistent anterograde amnesia during moderate
sedation than does diazepam, whereas diazepam is more likely to produce
anxiolysis with less amnesia.
f. Preparation: syrup parenteral injection solution
g. Dosage: oral—0.25 to 1.0 mg/kg to a maximum single dose of 20 mg; intramuscular
—0.1 to 0.15 mg/kg to a maximum dose of 10 mg
E. Flumazenil (Romazicon)
a. Direct specific reversal agent used in clinical practice to treat benzodiazepine
overdose.
b. Effective and safe reversal in adults is achieved by titration, by the injection of 0.2-
mg doses every 3 to 5 minutes up to a total dosage of 1 mg.
c. When an adequate dose is achieved, reversal of effects occurs within 2 minutes;
however, the duration of reversal is short, lasting only 20 to 45 minutes
d. For children, an initial intravenous dose of 0.01 mg/kg (maximum dose: 0.2 mg)
given over 15 seconds is recommended, with repeat 0.01 mg/kg (maximum dose:
0.2 mg) after 45 seconds, and then every minute to a maximum total cumulative
dose of 0.05 mg/kg or 1 mg, whichever is lower
e. Proper and effective airway management is always the first step undertaken when
respiratory distress is encountered. Delaying airway management for the purpose of
administering flumazenil may cause delays resulting in hypoxia, serious morbidity, or
death.
f. Supplies: 5 and 10ml multiple use vials containing 0.1mg/ml in boxes of 10.
④ Opioid agonists and antagonists.
A. Opioids are most useful during moderate sedation for their ability to suppress the cough
reflex, provide analgesia, and produce a sensation of well-being;
B. They are also closely linked with several important side effects, including respiratory
depression, nausea and vomiting, delayed gastric emptying, constipation and urinary
retention, and itching
C. Opioids differ from benzodiazepines
a. Opioid produce analgesia by raising the threshold for perceiving painful stimulation
whereas benzodiazepines have no effect
b. Opioids produce analgesia while not affecting awareness and memory, whereas
benzodiazepines produce profound, dose-dependent amnesia.
c. Opioids also induce nausea and vomiting through direct action on the
chemoreceptor trigger zone in the medulla. In comparison, benzodiazepines do not
depress ventilation at sedative doses and are not associated with the production of
nausea and vomiting.
D. All opioid agonists produce dose-dependent respiratory depression through direct action
 on the ventilatory control center in the medulla and blunt the response to hypercarbia
and hypoxia.
E. Fentanyl (Sublimaze)
a. Fentanyl acts rapidly, and after intramuscular injection the onset occurs in 7 to 15
minutes; duration of effects is 1 to 2 hours
b. Fentanyl produces little histamine release and has a much lower emetic effect than
does morphine or meperidine. Fentanyl can be administered by the intramuscular,
intravenous, or submucosal route
c. Supplied: 0.05mg/mL in 2 and 5mL ampules.
d. Dosage: 0.002 to 0.004mg/kg
F. Meperidine (Demerol)
a. By enteral and parenteral administration.
b. Rapidly and well absorbed from the GI tract, reacing peak effect in about 60minutes.
c. Its use is contraindicated in patients with a history of hepatic disease, renal disease
or dysfunction, or seizure disorders
d. Supplied: oral tablets- 50 and 10mg; oral syrup – 50mg/5mL; parenteral solution 25,
50, 75 and 100mh/mL
e. Dosage: oral, subcutaneous , or IM- 1.0 to 2.2mg/kg not to exceed 100mg when
given alone or 50mg when in combination with other CNS depressants
G. Naloxone (Narcan)
a. Used to reverse the opioid drug overdose.
b. Following subcutaneous or intramuscular injection, reversal begins within 2 to 5
minutes, as compared with 30 seconds to 2 minutes following intravenous
administration
c. Reversal persists for approximately 45 minutes via either route. Excessive or too
rapid reversal may result in adverse reactions including nausea, vomiting, sweating,
hypotension, hypertension, ventricular tachycardia and fibrillation, and pulmonary
edema.
d. Dosage: IV, subcutaneous, IM- initial dose: 0.01 mg/kg; subsequent doses: 0.1
mg/kg (2 mg maximum) every 2 to 3 minutes
e. Supplied: parenteral solution—0.02, 0.4, 1.0 mg/kg
⑤ Other sedative-hypnotics.
A. Chloral hydrate, which was used by many pediatric dentists until it was discontinued in
2012
B. Chloral hydrate
a. Metabolized by liver by alcohol dehydrogenase to its active metabolite,
trichloroethanol
b. It is a chemical irritant to the skin and mucous membranes and is associated with a
high rate of nausea and vomiting, particularly when administered on an empty
stomach
c. Slow onset time (30~60min) and had a duration of action of 4~8 hours
d. Large doses sensitize the myocardium to the effects of epinephrine, resulting in
arrhythmias

7. Monitoring
① Intraoperative monitoring
A. The depth of sedation dictates the degree and frequency of monitoring required
B. As the treatment progresses, the state of consciousness should be evaluated frequently
by verbal communication with the patient.
C. The oral mucosa, the nail beds, and the complexion of the skin provide indications of
perfusion of the patient. It should be monitored and documented.
D. If restraining devices that cover the patient are used, a hand or foot should be exposed.
 These devices should be carefully applied to the sedated patient to ensure that there is
no restriction of the chest
E. The heart and respiratory rates can be continuously monitored with a pretracheal
stethoscope, it should be secured in the suprasternal notch
F. Ventilation, i.e., the mechanical act of moving air throughout the respiratory system,
must be evaluated independently from oxygenation. Capnography is the most sensitive.
② Post-op monitoring
A. The child must be reasonably alert, able to talk, ambulating with minimal assistance, and
sitting unaided.
B. The child should be able to remain awake for at least 20 minutes, unstimulated, before
discharge

8. Discharge criteria and post-sedation instructions

Before the procedure is undertaken, a “time out” should be performed to confirm the patient’s
name, the procedure to be performed, and the site of the procedure
Opioids have also been associated with significant local anesthetic toxicity when both have been
used as part of a pediatric sedation regimen
 Opioids may produce a mild respiratory acidosis that decreases the binding of local
anesthetics to serum albumin, permitting more free drug to circulate to the CNS
 Particularly the combination of meperidine and mepivacaine.

9. 3 principles for moderate sedation

① Primum non nocere: first, do no harm.
② Airway management supersedes pharmacologic management
③ Appreciate the limits of moderate sedation.

LOCAL ANESTHESIA
1. Topical anesthetics
① Numerous anesthetic agents have been used in topical anesthetic preparations, including
ethyl aminobenzoate, butacaine sulfate, cocaine, dyclonine, lidocaine, and tetracaine.
② Ethyl aminobenzoate (benzocaine) liquid, ointment, or gel preparations are probably best
suited for topical anesthesia in dentistry
A. Offer a more rapid onset and longer duration of anesthesia than others.
B. However few localized allergic reactions have been reported from prolonged or repeated
use.
③ The mucosa at the site of the intended needle insertion is dried with gauze, and a small
amount of the topical anesthetic agent is applied to the tissue with a cotton swab. Topical
 anesthesia should be produced in approximately 30s

2. Jet injection
① Based on the principle that small quantities of liquids forced through very small openings
under high pressure can penetrate mucous membrane or skin without causing excessive
tissue trauma.
② Jet injection produces surface anesthesia instantly and is used instead of topical anesthetics
by some dentists
③ The method is quick and painless; it is also useful for obtaining gingival anesthesia before a
rubber dam clamp is placed for isolation procedures, or soft tissue anesthesia such as band
adaptation or removal of a very loose (soft-tissue-retained) primary tooth.

Some recommends to use of larger-gauge needle (i.e. 25 gauge) for injection into highly vascular
areas or areas where needle deflection through soft tissue may be a factor.
Regardless of the size of the needle used, it is generally agreed that the anesthetic solution
should be injected slowly

3. Anesthetization of mandibular teeth and soft tissue.

① Inferior alveolar nerve block (conventional mandibular block)
A. Mandibular foramen is situated at a level lower than the occlusal plane of the primary
teeth in pediatric patient; therefore the injection must be made slightly lower and more
posteriorly than an adult patient.
B. Accepted technique
a. Thumb is laid on the occlusal surface of the molar, with the tip of the thumb resting
on the internal oblique ridge and the ball of the thumb resting in the retromolar fossa.
b. Firm support during the injection procedure can be given when the ball of the middle
finger is resting on the posterior border of the mandible.
c. The basrrel of the syringe should be directed on plane between the 2 primary molars
on the opposite side of the arch.
d. It is advisable to inject a small amount of the solution as soon as the tissue is
penetrated and to continue to inject minute quantities as the needle is directed
toward the mandibular foramen.
e. The depth of insertion averages about 15 mm but varies with the size of the
mandible and its changing proportions, depending on the age of the patient.
f. Approximately 1 mL of the solution should be deposited around the inferior alveolar
nerve
② Lingual nerve block While blocking of the IAN, one can block the lingual nerve by bringing
the syringe to the opposite side with the injection of a small quantity of the solution as the
needle is withdrawn.
③ Long buccal nerve block
A. For removal of mandibular permanent molars or sometimes for the placement of the
rubber dam clamp on these teeth, it is necessary to anesthetize the long buccal nerve.
B. A small quantity of the solution may be deposited in the MB fold at a point distal and
buccal to the indicated tooth
C. All facial mandibular gingival tissue on the side will be anesthetized, with the possible
exception of the tissue facial to the central and lateral incisors.

④ Infiltration anesthesia for mandibular primary molars

A. No difference in pain control effectiveness between infiltration/ intrapapillary injection
and IAN block/ long buccal infiltration
B. Since articaine has a high bone-penetrating ability, which suggest that it may be more
successful as a locally injected infiltration.
C. Mandibular infiltration anesthesia may produce adequate anesthesia in mandibular
deciduous molars for most restorative procedures
Articaine is unique among local anesthetics because it contains a thiophene group and both ester
and amide groups.
 Articaine is an amide anesthetic that is metabolized in the liver, the associated ester group
also allows for plasma metabolism via pseudocholinesterase
 This increase the rate of breakdown and reduces toxicity, and the half-life of the articain is
30-minutes compared to 90-minutes half-life of lidocaine
⑤ Infiltration for mandibular incisors
A. The terminal ends of the inferior alveolar nerves cross over the mandibular midline
slightly and provide conjoined innervation of the mandibular incisors. Thus a single IAN
block may not be adequate for operative or surgical procedures
B. If only superficial caries excavation of mandibular incisors is needed or if the removal of
a partially exfoliated primary incisor is planned, infiltration anesthesia alone may be
adequate.
C. When used as an adjunct with IAN block, the infiltration is made close to the midline on
the side of the block anesthesia, but the solution is deposited labial to the incisors on the
opposite side of the midline.
⑥ Mandibular conduction anesthesia (Gow-gates mandibular block technique)
A. Uses external anatomic landmarks to align the needle so that anesthetic solution is
deposited at the base of the neck of the mandibular condyle
B. This technique blocks the entire distribution of the 5 th cranial nerve in the mandibular
area including the IAN, lingual, buccal, mental, incisive, auriculotemporal and mylohyoid
nerves. (except possibly the mandibular incisor)
C. Technique
a. External landmark: tragus of the ear and the corner of the mouth.
b. The needle is inserted just medial to the tendon of the temporal muscle and
considerably superior to the insertion point for conventional mandibular block
anesthesia.
c. The needle is also inclined upward and parallel to a line from the corner of the
patient’s mouth to the lower border of the tragus (intertragic notch)
d. The needle and the barrel of the syringe should be directed toward the injection site
from the corner of the mouth on the opposite side
4. Anesthetization for maxillary teeth
① Maxillary primary and permanent incisors and canines
A. Primary tooth
a. The injection should be made closer to the gingival margin than in the patient with
permanent teeth and the solution should be deposited close to the bone.
b. After the needle tip has penetrated the soft tissue at the MB fold, it needs little
advancement before the solution is deposited (2mm at most) because the apices of
the maxillary primary anterior teeth are essentially at the level of the mucobuccal
fold
c. Some dentists prefer to pull the upper lip down over the needle tip to penetrate the
tissue rather than advancing the needle upward. This approach works quite well for
the maxillary anterior region
B. Permanent tooth: Puncture site is M fold, the solution may be deposited slowly and
slightly above and close to the apex of the tooth.
C. Because nerve fibers may be extending from the opposite side, it may be necessary to
deposit a small amount of the anesthetic solution adjacent to the apex of the other
central incisor to obtain adequate anesthesia in either primary or permanent teeth
② Primary molars and premolars
A. Middle superior alveolar nerve supplies the maxillary primary molars, the premolars, and
the mesiobuccal root of the first permanent molar, however Jorgensen and Hayden
demonstrated plexus formation of the MSAN and PSAM in the primary molar area.
B. For first primary molar - The bone overlying is thin, and this tooth can e adequately
anesthetized by injection of anesthetic solution opposite the apices of the roots.
C. For 2nd primary and 1st permanent molars: the thick zygomatic process overlies the
buccal roots of 2nd primary and 1st permanent molars, this makes the infiltration less
effective and should be supplemented with posterior superior alveolar nerve block.
D. For anesthetization of the maxillary 1st and 2nd pm
a. A single injection is made at the mucobuccal fold to allow the solution to be
deposited slightly above the apex of the tooth.
b. Because of the horizontal and vertical growth of the maxilla that has occurred by the
time the premolars erupt, the buccal cortical bone overlying their roots is thin enough
to permit good anesthesia with this method.
E. The greater palatine injection is indicated if maxillary primary molars or premolars are to
be extracted or if palatal tissue surgery is planned

③ Maxillary permanent molars – PSAN block

A. Instructs the child to partially close the mouth to allow the cheek and lips to be stretched
laterally
B. The tip of the dentist’s left forefinger (for a righthanded dentist) will rest in a concavity in
the mucobuccal fold and is rotated to allow the fingernail to be adjacent to the mucosa.
C. The ball of the finger is in contact with the posterior surface of the zygomatic process.
D. Bennett suggests that the finger be on a plane at right angles to the occlusal surfaces of
the maxillary teeth and at 45° to the patient’s sagittal plane.
E. The index finger should point in the direction of the needle during the injection.
F. The puncture point is in the MB fold above and distal to the DB root of the 1st permanent
molar. If the second molar has erupted, the injection should be made above the second
molar. The needle is advanced upward and distally, depositing the solution over the
 apices of the teeth. The needle is inserted for a distance of approximately 2 cm
G. For complete anesthesia of the 1st permanent molar for operative procedures,
supraperiosteal injection is made by insertion at the apex of the MB root of the molar.

④ Palatal tissues: to minimize the pain during injection of palatal area, after buccal infiltration
do interdental (interpapillary) infiltration, with slow injection of the anesthetic solution as the
needle is penetrating the papilla. The interdental infiltration allows for diffusion of the
anesthetic to the palatal aspect via the col of interdental papila. Blanching of the area
indicates sufficient anesthesia of the superficial soft tissues; however, additional palatal
infiltration may be given as needed
A. Nasopalatine nerve block
a. For most restorative procedures or minor extractions can be accomplished by first
depositing anesthetic via the free marginal gingiva. If needed, this can be
supplemented by giving a palatal local infiltration injection in an area already
 blanched by anesthetic given previously
b. If the patient experiences incomplete anesthesia after supraperiosteal injection
above the apices of the anterior teeth on the labial side, it may be necessary to
resort to the nasopalatine injection
c. The path of insertion of the needle is alongside the incisive papilla, just posterior to
the central incisors.
d. The needle is directed upward into the incisive canal. The discomfort associated
with the injection can be reduced by deposition of the anesthetic solution in advance
of the needle.
e. When anesthesia of the canine area is required, it may be necessary to inject a
small amount of anesthetic solution into the gingival tissue adjacent to the lingual
aspect of the canine to anesthetize overlapping branches of the greater palatine
nerve.

B. Greater palatine nerve block

a. Anesthetize the mucoperiosteum of the palate from the tuberosity to the canine
region and from the median line to the gingival crest on the injected side.
b. This is used with the middle or posterior alveolar nerve block before surgical
procedures.
c. For mixed and adult, bisect an imaginary line drawn from the gingival border of the
most posterior molar that has erupted to the midline. Approaching from the opposite
side of the arch, the dentist make injection along this imaginary line and distal to the
last tooth. .
d. In the child in whom only the primary dentition has erupted, the injection should be
made approximately 10 mm posterior to the distal surface of the second primary
molar

⑤ Supplemental injection technique

A. Infraorbital nerve block
a. The infraorbital nerve block anesthetizes the branches of the anterior and middle
superior alveolar nerves. It also affects innervation of the soft tissues below the eye,
 half of the nose, and the oral musculature of the upper lip on the injected side of the
face.
b. This lead to a feeling of numbness above the mouth similar to that below the mouth
when an IAN is blocked, in addition, there is temporary partial oral paralysis.
c. However this technique should not be used as a regular basis since supraperiosteal
technique is just as effective
- An infraorbital block technique is preferred when impacted teeth (esp. canines
or 1st pm) or large cysts are to be removed.
- Thus it is indicated for situation when the inflammation or infection prevents
effectiveness of infiltration technique or when longer duration or a greater area
of anesthesia is needed.

B. Mental nerve block

a. Same feelings of numbness as IAN block
b. Blocking the mental nerve anesthetizes all mandibular teeth in the quadrant except
the permanent molars. Thus the mental nerve block makes it possible for routine
operative procedures to be performed on all primary teeth without discomfort to the
patient.
c. However, IAN should be favored unless specific contraindication to its use since it’s
equally effective but puts the syringe in clear view of the patient

C. Periodontal ligament injection (Intraligmentary injection)

 a. The technique is simple, requires only small quantities of anesthetic solution, and
produces anesthesia almost instantly
b. The needle is placed in the gingival sulcus, usually on the mesial surface, and is
advanced along the root surface until resistance is met. Approximately 0.2 mL of
anesthetic is then deposited into the periodontal ligament.
c. For multirooted teeth, injections are made both mesially and distally. Considerable
pressure is necessary to express the anesthetic solution.
d. Although conventional syringe can be used, closed barrel syringe is preferable to
offer protection of the anesthetic cartridge breaks.

e. Advantage of the technique

- Provides reliable pain control rapidly and easily
- It provides pulpal anesthesia for 30 to 45 minutes, long enough for many single-
tooth procedures without an extended period of postoperative anesthesia.
- It is no more uncomfortable than other local anesthesia techniques.
- It is completely painless if used adjunctively.
- It requires very small quantities of anesthetic solution.
- It does not require aspiration before injection.
- It may be performed without removal of the rubber dam.
- It may be useful in patients with bleeding disorders that contraindicate use of
other injections.
- It may be useful in young or disabled patients in whom the possibility of
postoperative trauma to the lips or tongue is a concern
f. However the use of this technique may cause anxiety reaction in new or anxiety
prone patient. The pen-like syringe would be preferred in pediatric dentistry, but it is
even more expensive than the gunlike instrument
D. Intraosseous injection, interseptal injection
a. This is not particularly difficult in children because their cortical bone is less dense
than that of adults.
b. They do not seem to offer any advantages over the periodontal ligament injection
except when use of the latter is contraindicated by infection in the periodontal
ligament space

5. Complications after a local anesthetics

① Anesthetic toxicity
A. Young children are more likely to exp. toxic reactions because of their lower body
weight.
B. Young children are also often sedated with pharmacologic agents before the treatment.
The potential for toxic reactions increases when local anesthetics are used in
conjunction with sedation medications.
C. The maximum recommended dosages of the anesthetic agent 2 methods:
a. Calculation by weight
 - One cartridge roughly contains 1.7mL to 1.8mL
- Obtain the patient’s weight in pounds and convert to kilograms by dividing by 2.2
(44Ib= 20kg.)
- Multiply weight in kg by the maximum recommended dose of local anesthetic to
obtain the maximum mg dosage
Ex) 20kg x (4.4mg/kg lidocaine) = 88mg.

- Calculate the number of mg per cartridge of anesthetic by multiplying the

percent of local anesthetic times 10 then multiply the size of the cartridge
e.g 2% lidocaine in 1.8mL: 2%x10x1.8 = 36mg/ cartridge.
- The maximum allowable cartridge = maximum milligram dosage / number of mg
per cartridge
e.g. 88mg maximum dose /36mg/cartridge = 2.44 cartridge.
b. The rule of 25, for a healthy patients, a dentist can safely use 1 cartridge of
anesthetic for every 25 pounds of patient weight
D. 1% and 2% lidocaine were equally effective for minor procedures on primary molars.
The 1% lidocaine had a slightly lower effectiveness for major procedures, including
pulpotomies and extractions
E. Overdosage may cause central nervous system complications, such as dizziness,
blurred vision, seizures, central nervous system depression, and death.
Cardiac complications may include myocardial depression.
② Trauma to soft tissue
A. Parents of children who receive regional local anesthesia in the dental office should be
warned that the soft tissue in the area will be without sensation for 1 hour or more
B. These children should be observed carefully so that they will not purposely or
inadvertently bite the tissue.
C. Children with IAN block commonly bite the lip, tongue or inner surface of the check, this
may result in ulceration after 24 hours. – traumatic ulcer.
D. Complications after a self-inflicted injury of this type are rare. However, the child should
be seen in 24 hours, and a warm saline mouthrinse is helpful in keeping the area clean.
E. The study showed that in the group younger than age 4, patients receiving the unilateral
nerve blocks had a significantly higher incidence of trauma than patients receiving the
bilateral nerve blocks (35% vs. 5%).
F. There is no contraindication to the use of bilateral mandibular block anesthesia in
pediatric patients
 ③ Reversal of dental anesthesia
A. Phentolamine mesylate became the 1st pharmaceutical agent indicated for the reversl of
soft-tissue anesthesia (anesthesia of the lip and tongue) and the associated functional
deficits resulting from an intraoral submucosal injection of a local anesthetic containing a
vasoconstrictor
B. The most common adverse reaction was transient injection site pain.
C. Currently, OraVerse is not recommended for use in children younger than 6 years of age
or in those who weigh less than 15 kg (33 lb).

6. Analgesics
① selection and dosages of analgesics vary because of the changes in body weight and
composition that occur throughout childhood
② The first choice in most cases is the least potent analgesic with the fewest side effects
③ Rarely does the recommended dosage of acetaminophen or nonsteroidal anti-inflammatory
drugs fail to control the dental pain, and in such cases, the combination of codeine and
acetaminophen provides the needed pain relief.
④ Finally, in cases of severe pain in which codeine and acetaminophen are not effective,
hydrocodone and acetaminophen may be indicated