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

Pediatric Behavior Management Modalities

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

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

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

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

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

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

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

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

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

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

Safety & Handling