Chapter 19 - Pediatric Patients

Question 1

1. Why is it generally more critical to consider toxicity of LA n pediatric pts than in adults?
   a. Children react differently to local anesthetic agents than adults.
   b. LA doses are based on body weight
   c. Appropriate LA agents are different than for adults.
   d. Crying and screaming may allow more rapid anesthetic uptake.

Answer 1

b. LA doses are based on body weight

(a, c, d “may be true, but the greatly reduced body weight is the key issue”)

Question 2

2. How does excellent anesthesia serve as a management tool for children?
   a. Restorative procedures become tolerable, if not pain-free
   b. Clamp placement for rubber dam is simplified
   c. Quadrant (or half-mouth) treatment can be completed in one visit
   d. All of the above

Answer 2

d. All of the above

Question 3

3. In which of the following ways do anatomical variations affect the choice of injection techniques for children?
   a. Roots of primary teeth are generally shorter than permanent tooth roots
   b. The cortical plate is thicker and less porous in children vs. adults
   c. The IA foramen is often more superior in children than adults
   d. All of the above

Answer 3

a. Roots of primary teeth are generally shorter than permanent tooth roots

Question 4

4. Which of the following describe ways in which an assistant can play a vital role in the successful administration of LA to children?
   a. Showing the pt the needle to prepare them
   b. Calming the parent during the injection by explaining what is happening
   a. Roots of primary teeth are generally shorter than permanent tooth roots
   d. None of the above

Answer 4

a. Roots of primary teeth are generally shorter than permanent tooth roots

Question 5

5. Which of the following are benefits of using age-appropriate terminology and specific positive feedback during the successful anesthetic administration in pediatric patients?
   a. Using understandable terms to demystify the child’s experiences
   b. Using specific positive feedback teaches children what is expected and going well
   c. Avoiding frightening “trigger” words to reduce the chance of resistance
   d. All of the above

Answer 5

d. All of the above

Question 6

6. Which of the following is TRUE when considering injections techniques in children?
   a. Mandibular infiltrations rarely work for children
   b. Deposition of LA solutions for mandibular blocks are more inferior compared with adults
   c. Long needles are usually necessary
   d. All of the above

Answer 6

b. Deposition of LA solutions for mandibular blocks are more inferior compared with adults

Question 7

7. When children traumatize soft tissues immediately following injections, what is the best management?
   a. Place a cold pack immediately
   b. Place a warm pack immediately
   c. Always put the child on an antibiotic for infection
   d. a and c

Answer 7

a. Place a cold pack immediately

to minimize circulation and decrease initial swelling

after 8-12 hrs, warm packs are appropriate to increase circulation and promote healing

Question 8

Q19-3: What are the most important considerations when treating pediatric patients related to a child’s body weight and the immaturity of their organs?

Answer 8

A19-3: The potential for drug toxicity due to the relatively low body weight of small children and the immaturity of their organs.

Question 9

Q19-4: Explain why mepivacaine without a vasoconstrictor seems to be associated with a higher number of local anesthetic toxicity reports compared with other agents.

Question 10

Q19-5: Discuss why dose-dependent toxicity reactions in dentistry are most frequently reported in children.

Answer 10

A19-5: Several possible theories include:
- disproportion of orofacial anatomy to a child’s body weight (larger head compared with body) that may require larger volumes of anesthetic to achieve effect
- failed anesthesia leading to multiple injections
- inadequacy of pain assessment scales due to some patients perceiving the numb feeling as pain
- lack of or improper calculation of MRDs

Question 11

Q19-6: Discuss special consideration for maximum doses of anesthesia for morbidly obese children.

Answer 11

A19-6:
- When a young child has the body weight of an adult, the usual dosing guidelines likely do not apply

• advisable to use the ideal body weight (IBW) when calculating doses
• remaining alert to the development of adverse events and dosing below the MRD is paramount whenever local anesthetic drugs are administered to these children

Question 12

Q19-7: What is the treatment for postoperative trauma caused by lip/cheek biting?

Answer 12

A19-7:
- cold pack if notified of self-injury soon after apptmt to reduce swelling
- warm pack can be recommended to stimulate circulation and promote healing on day following tx
- Antibiotics usually not indicated; prescribed only in the unlikely event of infection

Question 13

Q19-8: Discuss the efficacy of articaine for pediatric patients.

Answer 13

A19-8: Articaine is believed by some to be more effective in its ability to diffuse through bone compared to other amide anesthetic solutions, thus having improved efficacy, especially as it relates to mandibular infiltration.

Question 14

Q19-9: Provide examples of the use of topical anesthetics for children.

Answer 14

A19-9: Topical anesthetics are useful for pre-anesthesia for injections, for comfortable rubber dam clamp placement, and to anesthetize the tissues retaining extremely mobile primary teeth to allow children to remove their teeth atraumatically at home.

Question 15

Q19-10: What is the primary focus of an assistant during injection procedures?

Answer 15

A19-10: The primary focus of an assistant during injection procedures is to provide passive restraint.
- DA places one hand over the child’s hands (which should be placed on their stomach)
- The other hand is placed on the child’s forehead to guard against sudden or unexpected movements.

Question 16

Q19-11: Why is vocal distraction helpful for children?

Answer 16

A19-11: Vocal distraction keeps the child focused on the clinician’s voice rather than on the dental procedures. Distraction can be created by a calm, reassuring, and informative narrative which is continuous throughout the procedure. When children have a focus other than an actual procedure, injections are more likely to succeed.

Question 17

Q19-13: Explain the anatomical reason a 10 mm needle is usually adequate length for a maxillary infiltration on a child patient.

Answer 17

A19-13: A 10 mm needle may be adequate for reaching the deposition site at the apex of a maxillary tooth because primary teeth roots are typically shorter than the roots of their permanent successors.

Question 18

Q19-14: Discuss the typical position of the mandibular foramen in children compared to its position in adults.

Answer 18

A19-14: The position of the inferior alveolar foramen in a child is inferior to its eventual adult location.

Question 19

Q19-15: What is the advantage of using bilateral mandibular nerve blocks with children?

Answer 19

A19-15:
- decreased incidence of postoperative lip-biting (less testing of the funny side by the child)

Question 20

Q19-16: Explain the anatomical reason mandibular infiltrations are commonly used for simple restorative procedures with children.

Answer 20

A19-16: Pediatric patients have thinner cortical plates and more porous bone, allowing for easy diffusion of anesthetic solutions. For this reason, mandibular infiltrations are commonly used for many simple restorative procedures and some mandibular extractions.