AAPD Reference Manual - Pediatric Dentistry 2010-2011

AAPD Reference Manual “ the manual ” American Academy of Pediatric Dentistry 2010-11 Definitions, Oral Health Policies,...

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AAPD Reference Manual “ the manual ”

American Academy of Pediatric Dentistry 2010-11 Definitions, Oral Health Policies, and Clinical Guidelines

American Academy of Pediatric Dentistry 2010-11 Definitions, Oral Health Policies, and Clinical Guidelines (aka “Reference”, “the Manual”) Introduction 2 4 5 7 10

Overview Vision Statement/Mission Statement Core Values Strategic Plan AAPD Research Agenda

Definitions Reaffirmed Dental Home

12 13 14 15 16 17

Reaffirmed Dental Neglect Dental Disability Early Childhood Caries Medically Necessary Care Special Health Care Needs

Oral Health Policies Medically Necessary Care Oral Health Care Programs for Infants, Children, and Adolescents Reaffirmed Dental Home Child Identification Programs Mandatory School-entrance Oral Health Examinations New

School Absences for Dental Appointments Emergency Oral Care for Infants, Children, and Adolescents Use of Fluoride

Revised

Use of Xylitol in Caries Prevention Interim Therapeutic Restorations (ITR) Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies Early Childhood Caries (ECC): Unique Challenges and Treatment Options Dietary Recommendations for Infants, Children, and Adolescents Vending Machines in Schools

Revised

Tobacco Use Intraoral and Perioral Piercing

Revised

Prevention of Sports-related Orofacial Injuries Use of Dental Bleaching for Child and Adolescent Patients Minimizing Occupational Health Hazards Associated With Nitrous Oxide Use of Deep Sedation and General Anesthesia in the Pediatric Dental Office

Revised

Hospitalization and Operating Room Access for Dental Care of Infants, Children, Adolescents and Persons With Special Health Care Needs

Revised

Hospital Staff Membership Model Dental Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care Needs Third-party Reimbursement of Medical Fees Related to Sedation/General Anesthesia for Delivery of Oral Health Services Third-party Reimbursement for Oral Health Care Services Related to Congenital Orofacial Anomalies Third-party Reimbursement of Fees Related to Dental Sealants Role of Pediatric Dentists as Both Primary and Specialty Care Providers Patient Safety Ethical Responsibility to Treat or Refer

New

Second Opinion for Pediatric Oral Health Care

Page i

19 24 25 27 29 31 33 34 36 39 41 45 48 50 52 56 58 62 65 67 69 71 73 76 78 80 81 82 85 86

88 90 91

Patient's Bill of Rights and Responsibilities Stem Cells Infection Control

Clinical Guidelines Reaffirmed Oral and Dental Aspects of Child Abuse and Neglect Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children Revised

Caries-risk Assessment and Management for Infants, Children, and Adolescents - (Chart) Perinatal Oral Health Care Infant Oral Health Care

Revised

Adolescent Oral Health Care Oral Health Care for the Pregnant Adolescent Management of Dental Patients With Special Health Care Needs Role of Dental Prophylaxis in Pediatric Dentistry Fluoride Therapy Behavior Guidance for the Pediatric Dental Patient Use of Local Anesthesia for Pediatric Dental Patients Use of Nitrous Oxide for Pediatric Dental Patients Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patient Pediatric Restorative Dentistry Pulp Therapy for Primary and Immature Permanent Teeth

Revised

Management of Acute Dental Trauma Management of the Developing Dentition and Occlusion in Pediatric Dentistry Oral Health Care/Dental Management of Heritable Dental Developmental Anomalies

Revised

Acquired Temporomandibular Disorders in Infants, Children, and Adolescents

Revised

Pediatric Oral Surgery Use of Antibiotic Therapy for Pediatric Dental Patients Antibiotic Prophylaxis for Patients at Risk for Infection Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation

137 93 101 109 114 119 127 132 141 143 147 156 163 167 184 187 194 202 213 226 232 238 246 249 253 260 268

Recordkeeping Informed Consent

Endorsements Prescribing Dental Radiographs for Infants, Children, Adolescents, and Persons With Special Health Care Needs Management of Patients With Cleft Lip/Palate and Other Craniofacial Anomalies Periodontal Diseases of Children and Adolescents Periodontal Therapy Treatment of Plaque-induced Gingivitis, Chronic Periodontitis, and Other Clinical Conditions

272 277 279 285 290

Resource Section Dental Growth and Development Revised

Growth Charts Body Mass Index (BMI) Charts Food Pyramid Recommended Childhood and Adolescent Immunization Schedules

Revised

Speech and Language Milestones Post-surgery Instructions for Extractions/Oral Surgery Preparing for Your Child's Sedation Visit Sedation Record Record Transfer

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301 302 306 308 310 311 320 316 318 321

New

Release for School Absences

New

Decision Trees for Management of an Avulsed Permanent Tooth Common Laboratory Values

Management of Medical Emergencies

324 325

Cardiopulmonary Resuscitation

326

Delineation of Privileges

327 334

Common Pediatric Medications

New

New

Analysis and Policy Recommendations Concerning Mid-level Dental Providers

Copyright © 2002-2010 American Academy of Pediatric Dentistry. All Rights Reserved. Website Designed by AmericanEagle.com, Inc. http://www.aapd.org/media/policies.asp

322 314 323

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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 advanced education program accredited by the Commission on Dental Accreditation of the American Dental Association (ADA). Such programs “must be designed to provide special knowledge and skills beyond the DDS or DMD training...”1 The curriculum of an advanced program provides the dentist with necessary didactic background and clinical experiences to provide 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 dentistry 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 the medically and developmentally compromised and disabled patient, 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 children 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. The membership provides care to millions of our nation’s infants, children, adolescents, and persons with special health care needs. They are the primary contributors to professional education programs and publications on pediatric oral health. The AAPD, in accordance with its vision and mission, advocates optimal oral health and health care for all children and persons with special health care needs. Its advocacy activities take place within the broader health care community and with the public at local, regional, and national levels. The Reference Manual is one of the components of the AAPD’s advocacy activities.

Intent of the AAPD Reference Manual The AAPD Reference Manual is intended to encourage a diverse audience to provide the highest possible level of care to 2

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children. This audience includes, but is not limited to: 1. pediatric dentists; 2. general dental practitioners and other dental specialists; 3. physicians and other health care providers; 4. government agencies and health care policy makers; 5. individuals interested in the oral health of children. The AAPD Reference Manual is divided into 5 sections: (1) definitions; (2) oral health policies; (3) clinical guidelines; (4) endorsements; and (5) resources. Oral health policies are statements relating to AAPD positions on various public health issues. Clinical guidelines are practice recommendations designed to assist the dental provider in making decisions concerning direct patient care. Adherence to the guidelines increases the probability of a favorable practice outcome and decreases the likelihood of an unfavorable practice outcome. Practice recommendations that have been developed by the AAPD appear in the “Clinical Guidelines” section. “Endorsements” includes clinical guidelines relevant to the practice of pediatric dentistry that have been developed by another organization 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 this Reference Manual necessitates recognizing the distinction between “standards” and “guidelines”. Although there are certain instances within the guidelines where a specific action is mandatory, the AAPD Reference Manual is not intended nor should it be construed to be either a standard of care or a scope of practice document. The AAPD Reference Manual contains practice guidelines which are intended to be 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.

Definitions For the purpose of this document, the following definitions shall apply. They are based on definitions established by the ADA, the Institute of Medicine, and the Joint Commission on Accreditation of Health Care Organizations. Standards: Any definite rule, principle, or measure established by authority. Standards 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. A standard of care indicates that measurable criteria are present and these criteria shall be used to arrive at a given level of outcome. Standards say what must be done. The courts define legal standards of care. Guidelines: Systematically developed recommendations designed to assist the practitioner, patient, and caregiver in making decisions relating to specific clinical situations.

american academy of pediatric dentistry

Guidelines are intended to be more flexible than standards. Guidelines 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, setting, and other factors. Deviations from guidelines could be fairly common and could be justified by differences in individual circumstances. Guidelines are designed to produce optimal outcomes, not minimal standards of practice. Guidelines originate in an organization with recognized professional expertise and stature. Although they may be unsolicited, they usually are developed following a stated request or perceived need for clinical advice or instruction. Guidelines are kept current by regular review and modification by the developing body. 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 suggested alternative. Parent: Unless otherwise indicated, the term “parent” as used in these oral health policies and clinical guidelines 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).

Policy and guideline development The oral health policies and clinical 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). CCA is comprised of individuals representing the 6 geographical (trustee) districts of the AAPD, along with additional consultants confirmed by the BOT. Council members and consultants derive no financial compensation from the AAPD for their participation and are asked to disclose potential conflicts of interest. Proposals to develop or modify policies and guidelines may originate from 4 sources: 1. the officers or trustees acting at any meeting of the BOT; 2. a council, committee, or task force in its report to the BOT; 3. any member of the AAPD who submits a written re quest 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 Web site at: “http://www.aapd.org/ members/resources/pdf/PolicyProcedure.pdf ”); 4. officers, trustees, council and committee chairs, or other participants at the AAPD’s Annual Strategic Planning Session.

Regardless of the source, proposals 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. Once a charge (directive from the BOT) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA, it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. Oral health policies and clinical guidelines utilize 2 sources of evidence: the scientific literature and experts in the field. CCA, in collaboration with the Council on Scientific Affairs, performs a comprehensive literature review for each document. When scientific data do not appear conclusive, experts may be consulted. The CCA meets on an interim basis to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is discussed, amended if necessary, and confirmed by the entire council. Once developed by the CCA, the proposed policy or guideline is submitted for the consideration 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 upcoming Annual Session. The Reference Committee hearing is an open forum for the membership to provide comment or suggestion for alteration of the document. 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 clinical guideline for publication in the AAPD’s Reference Manual and on the AAPD’s Web site (www.aapd.org-click on Policies and Guidelines on the left sidebar).

Review and revision of existing policies and guidelines Each AAPD oral health policy and clinical guideline is reviewed for accuracy, relevance, and currency by the CCA no less than once every 5 years and more often if directed by the BOT. AAPD members may submit (through a Web site survey) suggestions and/or resources for consideration during CCA’s review of existing documents. After completing a new literature review, the council may recommend retention of the document without change (ie, reaffirm), propose revision, or recommend elimination of a policy or guideline. Policies and guidelines 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.

Reference 1. American Dental Association Commission on Dental Accreditation. Accreditation standards for advanced specialty education programs in pediatric dentistry. Chicago, Ill; 2000.

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American Academy of Pediatric Dentistry Vision Statement / Mission Statement Adopted 2003

Revised 2008

Vision statement

Mission statement

The vision of the American Academy of Pediatric Dentistry (AAPD) is optimal health and care for infants and children through adolescence, including those with special health care needs. The Academy is the leader in representing the oral health interests of children. The pediatric dentist is a recognized primary oral health care provider and a resource for specialty referral.

The mission of the American Academy of Pediatric Dentistry is to advocate policies, guidelines, and programs that promote optimal oral health and oral health care for infants and children through adolescence, including those with special health care needs. The Academy serves and represents its membership in the areas of professional development and governmental and legislative activities. It is a liaison to other health care groups and the public.

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American Academy of Pediatric Dentistry Core Values Adopted 2003

Revised 2009

American Academy of Pediatric Dentistry values (AAPD) 1. Health and health care equity. A. AAPD values oral health as an inseparable part of the overall health and welfare of the infant, child, and adolescent. B. AAPD values universal access to comprehensive oral health care that meets each child’s unique needs and promotes optimal oral health. C. AAPD values effectiveness and efficiency in providing oral health services to infants, children, and adolescents and supports efforts that improve access through effective and efficient delivery systems. D. AAPD values improvements in access to oral health care that reduce or eliminate financial, logistic, and cultural barriers to care. E. AAPD values oral health care for children that is safe, comprehensive, accessible, affordable, high quality, continuous, and respectful of individual children and their families. F. AAPD values volunteerism and charitable care that improves children’s health but rejects these approaches as significant solutions to reducing disparities in oral health care for infants, children, and adolescents covered by public insurance programs. 2. An effective dental workforce. A. AAPD values a workforce that can meet the needs of infants, children, and adolescents by being adequate in size, distribution, diversity, and competency. B. AAPD values the unique skills and knowledge that pediatric dentists bring to children’s oral health care. C. AAPD values the role of other dental specialists and general dentists in caring for children. D. AAPD values programs that improve the capacity of general dentists, hygienists, and assistants to improve children’s oral health by providing appropriate care and effectively referring to pediatric dentists when unable to meet the comprehensive needs of individual infants, children, and adolescents. E. The AAPD values the educators who mentor those who treat children, including pediatric dentists, general

dentists, dental hygienists, and auxiliary personnel, by teaching the skills and promoting the professional behaviors that serve children’s interests. 3. Effective public programs. A. AAPD values government’s role in assuring comprehensive dental care for vulnerable children and values the legal requirements of Early and Periodic Screening, Diagnosis and Treatment (EPSDT), which ensure access for covered children that is equivalent to access for noncovered children in the same geographic area. B. AAPD values public health programs proven to prevent or minimize disease in infants, children, and adolescents. 4. Oral health promotion. A. AAPD values health promotion and disease prevention, including effective anticipatory guidance beginning with comprehensive dental care in a dental home starting at age 1. B. AAPD values the critical role of the dental home in promoting optimal oral health for all children. C. AAPD values health promotion and disease prevention as integral components of perinatal care. 5. Child and adolescent welfare. A. AAPD values health, health equity, and the quality of life that results from health attainment, including oral health attainment. B. AAPD values society’s recognition of oral disease as a significant health problem for infants, children, and adolescents that needs to be addressed in all pediatric health policies. C. AAPD values society’s recognition of oral diseases that affect children’s function, development, and quality of life as significant health problems. 6. Science, education, research, and evidence-based care. A. AAPD values the scientific basis of its profession and the need to continue improving that base through research, experimentation, and the promotion of evidence-based care.

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B. AAPD values the critical role of clinical judgment to promote primary and comprehensive preventive and therapeutic oral health care for which evidence is incomplete or unavailable. C. AAPD values professional education programs and their faculties, community service, scientific contributions to pediatric dentistry, and the preparation of skilled practitioners. D. AAPD values the dissemination of valid information about children’s oral health to the professions and the public. 7. Children with special health care needs. A. AAPD values the unique qualities of each person and the need to ensure maximal health attainment for all regardless of their developmental or other special health needs. B. AAPD values dentists’ unique roles and responsibilities in diagnosing oral conditions and in coordinating, managing, and directing the oral health care of infants, children, and adolescents.

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8. Families and communities. A. AAPD values the roles of families and communities in promoting infant, child, and adolescent health and welfare and attaining maximal oral health. B. AAPD values the diversity of children, their families, and their communities and respects the contribution of culture to the attainment of oral health and use of dental services. 9. Membership. AAPD values its members–their involvement with the Academy, their commitment to children and youth, their professional endeavors, and their support of policies that improve the health and welfare of children and youth.


American Academy of Pediatric Dentistry 2009-12 Strategic Plan Revised 2009

Goal 1—Optimal Health for All Children and Persons with Special Health Care Needs Objective 1.1: An oral disease-free population. Strategy 1.1.1 Promote universal acceptance of antici patory guidance and preventive oral health care in a dental home beginning no later than age 1. Strategy 1.1.2 Support water fluoridation efforts and appropriate use of other topical and sys temic fluoride vehicles. Strategy 1.1.3 Increase public and governmental aware ness and education regarding pediatric oral health strategies. Strategy 1.1.4 Encourage and support research in oral disease prevention and evidence-based care. Strategy 1.1.5 Employ risk assessment and tailored interventions. Objective 1.2: Access to appropriate oral health care for all children and persons with special health care needs. Strategy 1.2.1 Recognize and address barriers to access and quality care. Strategy 1.2.2 Assure adequate and appropriate financ ing in public sector programs. Strategy 1.2.3 Recognize and support appropriate pro vision of care by safety net providers. Strategy 1.2.4 Increase the availability of reimbursement for medically necessary care (general anesthesia and sedation).

Goal 2—Valued and Worthwhile Membership Services Objective 2.1: An informed membership. Strategy 2.1.1 Provide valuable continuing education. Strategy 2.1.2 Communicate through Pediatric Dentistry Today and other appropriate venues Aca demy activities and programs on behalf of the membership. Strategy 2.1.3 Produce respected scientific publications Strategy 2.1.4 Maximize utilization of information technology.

Objective 2.2: A membership adept at adapting to changes in delivery of care and technological advances. Strategy 2.2.1 Provide contemporary guidance in prac tice administration, communication, and marketing skills in pediatric dentistry. Strategy 2.2.2 Assist in disseminating information con cerning member career transitions and business opportunities, including those designed for the new pediatric dentist. Strategy 2.2.3 Involve the Academy in the dissemination of information regarding new products and techniques. Objective 2.3: Maximized membership dues value. Strategy 2.3.1 Support the personal issues of Academy members. Strategy 2.3.2 Provide office brochures and other valu able materials. Strategy 2.3.3 Monitor and evaluate membership bene fits on a continuing basis. Objective 2.4: Effective response to crucial pediatric dental issues. Strategy 2.4.1 Identify and anticipate emergent mem bership issues. Strategy 2.4.2 Develop and maintain a protocol and mechanism for responding to the public, media, and membership on anticipated and unanticipated critical issues. Strategy 2.4.3 Develop and maintain a network of trained spokespersons. Objective 2.5: Strong pediatric dental organization representation. Strategy 2.5.1 Development of international mem bership. Strategy 2.5.2 Sustain recruitment and retention efforts, including programs and policies directed to the new pediatric dentist and dental faculty.

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Goal 3—Recognized Authority in Pediatric Oral Health Objective 3.1: Optimal care, including translation of science into clinical practice. Strategy 3.1.1 Develop optimal care through our oral health policies, clinical guidelines, and other venues. Strategy 3.1.2 Promote optimal care through our oral health policies, clinical guidelines, and other venues. Strategy 3.1.3 Maintain optimal care through our oral health policies, clinical guidelines, and other venues. Objective 3.2: Expert resource on children’s oral health recognition. Strategy 3.2.1 Build and maintain coalitions with other healthcare organizations. Strategy 3.2.2 Anticipate and respond effectively to changes in the clinical and scientific environment. Strategy 3.2.3 Identify and support areas of clinical and scientific research important to pediatric oral health. Strategy 3.2.4 Communicate to the profession and the public issues about pediatric oral health. Strategy 3.2.5 Encourage and support volunteer leader ship by pediatric dentists in all organiza tions involved in oral health or child welfare. Objective 3.3: Effective advocate of public policy. Strategy 3.3.1 Coordinate all elements of advocacy resources, including the congressional liaison, child advocate, political action committee (PAC), Children’s Dental Health Project (CDHP), volunteer advo cates, and lobbyists. Strategy 3.3.2 Identify public policy issues, conduct policy research and development, and develop implementation strategies. Strategy 3.3.3 Develop an effective advocacy network.

Goal 4—Satisfy Worforce Issues Objective 4.1: Enlarged and appropriately distributed pediatric dental workforce. Strategy 4.1.1 Encourage effective geographic distribu tion of pediatric dentists. Strategy 4.1.2 Expansion of pediatric dental residency and fellowship programs. Strategy 4.1.3 Innovate and support programs to assure a well-qualified applicant pool for pedia tric dental training.

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Objective 4.2: Greater engagement of the general dentist and dental specialists in the treatment of children. Strategy 4.2.1 Improve pre-doctoral education and experience in pediatric dentistry. Strategy 4.2.2 Development of continuing education programs. Strategy 4.2.3 Promote the value of the Affiliate mem bership category. Objective 4.3: Appropriate and optimized utilization of allied dental health professionals. Strategy 4.3.1 Development of continuing education programs. Strategy 4.3.2 Identify appropriate roles for allied den tal health professionals which include dental assistants, expanded function dental assistants (EFDA), and hygienists. Objective 4.4: Appropriate and effective utilization of nondental healthcare providers. Strategy 4.4.1 Development of continuing education programs. Strategy 4.4.2 Identify appropriate roles for physicians and non-dental health care providers.

Goal 5—Meet Dental Education Needs Objective 5.1: Academic faculties of excellent caliber and sufficient number. Strategy 5.1.1 Educate AAPD membership on academic crisis issues. Strategy 5.1.2 Foster a fundraising campaign for aca demic support. Strategy 5.1.3 Foster improved business practices in teaching clinics. Strategy 5.1.4 Foster academic career loan forgiveness programs. Strategy 5.1.5 Foster creative use of private clinics and practitioner mentors in residency programs. Strategy 5.1.6 Foster effective modeling, mentoring, and education for potential academicians. Strategy 5.1.7 Foster development of shared basic in formation distance learning modules. Strategy 5.1.8 Increase the transition of “master clinicians” into teaching, including full time positions. Strategy 5.1.9 Foster dissemination of “best practice” models. Objective 5.2: Physical plants of educational institutions adequate to support educational objectives. Strategy 5.2.1 Aid and support facility development programs. Strategy 5.2.2 Support legislation to secure capital fund ing for pediatric dentistry education facilities.


Objective 5.3: Increased standardization of pre- and postdoctoral training experiences. Strategy 5.3.1 Implement consistent standards in pre and postdoctoral programs.

Objective 5.4: Appropriate accreditation standards for the pre- and postdoctoral level. Strategy 5.4.1 Support Academy initiatives on pre- and postdoctoral curriculum standardization.

Goal 6—Efficient and Effective Organization Objective 6.1: The structure of the Academy serves and represents its membership. Strategy 6.1.1 Increase communication between mem bership and leadership. Strategy 6.1.2 Review the mechanism of accountability of the headquarters office to leadership. Objective 6.2: Adequate funding for Academy operations, programs, and initiatives. Strategy 6.2.1 Offset expenses by appropriately maximiz ing corporate and other outside support of Academy projects and endeavors. Strategy 6.2.2 Assure an appropriate dues structure and other sources of income. Objective 6.3: Efficient headquarters office operations. Strategy 6.3.1 Assure a technologically-advanced com munication to the membership. Strategy 6.3.2 Provide an appropriately-sized and ad equately-equipped facility for business operations. Strategy 6.3.3 Support a qualified and well-motivated staff in appropriate numbers and respon sibilities to accomplish Academy business operations.

Objective 6.4: Effective volunteer leadership. Strategy 6.4.1 Assure appropriate leadership training. Strategy 6.4.2 Assure objective assessment of the volunteer leadership. Strategy 6.4.3 Assure a fair and equitable process to identify and select individuals at al l volunteer leadership levels. Objective 6.5: Effective tripartite organizational structure. Strategy 6.5.1 Clarify and enhance the role of District Trustee in Academy operations. Strategy 6.5.2 Promote efforts to strengthen effectiveness and number of district organizations and state units. Strategy 6.5.3 Explore opportunities for increased mem bership participation in Academy deci sion making. Objective 6.6: Effective relationship between the Academy and its Foundation. Strategy 6.6.1 Healthy Smiles, Healthy Children: The Foundation of the American Academy of Pediatric Dentistry will function as the tax-exempt charitable research, education, and service arm of the Academy. Strategy 6.6.2 Reflecting the AAPD Research Agenda and to further developments in the spe cialty, Healthy Smiles, Healthy Children: The Foundation of the American Acad emy of Pediatric Dentistry will sponsor research grants and awards, along with professional and public education opportunities. Objective 6.7: Effective relationship between the Academy and the American Board of Pediatric Dentistry (ABPD). Strategy 6.7.1 Sponsor and support a strong and vital American Board of Pediatric Dentistry.

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American Academy of Pediatric Dentistry Research Agenda Adopted 2005

Reaffirmed 2007

The American Academy of Pediatric Dentistry (AAPD) recognizes that the clinical practice of pediatric dentistry has to be driven by science and evidence-based dentistry (EBD). Where possible, our clinical guidelines in pediatric dentistry should be supported by the best available evidence. No longer is it acceptable for our clinical guidelines to be based on expert opinions solely. Where the evidence or science is lacking, research needs to be conducted to answer the relevant questions that arise in our clinical practice. The AAPD Research Agenda is a strategic list of scientific and clinical questions and topics that are specific to the clinical practice of pediatric dentistry. These questions will benefit from scientific review and set the agenda for the AAPD, as well as the AAPD Foundation research grants. The AAPD Council on Scientific Affairs (CSA) is charged with proposing a mechanism by which the AAPD Research Agenda is to be developed and maintained. Other dental organizations have embraced evidence-based research. The National Institute of Dental and Craniofacial Research (NIDCR) has a Strategic Plan that outlines research opportunities to support its mission to improve oral, dental, and craniofacial health through research, research training, and the dissemination of health information by performing and supporting basic and clinical research. While interested in supporting clinical research, the NIDCR supports research that offers the most significant scientific promise. The American Dental Association (ADA) is committed to bringing EBD concepts and practices to the dental profession. The ADA Research Agenda was developed to promote research in areas of dental practice and to designate priorities for conducting and funding evidence-based studies. The ADA Research Agenda reflects important clinical questions that are relevant to the entire profession of dentistry.

Methodology, Results, and Recommendations The 14 members of the 2004-05 AAPD CSA submitted 41 research topics/questions/issues that were thought to be the most pertinent to pediatric dentistry. These topics were evaluated for duplication, consolidated, and returned to the CSA members for ranking in terms of importance. After 2 rounds of elimination, the CSA members identified the 5 research topics that were deemed to be the most important for pediatric dentistry and would benefit the most from scientific review. These topics are listed below in descending order of priority: 1. Transmission, etiology, risk assessment, early detection, prevention, and management of caries. introduction 10

2. Caries management using antimicrobials, fluorides, and remineralizing agents. 3. Disparities and barriers to accessing dental care. 4. Development of a national databank on pediatric den tal issues. 5. Efficacy of infant oral health (ie, first dental visit by age 12 months). Additional topics of relevance are as follows: 1. Pulp biology and efficacious and biocompatible pulp treatment. 2. Safe and effective sedative agents for pain and anxiety control. 3. Specific (immunity) and non-specific host factors in the etiology and prevention of dental caries. 4. Interface between medicine and dentistry in address ing access to care. 5. Biologic and behavioral factors in the natural history of caries. 6. Parenting styles. 7. Non-pharmacologic behavior guidance approaches. 8. Efficacy and biocompatibility of restorative materials. 9. Pediatric dentist’s role in monitoring, preventing, and managing obesity. 10. Etiology, detection, prevention, and management of pre-pubertal and juvenile periodontal disease. As to be expected from a group of individuals who practice in different regions of the United States and who possess a wide array of scientific expertise and interests, CSA members did not share a consensus in terms of how the research topics ought to be ranked. Some CSA members found it difficult to rank the research topics. Some members felt that the AAPD Research Agenda should reflect the unique aspects of pediatric dentistry practice that have limited appeal to other dental disciplines. Others felt that while some topics have been left off the “top 10,” they are important to include in the overall Research Agenda. Nevertheless, the “top 5” topics received composite ranking scores that were significantly higher than the rest and they were ranked more frequently. The Council on Clinical Affairs was consulted. The Cariesrisk Assessment Tool (CAT) was specifically recommended to be included in the list of research topics of relevance. Although CAT could be included under the broad topic of “Transmission, etiology, risk assessment, early detection, prevention, and management of caries,” it was singled out as needing research. CSA recommends that council reevaluate and update the AAPD Research Agenda on an annual basis.

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Definition of Dental Home Originating Council

Council on Clinical Affairs Adopted 2006

Reaffirmed 2010

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, coordinated,

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and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate.

american Academy of Pediatric Dentistry

Definition of Dental Neglect Originating Committee

Child Abuse Committee Review Council

Council on Clinical Affairs

Adopted 1983

Revised 1987, 1992

Reaffirmed 1996, 2001, 2006, 2010

Dental caries, periodontal diseases, and other oral conditions, if left untreated, 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.

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.

definitions

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Definition of Dental Disability Originating Committee

Child Abuse Committee Review Council

Council on Clinical Affairs

Adopted 1983

Revised 1992, 2000, 2008

Reaffirmed 1996, 2003

Dental caries, periodontal disease, dentoalveolar trauma, and other oral conditions left untreated can limit substantially a child’s development and an individual’s participation in life activities. An individual should be considered to have a dental disability if pain, infection, or lack of stable and functional dentition:

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definitions

1. restricts nutritional intake adequate for growth and energy needs; 2. delays or otherwise alters growth and development; 3. inhibits participation in life activities; or 4. diminishes quality of life.


Definition of Early Childhood Caries (ECC) Originating Council Council on Clinical Affairs

Review Council Council on Clinical Affairs

Adopted 2003

Revised 2007, 2008

Caries is a biofilm (plaque)-induced acid demineralization of enamel or dentin, mediated by saliva. The disease of early childhood caries (ECC) is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. In children younger than 3 years

of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC.

definitions

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Definition of Medically Necessary Care Originating Committee Clinical Affairs Committee


Adopted 1997

Revised 2001, 2003, 2007

Medically necessary care (MNC) is the reasonable and appropriate diagnostic, preventive, and treatment services (including supplies, appliances, and devices) and follow-up care as determined by qualified, appropriate health care providers in treating any condition, disease, injury, or congenital or developmental malformation. 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

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definitions

limited to, sedation, general anesthesia, and utilization of surgical facilities. MNC must take into account the patient’s age, developmental status, and psychosocial well-being, in addition to the setting appropriate to the needs of the child 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.


Definition of Special Health Care Needs Originating Council

Council on Clinical Affairs Review Council Council on Clinical Affairs

Adopted 2004

Revised 2008

Special health care needs include 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. The condition may be developmental or acquired and may cause 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, increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine.

definitions

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american academy of pediatric Dentistry

Policy on Medically Necessary Care Originating Council


Purpose The American Academy of Pediatric Dentistry (AAPD) 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.

Methods This policy is based upon a review of the current dental and medical literature related to the concept of medically necessary care. A MEDLINE search was performed using the terms “medically necessary care”, “systemic disease and oral disease”, “dentistry as medically necessary care”, “periodontal disease and cardiovascular disease”, “maternal oral disease and pregnancy”, and “oral disease and respiratory illness”.

Background The AAPD defines medically necessary care (MNC) as the reasonable and appropriate diagnostic, preventive, and treatment services (including supplies, appliances, and devices) and follow-up care as determined by qualified, appropriate health care providers in treating any condition, disease, injury, or congenital or developmental malformation. 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. MNC must take into account the patient’s age, developmental status, and psychosocial well-being, in addition to the setting appropriate to the needs of the child 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 observations. 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, 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 US Surgeon General’s report3 emphasizing that oral health is integral to general health, the US 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 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% of children experience caries in their primary teeth by age 5.5 Between 1988-1994 and 1999-2004, prevalence of caries in primary teeth increased for youths aged 2 to 11 years, with a significant increase noted for those in the 2-5 year age range.6 By 17 years of age, 78% of children in the US have experienced caries.4 As much as 90% of all caries in school-aged children occurs in pits and fissures. Caries, periodontal diseases, and other oral conditions, if left untreated, 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.7 Rampant caries is one of the factors causing insufficient development in children who have no other medical problems.8 Children with early childhood caries (ECC) may be severely underweight because of the associated pain and disinclination to eat. Nutritional deficiencies during childhood can impact cognitive development.9 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.10 There exists a relationship between periodontal disease and cardiovascular disease11,12 and periodontal disease and adverse pregnancy outcomes.13,14 An association between oral health and respiratory diseases has been recognized.15,16 Oral health, oral microflora, and bacterial pneumonia, especially in populations at high risk for respiratory disease, have been linked. The mouth can harbor respiratory pathogens that susbequently are aspirated, resulting in airway infections.16 Problems of esthetics, form, and function can affect the developing psyche of children, with life-long consequences in social, educational, and occupational environments.17 Self-image, self-esteem, and selfconfidence are unavoidable issues in society, and an acceptable orofacial presentation is a necessary component of these psychological concepts.18

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Congenital orofacial anomalies (eg, ectodermal dysplasia, cleft defects) that result in malformed or missing teeth can have significant negative functional, esthetic, and psychological effects on individuals and their families.19,20 Patients with craniofacial anomalies often require oral health care as a direct result of their craniofacial condition. These services are an integral part of the rehabilitative process.19 Young children benefit from esthetic and functional restorative 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 have to be remade as the individual grows. Professional care is necessary to maintain oral health,3 and risk assessment is an integral element of contemporary preventive care for infants, children, adolescents, and persons with special health care needs.21 The goal of caries risk assessment is to prevent disease by identifying and minimizing causative factors (eg, microbial burden, dietary habits, dental morphology) and optimizing protective factors (eg, fluoride exposure, personal oral hygiene, sealants).22 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 development of dietary habits and childhood food preferences. Children are most likely to develop caries if mutans streptococci is acquired at an early age.23 High-risk dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood.24 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.25,26 An analysis of caries risk includes determination of protective factors, such as fluoride exposure. More than one-third of the US population does not benefit from community water fluoridation.3 Fluoride contributes to the prevention, inhibition, and reversal of caries.27 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.9 An individualized preventive plan based on the Caries-risk Assessment Tool (CAT)21 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.28 Early diagnosis and timely intervention, including appropriate referrals, can prevent the need for more extensive and expensive care often required when problems have gone unrecognized and/or untreated.29 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

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of ECC, treatment should be definitive yet specific for each individual patient. Conventional restorative approaches may not arrest the disease.30 Areas of decalcification and hypoplasia can develop cavitation rapidly. The placement of stainless steel crowns may be necessary to inhibit the caries process. Stainless steel crowns decrease the number of tooth surfaces at risk for new or secondary caries and are less likely than other restorations to require retreatment.31,32 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 ECC.33 Sealants are particularly effective in preventing pit and fissure caries and providing cost savings if placed on patients during periods of greatest risk.34 Children with multiple risk factors and tooth morphology predisposed to plaque retention (ie, developmental defects, pits and fissures) benefit from having such teeth sealed prophylactically. A child who receives sealants is 72% less likely to receive restorative services over the next 3 years than children who do not.35 Although sealant retention rates initially are high, sealant loss does occur.36 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%, even after a decade.36 The extent of the disease process, as well as the patient’s developmental level and comprehension skills, affect the practitioner’s behavior guidance approaches. To perform treatment effectively and efficiently while instilling a positive dental attitude, the practitioner caring for a pediatric patient may employ advanced behavior guidance techniques such as protective stabilization and/or sedation or general anesthesia.36 The patient’s age, dental needs, disabilities, medical conditions, and/or acute situational anxiety may preclude the patient’s being treated safely in a traditional outpatient setting.37 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 represents the only appropriate method to deliver necessary oral health care.37 The success of restorations may be influenced by the child’s response to the chosen behavior guidance technique. Although general anesthesia may provide optimal conditions to perform restorative procedures, it can add significantly to the cost of care. General anesthesia, under certain circumstances, may offer a cost-saving alternative to sedation for children with ECC.9,38 Reimbursement issues defined by the concept of MNC have been a complicated topic for dentistry. Pediatric dental 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”. This determination appears to be based on arbitrary and inconsistent criteria.39-44 For instance, medical policies often provide reimbursement for sedation/general anesthesia or facility fees related to myringotomy for a 3-year-old child, but deny these benefits when related to treatment of dental disease and/or infection for the same patient. American Dental 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.”44 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. For instance, health care policies may provide reimbursement 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.45 Although sealants are safe and effective, their use continues to be low.46 Initial insurance coverage for sealants often is denied, and insurance coverage for repair and/or replacement may be limited.47,48 Although 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, caries risk may increase at any time during a patient’s life due to changes in habits (eg, dietary, home care), oral microflora, or physical condition, and previously unsealed teeth subsequently might benefit from sealant application.36

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.

The AAPD: 1. recommends oral health care be included in the design and provision of individual and community-based health care programs to achieve comprehensive health care.

2. encourages 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 patient’s unique caries risk assessment. 3. recommends that health care providers who diagnose oral disease either provide therapy or refer the patient to an appropriately trained individual for treatment. Immediate intervention is necessary to prevent further dental destruction, as well as more widespread health problems. 4. recognizes 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 complex services. 5. believes that the dentist providing the oral health care for the patient determines 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. Furthermore, the AAPD encourages third party payors to: 1. recognize that malformed and missing teeth and resultant anomalies of facial development seen in orofacial anomalies are congenital defects, just as the congenital absence of other body parts, requiring care over the lifetime of the patient; 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 examinations, 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 a patient’s age; 5. ensure that all children have access to the full range of oral health delivery systems. If sedation or general anesthesia and related facility fees are payable benefits of a health care plan, these same benefits shall apply for the delivery of oral health services; and 6. regularly consult the AAPD with respect to the development 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 anomalies.

References 1. American Academy of Pediatric Dentistry. Definition of medically necessary care. Pediatr Dent 2007;29(suppl):14. 2. American Academy of Pediatrics. Policy statement: Model contractural language for medical necessity for children. Pediatrics 2005;116(1):261-2.


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3. US Dept of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 4. US Dept of Health and Human Services. National call to action to promote oral health. Rockville, Md: US Dept of Health and Human Services, Public Health Service, National Institute of Health, National Institute of Dental and Craniofacial Research; NIH Publication No. 03-5303, Spring 2003. 5. Crall JJ. Development and integration of oral health services for preschool-age children. Pediatr Dent 2005;27 (4):323-30. 6. D ye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 11 (248). Hyattsville, Md; 2007. 7. A merican Academy of Pediatric Dentistry. Definition of dental neglect. Pediatr Dent 2007;29(suppl):11. 8. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14(5):302-5. 9. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. Pediatr Dent 2007;29(suppl):39-41. 10. American Academy of Periodontology. Periodontal Diseases of Children and Adolescents. J Periodontol 2003; 74(11):1696-704. 11. Geismar K, Stoltze K, Sigurd B, Gyntelberg F, Holmstrup P. Periodontal disease and coronary heart disease. J Periodontol 2006;77(9):1547-54. 12. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: The heart of the matter. J Am Dent Assoc 2006;137(suppl):14-20. 13. Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc 2006;137(suppl):7-13. 14. Muerman JH, Furuholm J, Kaaja R, Rintamaki H, Tikkanen U. Oral health in women with pregnancy and delivery complications. Clin Oral Investig 2006;10(2):96-101. 15. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol 2006;77(9):1465-82. 16. Scannapieco FA. Pneumonia in nonambulatory patients: The role of oral bacteria and oral hygiene. J Am Dent Assoc 2006;137(suppl):21-5. 17. Shaw WC. The influence of children’s dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981;79(4):399-415. 18. Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthod 1985;87(1):21-6.

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19. American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of patients with cleft lip/ palate or other craniofacial anomalies. Revised ed. Chapel Hill, NC: American Cleft Palate-Craniofacial Association; April 2000. 20. National Foundation for Ectodermal Dysplasias. Parameters of oral health care for individuals affected by ectodermal dysplasias. National Foundation for Ectodermal Dysplasias. Mascoutah, Ill; 2003:9. 21. American Academy of Pediatric Dentistry. Policy on use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent 2007;29(suppl):29-33. 22. Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;37(9):1231-9. 23. 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. 24. Douglass JM. Response to Tinanoff and Palmer: Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 2000; 60(3):207-9. 25. American Psychological Association. Developing adolescents: A reference for professionals. Washington DC: American Psychological Association; 2002. 26. Macgregor ID, Regis D, Balding J. Self-concept and dental health behaviors in adolescents. J Clin Periodontol 1997; 24(5):335-9. 27. CDC. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50(RR14):1-42. 28. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2007;29(suppl):81-4. 29. Lee LJ, 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. 30. Randall RC, Vrijhoef MMA, Wilson NHF. Efficacy of preformed metal crowns vs amalgam restorations in primary molars: A systematic review. J Am Dent Assoc 2000; 131(3):337-43. 31. Foster T, Perinpanayagam H, Pfaffenbach A, Certo M. Recurrence of early childhood caries after comprehensive treatment with general anesthesia and follow-up. J Dent Child 2006;73(1):25-30. 32. Eidelman E, Faibis S, Peretz B. A comparison of restorations for children with early childhood caries treated under general anesthesia or conscious sedation. Pediatr Dent 2000;22(1):33-7. 33. 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.


34. Weintraub JA. Pit and fissure sealants in high-caries risk individuals. J Dent Educ 2001;65(10):1084-90. 35. A nderson M. Risk assessment and epidemiology of dental caries: Review of the literature. Pediatr Dent 2002; 24(5):377-85. 36. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent 2002;24(5):415-22. 37. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2007;29(suppl):115-24. 38. Lee JY, Vann WF, Roberts MW. A cost analysis of treating pediatric dental patients using general anesthesia vs conscious sedation. Pediatr Dent 2000;22(1):27-32. 39. Patton LL, White BA, Field MJ. State of the evidence base for medically necessary oral health care. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(3):272-5. 40. Flick WG, Claybold S. Who should determine the medical necessity of dental sedation and general anesthesia? A clinical commentary supported by Illinois patient and practitioner surveys. Anesth Prog 1998;45(2):57-61. 41. Conway TE. What is currently available in terms of medically necessary oral care? Spec Care Dentist 1995;15(5); 187-91.

42. White BA. The costs and consequences of neglected medically necessary oral care [Review]. Spec Care Dentist 1995;15(5):180-6. 43. Cameron CA, Litch CS, Liggert M, Heimburg S. National alliance for oral health consensus conference on medically necessary oral health care: Legal issues. Spec Care Dentist 1995;15(5):192-200. 44. American Dental Association. Transactions of the ADA: Benefits for services by qualified practitioners. Chicago, Ill; 1989:546. 45. Strauss RP. The organization and delivery of craniofacial services: The state of the art. Cleft Palate Craniofac J 1999; 36(3):189-95. 46. US Dept of Health and Human Services. Healthy people 2010. Rockville, Md: US Dept of Health and Human Services, National Institutes of Health; 2000. 47. American Dental Association. Statement on preventive coverage in dental benefits plans. Chicago, Ill; 1992:602; 1994:656. 48. American Dental Association Council on Access, Prevention, and Interprofessional Relations, American Dental Association Council on Scientific Affairs. Dental sealants. J Am Dent Assoc 1997;128(4):485-8.


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Policy on Oral Health Care Programs for Infants, Children, and Adolescents Originating Committee Dental Care Programs Committee


Adopted 1972

Revised 1976, 1992, 1995, 2002, 2006

Reaffirmed 1999

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes the importance of prevention, diagnosis, and treatment necessary to restore and maintain the oral health of infants, children, and adolescents. Comprehensive health care cannot be achieved unless oral care is included in all health service programs.

Methods This policy revision is based upon a review of current publications and Web sites of health care organizations. A MEDLINE search was performed using the terms “oral health policy”, “infant oral health policy”, “child oral health policy”, and “adolescent oral health policy”.

Background The US Department of Health and Human Services (DHHS) documents there exists a perception that oral health is separate from general health and, therefore, less important. By raising oral health awareness, the prevention, early detection, and management of dental, oral, and craniofacial tissues can become integrated into health care, community-based programs, and social services.1 DHHS recognizes that oral health can have a significant impact on overall health and well-being. Major themes of the US Surgeon General’s report on “Oral Health in America”1 include: 1. “Oral health means much more than healthy teeth.” 2. “Oral health is integral to general health.” Accordingly, the DHHS report “National Call to Action to Promote Oral Health”2 recommends: 1. Changing perceptions of the public, policymakers, and health providers regarding oral health and disease so that oral health becomes an accepted component of general health.

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2. Removing known barriers between people and oral health services. 3. Accelerating the building of the scientific and evidence base, as well as the application of research findings, to improve oral health. 4. Ensuring the adequacy of public and private health personnel and resources to meet the oral health needs of all Americans and enable the integration of oral health effectively with general health. The focus is on having a responsive, competent, diverse, and flexible workforce. 5. Expanding public-private partnerships and building upon common goals to improve the oral health of those who suffer disproportionately from oral diseases.

Policy statement The AAPD recommends oral health care be included in the design and provision of individual and community-based health care programs to achieve comprehensive health care. This can be achieved through the recommendations of the DHHS report “National Call to Action to Promote Oral Health.”2

References 1. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 2. US Dept of Health and Human Services. National Call to Action to Promote Oral Health. Rockville, Md: US Dept of Health and Human Services, Public Health Service, National Institute of Health, National Institute of Dental and Craniofacial Research; NIH Publication No. 035303, Spring 2003.


Policy on the Dental Home Originating Council Council on Clinical Affairs


Adopted 2001

Revised 2004

Reaffirmed 2010

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, nondental professionals, and dental professionals. Establishment of the dental home is initiated by the identification and interaction of these individuals, resulting in a heightened awareness of all issues impacting the patient’s oral health. This concept is derived from the American Academy of Pediatrics’ (AAP) definition of a medical home which states pediatric primary health care is best delivered where comprehensive, continuously-accessible, family-centered, coordinated, compassionate, and culturallyeffective care is available and delivered or supervised by qualified child health specialists.1-4

Methods This policy is based on a review of the current dental and medical literature related to the establishment of a dental home. A MEDLINE search was conducted using the terms “dental home”, “medical home in pediatrics”, and “infant oral health care”. 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 1992.5 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.4-6 Strong clinical evidence exists for the efficacy of early professional dental care complemented with caries-risk assessment, anticipatory guidance, and periodic supervision. The establishment of a dental home may follow the medical home model as a cost-effective and higher quality health care alternative to emergency care situations.

Children who have a dental home are more likely to receive appropriate preventive and routine oral health care. Referral by the primary care physician or health provider has been recommended, based on risk assessment, as early as 6 months of age, 6 months after the first tooth erupts, and no later than 12 months of age.7-9 Furthermore, 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.10

Policy statement 1. The AAPD encourages parents and other care provi 2.

ders to help every child establish a dental home by 12 months of age. The AAPD recognizes a dental home should provide:11 a. comprehensive oral health care including acute care and preventive services in accordance with AAPD periodicity schedules12; b. comprehensive assessment for oral diseases and conditions; c. individualized preventive dental health program based upon a caries-risk assessment 13 and a periodontal disease risk assessment14; d. anticipatory guidance about growth and development issues (ie, teething, digit or pacifier habits); e. plan for acute dental trauma; f. information about proper care of the child’s teeth and gingivae. 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; g. dietary counseling; h. referrals to dental specialists when care cannot di rectly be provided within the dental home;


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i. education regarding future referral to a dentist know ledgeable and comfortable with adult oral health issues for continuing oral health care; referral at an age determined by patient, parent, and pediatric dentist. 3. 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.15

References 1. American Academy of Pediatrics Committee on Children with Disabilities. Care coordination: Integrating health and related systems of care for children with special health care needs. Pediatrics 1999;104(4Pt1):978-81. 2. American Academy of Pediatrics. Committee on Pediatric Workforce. Culturally effective pediatric care: Education and training issues. Pediatrics 1999;103(1):167-70. 3. American Academy of Pediatrics Committee on Pediatric Workforce. Pediatric primary health care. AAP News November 1993;11:7. Reaffirmed June 2001. 4. American Academy of Pediatrics. The medical home. Pediatrics 2002;110(1Pt1):184-6. 5. American Academy of Pediatrics Ad Hoc Task Force on the Definition of the Medical Home. The medical home. Pediatrics 1992;90(5):774. 6. Kempe A, Beaty B, Englund BP, Roark RJ, Hester N, Steiner JF. Quality of care and use of the medical home in a state-funded capitated primary care plan for low-income children. Pediatrics 2000;105(5):1020-8. 7. Nowak AJ, Casamassimo PS. The dental home: A primary oral health concept. J Am Dent Assoc 2002;133 (1):93-8.

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8. Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatr Dent 1997;19(1):8-11. 9. American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;111(5): 1113-6. 10. US Dept of Health and Human Services. Healthy People 2010: Understanding and improving health. 2 nd ed. Washington, DC. US Government Printing Office; November 2000. 11. Poland C. Pediatric oral health. In: Burns CE, Brady MA, Dann AM, Starr N, eds. Pediatric Primary Care: A Handbook for Nurse Practitioners. 2nd ed. Philadelphia, Pa: WB Saunders Co; 2000. 12. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatr Dent 2009;31(special issue):118-25. 13. A merican Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2010;32(special issue):101-8. 14. American Academy of Periodontology. Periodontal diseases of children and adolescents. J Periodontol 2003; 74(11):1696-704. 15. American Academy of Pediatric Dentistry. Dental home resource center. Available at: “http://www.aapd.org/ dentalhome/”. Accessed June 24, 2010.

AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Policy on Child Identification Programs Originating Council Council on Clinical Affairs


Adopted 2003

Revised 2008

Purpose The American Academy of Pediatric Dentistry (AAPD), recognizing the role that dental records play in forensic identification, 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/or abducted persons.

Methods This policy revision is based on a review of the current dental, medical, and public literature, and interviews with forensic odontologists, pathologists, and law enforcement agencies. A MEDLINE search was conducted using the terms “child”, “forensic”, “dental”, and “identification”. An electronic search using “child identification” also was conducted. Manuals on forensics1,2 utilized by the American Academy of Forensic Science and the American Society of Forensic Odontology demonstrate the vital role of dentistry in identification of missing and unknown persons.

Background More than 800,000 children in America are reported missing each year.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 information used to compare missing persons with the unidentified living and dead.4 Numerous cases have been published in which law enforcement agencies called upon dentistry to provide information that proved vital to the identification process.5-7 Dental records used for identification purposes have included dental radiographs, facial photographs, study casts, dental histories documenting teeth present and distinguishing features of oral structures, restorative history documenting restored surfaces and materials used, and bite registrations.8 Nondental sources of distinguishing information currently include fingerprints, photographs, physical descriptions, and DNA from blood, saliva, and other tissue.9 Some of these

nondental sources have practical limitations. Few children have fingerprint records. DNA sampling, while being state of the art, can be protracted and costly. Dentistry can provide data without many of these limitations. Many programs have been developed and sponsored by community groups that use various child identification methods. Examples are: 1. Child Identification Program (CHIP), sponsored by the Masons. This program gathers saliva samples for DNA fingerprinting, videos, toothprints, and fingerprints.10 2. The National Child Identification Program, sponsored by the American Football Coaches Association with the Optimist International and Clear Channel Int. They use an identification card which includes fingerprints, a physical description, photographs, and the physician’s office address/telephone number.3 3. New England Kids Identification System (KIDS) sponsored by the Massachusetts Free Masons and the Massachusetts Dental Society, which incorporated dental bite impression and cheek swabs to gather DNA material into the CHIP events.10,11

Policy statement The AAPD recognizes the importance of dentistry’s role in the provision of data for identification of missing and/or deceased children and encourages dental professionals to assist in identifying such individuals through dental records and other mechanisms. The AAPD also encourages community identification programs to include a dental component documenting the child’s dental home12 and encouraging consistent dental visits. A dental home should be established for every child by 12 months of age.13 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 updated properly. 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 radiographs,14 photographs, study casts, and bite registration.

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References 1. Bowers CM, Bell GL, eds. Dental identification. Manual of Forensic Odontology. 3 rd ed. Saratoga Springs, NY: American Society of Forensic Odontology; 1997:9-73. 2. Stimson PG, Mertz CA, eds. Scientific methods of investigation. Forensic Dentistry. New York, NY: Robert Stern, CRC Press; 1997:1-29. 3. National Child Identification Program Web site. Available at: “http://www.childidprogram.com”. Accessed March 21, 2008. 4. Sperber N. Identification of children and adults through federal and state identification systems: Recognition of human bite marks. Forensic Sci Int 1986;3(2-3):87-93. 5. Berthold M. Police seek ID in Illinois. ADA News 2002: 33:27. 6. Goodman NR, Himmerberger LK. Identifying skeletal remains found in a sewer. J Am Dent Assoc 2002;133 (11):1508-13. 7. Dental ID beats DNA. Available at: “http://www.newscientist.com/article.ns?Id+mg18725163.900”. Accessed July 30, 2007. 8. Adams BJ. Establishing personal identification based on specific patterns of missing, filled and unrestored teeth. J Forensic Sci 2003;48(3):487-96.

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9. Bowers CM, Johansen RJ. Digital analysis of bite marks and human identification. ASFO News 2001; Spring:1: 15-9. 10. Massachusetts Free Masons Child Identification Program Web site. Available at: “http://www.mychip.org”. Accessed July 31, 2007. 11. Tesini DA, Harte DB, Crowley K. Dentistry’s role in identification of missing and unknown children: Update on the dental bite impression technique. J Mass Dent Soc 1999;48(2):29-34, 50. 12. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2007;29(suppl):22-3. 13. American Academy of Pediatric Dentistry. Guideline on infant oral health. Pediatr Dent 2007:29(suppl):81-4. 14. American Dental Association, US Dept of Health and Human Services. The Selection of Patients for X-Ray Examination: Dental Radiographic Examinations. Rockville, Md: Food and Drug Administration, 2004; HHS Publication Number 88-8273. Available at: “http:// www.ada.org/prof/resources/topics/radiography.asp”. Accessed August 8, 2008.


Policy on Mandatory School-entrance Oral Health Examinations Originating Council Council on Clinical Affairs


Adopted 2003

Revised 2008

Purpose The American Academy of Pediatric Dentistry (AAPD) encourages policy makers, public health and education officials, and the dental community to recognize that poor oral health can affect a child’s ability to learn. An oral examination prior to matriculation into school could improve school readiness by providing a timely opportunity for diagnosis and treatment of oral conditions.

Methods This policy is based on a review of current dental and medical literature, including the US Surgeon General’s report “Oral Health in America”,1 as well as policies and guidelines established by stakeholders in the health and education of our nation’s children. Data is not available to determine the effectiveness of various approaches by states that currently encourage schoolentry dental examinations.

Background Professional care is necessary to maintain oral health.1 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 individual needs and risk indicators.”2 The American Academy of Pediatrics recommends that, beginning at age 3, a child’s comprehensive health assessment should include attention to problems that might influence school achievement.3 General health examinations prior to school entrance are mandated by many states. Integration of general health and oral health care programs is lacking.1 Only 6 states and Washington, DC require a dental examination prior to school matriculation. In the United States, many children have not received a professional oral health assessment prior to entering kindergarten.1 While laws may not guarantee that every child will be examined by a dentist, they do increase the likelihood of this happening. Caries is the most common chronic disease of childhood.1 Caries and gingivitis can be prevented and eradicated, but not

everyone is aware of the measures necessary to do so. More than one third of the population of the United States does not benefit from community water fluoridation.1,4 Because the use of fluoride contributes to the prevention, inhibition, and reversal of caries,5,6 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 ongoing risk assessment and education, to improve and maintain the oral health of infants, children, and adolescents.7,8 To maximize effectiveness, the dental home should be established within 6 months of eruption of a child’s first tooth and no later than his/her first birthday.9 The public’s lack of awareness of the importance of oral health is a major barrier to dental care.1 Oral health is integral to general health. Oral conditions can interfere with eating and adequate nutritional intake, speaking, self-esteem, and daily activities.10 Children with early childhood caries may be severely underweight because of associated pain and the disinclination to eat. Nutritional deficiencies during childhood can impact cognitive development.10,11 Rampant caries is one of the factors causing insufficient development in children who have no other medical problems.12 Unrecognized disease and postponed care result in exacerbated problems, which lead to more extensive and costly treatment needs. Early recognition and intervention could result in savings of health care dollars for individuals, community health care programs, and third-party payors. The National Association of State Boards of Education recognizes “health and success in school are interrelated. Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially.”13 Children with dental pain may be irritable, withdrawn, or unable to concentrate. Pain can affect test performance as well as school attendance.10 In 1996, students aged 5 to 17 missed an average of 3.1 days/100 students due to acute dental problems.10 When these problems are treated and children no longer are experiencing pain, their learning and school attendance improve.10


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According to the US Surgeon General, “a national public health plan for oral health does not exist.”14 Profiles on state and local populations, although rarely available, are necessary for planning oral health care programs. Descriptions of requirements for oral health examinations (oral health indicators), implementation/enforcement of regulations, and administrative disposition of collected data vary both among and within states that encourage dental examinations prior to school matriculation.

Policy statement Early detection and management of oral conditions can improve a child’s oral health, general health and well-being, and school readiness. Recognizing the relationship between oral health and education, the AAPD supports legislation mandating a comprehensive oral health examination by a qualified dentist for every student prior to matriculation into school. The examination should be performed in sufficient detail to provide meaningful 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, caries (including white-spot lesions), and existing restorations. The examination also should provide an educational experience for both the child and the parent. The child/parent should be made aware of age-related caries-risk and caries-protective factors, as well as the benefits of a dental home. Because a child’s risk for developing dental disease changes and oral diseases are cumulative and progressive, the AAPD also supports such legislation to include subsequent comprehensive oral examinations at periodic intervals throughout the educational process. In addition, the AAPD 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, work toward improved oral health and school readiness for all children, and address related issues such as barriers to oral health care. The AAPD recognizes that, without appropriate follow-up care, requiring oral health examinations is insufficient to ensure school readiness. Thus, the AAPD encourages local leaders to establish a referral system to help parents obtain needed oral health care for their children. The AAPD opposes regulations that would prevent a child from attending school due to noncompliance with mandated examinations.

References 1. US Dept of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

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2. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatr Dent 2007;29(suppl):102-8. 3. American Academy of Pediatrics. School health assessment. Pediatrics 2000;105(4Pt1):875-7. 4. National Center for Fluoridation Policy and Research. University of Buffalo School of Dental Medicine. Available at: “http://www.fluoride.oralhealth.org”. Accessed December 23, 2007. 5. CDC. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50(RR14):1-42. 6. Burt B, Eklund S. Dentistry, Dental Practice, and the Community. Philadelphia, Pa: WB Saunders Company; 1999. 7. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2007;29(suppl):22-3. 8. Poland C. Pediatric oral health. In: Burns CE, Brady MA, Dann AM, Starr N, eds. Pediatric Primary Care: A Handbook for Nurse Practitioners. 2nd ed. Philadelphia, Pa: WB Saunders Co; 2000. 9. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2007;29(suppl):81-4. 10. National Center for Education in Maternal and Child Health and Georgetown University. Fact sheet: Oral health and learning. Arlington, Va: NCEMCH; 2001. 11. Center on Hunger, Poverty, and Nutrition Policy. Statement on the link between nutrition and cognitive development in children. Medford, Ma: Tufts University, Center on Hunger, Poverty, and Nutrition Policy; 1998, 4th ed. 12. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14(5):302-5. 13. Bogden JF, Vega-Matos CA. Fit, healthy, and ready to learn: A school health policy guide, part 1: Physical activity, healthy eating, and tobacco-use prevention. Alexandria, Va: National Association of State Boards of Education; 2000. 14. US Dept of Health and Human Services. Oral health in America: A report of the Surgeon General–Executive summary. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000:12.


Policy on School Absences for Dental Appointments Originating Council Council on Clinical Affairs

Adopted 2010

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes dental care as 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. It also is intended to assist parents in making informed decisions.

Methods This policy is based on a review of current dental, medical, educational, and public health literature and state statutes and regulations related to student absence for dental appointments. An electronic search was conducted using the search parameters: Terms: “school absences for dental appointments”, “excused school absences”, and “department of education”; Fields: all fields; Limits: within the last 10 years; humans; English. 841 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, recommendations 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. Oral conditions can interfere with eating and adequate nutritional intake, speaking, self-esteem, and daily activities.1 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.2 The public’s lack of awareness of the importance of oral health is a major barrier to dental care.3 Unrecognized disease and postponed care result in exacerbated problems, which lead to more extensive and costly treatment needs.2 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 with dental pain may be irritable, withdrawn, or unable to concentrate. Pain can affect

test performance as well as school attendance.3 Left untreated, the pain and infection caused by tooth decay can lead to problems in eating, speaking, and learning.5 In 1996, students aged 5 to 17 years missed an average of 3.1 days/100 students due to acute dental problems.1 When these problems are treated and children no longer are experiencing pain, their learning and school attendance improve.1 According to the US Surgeon General, “a national public health plan for oral health does not exist”.3 This corresponds with the fact that there is no national policy on excused absences from school for dental appointments. Some states (eg, California, Texas) have very specific laws excusing students for dental appointments.6,7 Other state laws are more general and recognize absences due to doctor’s appointments or illness.8,9

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. Schools’ 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 dental conditions corrected improve their 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 AAPD: 1. Supports state law or school policy that allows the absence for legitimate healthcare delivery, including that of oral health services. 2. Encourages parents, school administrators, and dentists to work together to ensure that children receive dental care while minimizing school absences.


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References 1. 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://www.collierhealthdept.org/pdf/dental/oral healthlearning.pdf\”. Accessed October 21, 2009. 2. American Academy of Pediatric Dentistry. Policy on medically necessary care. Pediatr Dent 2009;31(special issue):16-20. 3. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000:12. 4. Bogden JF, Vega-Matos CA. Fit, healthy, and ready to learn: A school health policy guide, part 1: Physical activity, healthy eating, and tobacco-use prevention. Alexandria, Va: National Association of State Boards of Education; 2000.

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5. US General Accounting Office. Oral Health; Dental Disease is a Chronic Problem Among Low-income and Vulnerable Populations. Washington, DC; US General Accounting Office. 2000. 6. California Education Code. Available at: “http://Law. Onecle.com/california/education/48205.html”. Accessed March 8, 2010. 7. Texas Education Code. Available at: “http://law.onecle. com/Texas/education/25.087.00.html”. Accessed March 8, 2010. 8. Georgia Department of Education. Available at: “http:// www.doeK12.ga.us/_documents/doe/legalservices/1605-1-.10pdf ”. Accessed March 8, 2010. 9. Michigan Department of Education. Available at: “http: //www.Michigan.gov/documents/mde/compulsory_ attendance_257944_7.pdf ”. Accessed March 8, 2010.


Policy on Emergency Oral Care for Infants, Children, and Adolescents Originating Committee

Policy and Review Committee Review Council Council on Clinical Affairs

Adopted 1976

Revised 1993, 2000, 2003

Reaffirmed 1996, 2007

The American Dental Association’s Principles of Ethics and Code of Professional Conduct states that emergency care is an essential duty of every dentist.1 A dentist who accepts an infant, child, or adolescent as a patient of record shall make reasonable arrangements for emergency oral/dental care, along with providing instructions to the parent for accessing emergency care. When consulted in an emergency by patients not of record, the dentist should make reasonable arrangements for emergency care.

Reference 1. American Dental Association. Principles of Ethics and Code of Professional Conduct. Available at: “http://www. ada.org/prof/prac/law/code/index.asp”. Accessed February 28, 2007.


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Policy on Use of Fluoride Originating Committee

Liaison with Other Groups Committee Review Council Council on Clinical Affairs

Adopted 1967

Revised 1978, 1995, 2000, 2001, 2003, 2007, 2008

Reaffirmed 1977

Purpose The American Academy of Pediatric Dentistry (AAPD), affirming that fluoride is a safe and effective adjunct in reducing the risk of caries and reversing enamel demineralization, encourages public health officials, health care providers, and parents/ caregivers to optimize fluoride exposure.

Methods A MEDLINE search was conducted using the terms “fluoride”, “fluoridation”, “acidulated phosphate fluoride”, “fluoride varnish”, “fluoride therapy”, and “topical fluoride”. Expert opinions and best current practices also were relied upon for this guideline.

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.1 Epidemiologic data within the last half-century indicate reductions in caries of 55 to 60% and recent data still shows caries reduction of approximately 25%, without significant enamel fluorosis, when domestic water supplies are fluoridated at an optimal level.2 Evidence accumulated from long-term use of fluorides has demonstrated that the cost of oral health care for children can be reduced by as much as 50%.3 These savings in health dollars accrue to private individuals, group purchasers, and government care programs. An even higher caries reduction can be obtained if the proper use of fluorides is combined with other dietary, oral hygiene, and preventive measures4,5 as prescribed by a dentist familiar with the child’s oral health and family history. A large body of literature supports the incorporation of optimal fluoride levels in drinking water supplies. When fluoridation of drinking water is impossible, effective systemic fluoridation can be achieved through the intake of daily fluoride supplements. Before supplements are prescribed, it is essential to review dietary sources of fluoride (eg, all drinking water sources, consumed beverages, prepared food, toothpaste) to determine

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the patient’s true exposure to fluoride.1,6-9 Fluoride content of ready to use infant formulas in the US and Canada ranges from 0.1 to 0.3 mg/L10, which provides only a modest source of fluoride. Non-milk based formulas have higher fluoride content because the calcium that is added to formula contains fluoride. The more important issue, however, is the fluoride content of concentrated or powdered formula when reconstituted with fluoridated water. Considering the potential for mild fluorosis, caution is advised for infants consuming formula that is reconstituted with optimally-fluoridated water. Significant cariostatic benefits can be achieved by the use of fluoride-containing preparations such as toothpastes, gels, and rinses, especially in areas without water fluoridation.11 Monitoring children’s use of topical fluoride-containing products, including toothpaste, may prevent ingestion of excessive amounts of fluoride.12 A number of clinical trials have confirmed the anticaries effect of professional topical fluoride treatments, including 5% neutral sodium fluoride varnish.13,14 Fluoride varnishes can prevent or reverse enamel demineralization.15 In children with moderate to high caries risk, fluoride varnishes14,16 and fluoridereleasing restorative and bonding materials have been shown to be beneficial and are best utilized as part of a comprehensive preventive program in the dental home.17-19

Policy statement 1. The AAPD endorses and encourages the adjustment of fluoride content of domestic community water supplies to optimal levels where feasible. 2. When fluoride levels in community water supplies are suboptimal, and after consideration of sources of dietary fluoride, the AAPD endorses the supplementation of a child’s diet with fluoride according to the guidelines jointly recommended by the AAPD8, the American Academy of Pediatrics20, and the American Dental Association (ADA)21 and endorsed by the Centers for Disease Control and Prevention.1


3. The AAPD encourages dental professionals to inform medical peers of the potential of enamel fluorosis when excess fluoride is ingested prior to enamel maturation. 4. The AAPD encourages continued research on the causes of enamel fluorosis. 5. The AAPD does not support the use of prenatal fluoride supplements.19 6. The AAPD recommends an individualized patient cariesrisk assessment before prescribing the use of supplemental fluoride-containing products.8,22 7. The AAPD encourages the continued research on safe and effective fluoride products, including fluoride-releasing restorative materials. 8. The AAPD supports the delegation of fluoride application to auxiliary dental personnel, or other trained allied health professionals, by prescription or order of a qualified dentist, after a comprehensive oral examination has been performed. 9. The AAPD endorses ADA 2002 House of Delegates Resolution 67H to encourage labeling of bottled water with the fluoride concentration and company contact information. 23 The resolution also supports including information with each home water treatment system on the system’s effects on fluoride levels. 10. The AAPD encourages all beverage and infant formula manufacturers to include fluoride concentration with the nutritional content on food labels. 11. The AAPD encourages dentists and other health care providers to educate parents that both infant formula and the water used to reconstitute the formula may contain fluoride. Dentists and other health care providers, therefore, should assist parents in determining the infant’s fluoride exposure.

References 1. CDC. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50(RR14):1-42. 2. CDC. Achievements in public health, 1900-1999: Fluoridation of drinking water to prevent dental caries. MMWR 1999;48(12):933-40. 3. Griffen SO, Jones K, Tomar, SL. An economic evaluation of community water fluoridation. J Pub Health Dent 2001;61(2):78-86. 4. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc 2000;131(7):887-99. 5. Burrell KH, Chan JT. Systemic and topical fluorides. In: Ciancio SG, ed. ADA Guide to Dental Therapeutics. 2nd ed. Chicago, Ill: ADA Publishing; 2000:230-41. 6. Levy SM, Kohout FJ, Kiritsy MC, Heillman JR, Wefel JS. Infants’ fluoride ingestion from water, supplements, and dentifrice. J Am Dent Assoc 1995;126(12):1625-32.

7. Bowen WH. Fluorosis, is it a problem? J Am Dent Assoc 2002;133(10):1405-7. 8. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent 2008;30(suppl):121-4. 9. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006:28(2): 133-42. 10. Foman SJ, Ekstrand J. Fluoride intake. In Fejerskov O, Ekstrand J, Burt BA eds. Fluoride in Dentistry, 2 nd ed. Copenhagen: Munksgaard; 1996:40-52. 11. Forsyth Dental Center – Report on the Remineralization Symposium 22-24, June 1999. Emerging issues and future directions in remineralization. J Clin Dent 1999;10 (special issue):55-93. 12. Warren JJ, Levy SM. A review of fluoride dentifrice related to dental fluorosis. Pediatr Dent 1999;21(4):265-71. 13. B eltran-Aguilar E, Goldstein J. Fluoride varnishes: A review of their clinical use, cariostatic mechanisms, efficacy, and safety. J Am Dent Assoc 2000;131:589-96. 14. 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. 15. Castellano JB, Donly KJ. Potential remineralization of demineralized enamel after application of fluoride varnish. Am J Dent 2004;17(6):462-4. 16. Hicks J, García-Godoy F, Donly K, Flaitz C. Fluoridereleasing restorative materials and secondary caries. Dent Clin North Am 2002;46(2):247-76, vi. 17. Nowak AJ, Casamassimo PS. The dental home: A primary care oral health concept. J Am Dent Assoc 2002;133(1): 93-8. 18. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2006;28(suppl):17-8. 19. L everett DH, Adair SM, Vaughan BM, Proskin HM, Moss ME. Randomized clinical trial of the effect of prenatal fluoride supplements in preventing dental caries. Caries Res 1997;31(3):174-9. 20. American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation for children: Interim policy recommendations. Pediatrics 1995;95(5):777. 21. Meskin LH, ed. Caries diagnosis and risk assessment: A review of preventive strategies and management. J Am Dent Assoc 1995;126(suppl):1-24. 22. American Academy of Pediatric Dentistry. Policy on use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent 2006;28(suppl):24-8. 23. A merican Dental Association. House of Delegates Resolution 67H: Chicago, Ill; 2002.


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Policy on the Use of Xylitol in Caries Prevention Originating Council



Revised 2010

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes the benefits of caries preventive strategies involving sugar substitutes, particularly xylitol, on the oral health of infants, children, adolescents, and persons with special health care needs. This policy is intended to assist oral health care professionals make informed decisions about the use of xylitol-based products in caries prevention.

Methods This policy is an update of the previous policy, adopted in 2006. The update is based upon a review of current dental and medical literature related to the use of xylitol in caries prevention. A MEDLINE literature search was conducted using PubMed with the following parameters: Terms: “xylitol” AND “caries prevention”; Field: all fields; Limits: within the last 10 years; humans, English; birth through 18. Two hundred forty articles matched these criteria; 25 papers were reviewed at 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 Xylitol is a five-carbon sugar alcohol derived primarily from forest and agricultural materials. It has been used since the early 1960’s in infusion therapy for post-operative, burn, and shock patients; in the diet of diabetic patients; and, most recently, as a sweetener in products aimed at improved oral health.1 Dental benefits of xylitol first were recognized in Finland in 1970, using animal models.2 The first chewing gum developed with the aim of reducing caries and improving oral health was released in Finland in 1975 and in the United States shortly after. The first xylitol studies in humans, known as the Turku Sugar Studies,3,4 demonstrated the relationship between dental plaque and xylitol, as well as the safety of xylitol for human consumption. These early studies showed the decayed, missing, and filled (dmf) incidence in teeth in a sucrose chewing-gum group was 2.92 compared to 1.04 in the xylitol gum group. The most comprehensive study with xylitol gum,

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conducted in 1995, compared the effect on caries incidence for xylitol, sorbitol, and sucrose consumption.5 The group that received 100% xylitol gum 5 times/day had significantly lower levels of sucrose and free sialic acid in whole saliva than at baseline and significantly lower plaque index scores.5 The xylitol group also exhibited the lowest levels of salivary lactobacilli at endpoint, and this group did not experience the age-related increase in Mutans streptococci (MS) as did the other groups.5 Xylitol studies show varying results in the reduction of the incidence of caries or MS levels.5-13 Studies suggest xylitol intake that consistently produces positive results ranged from 4-10 grams per day divided into 3 to 7 consumption periods.5-12 Higher amounts did not result in greater reduction in incidence of caries and may lead to diminishing anticariogenic results.5-13 Similarly, consumption frequency of less than 3 times per day at optimal xylitol amount showed no effect.14-16 Abdominal distress and osmotic diarrhea have been reported following the ingestion of xylitol.17-18 Diarrhea has been reported in patients who have consumed 3-60 grams of xylitol per day.19-23 Xylitol reduces plaque formation and bacterial adherence (ie, is antimicrobial), inhibits enamel demineralization (ie, reduces acid production), and has a direct inhibitory effect on MS. Prolonged use of xylitol appears to select for a “xylitolresistant” mutant of the MS cells.24 These mutants appear to shed more easily into saliva than the parent strains,23 resulting in a reduction of MS in plaque26 and possibly hampering their transmission/colonization from mother to child. Long-lasting effects have been demonstrated up to 5 years after 2 years of using xylitol chewing gum.27-28 Use of xylitol gum by mothers (2-3 times per day starting 3 months after delivery and until the child was 2 years old) reduced the MS levels in children up to 6 years of age and was significantly better than applying fluoride varnish or chlorhexidine varnish at 6, 12, and 18 months after delivery. At 5 years of age, the xylitol group had 70% reduction in caries (dmf ) as compared with the varnish and chlorhexidine groups. Fluoride varnish alone had little effect on total salivary levels of MS.27 Some studies suggest the chewing process may enhance the caries inhibitory effect of xylitol chewing gum.28-31


Xylitol currently is available in many forms (eg, gums, mints, chewable tablets, lozenges, toothpastes, mouthwashes, cough mixtures, nutraceutical products).32-33 Xylitol chewing gum has been shown to be effective as a preventive agent. The effectiveness of other xylitol products is being studied at this time.

Policy statement The AAPD: 1. supports the use of xylitol as part of a preventive strategy aimed specifically at long term caries pathogen suppression and caries (dmf ) reduction in higher risk populations. 2. recommends that, as further research and evidence-based knowledge is available, protocols be established to further clarify the impact of delivery vehicles, the frequency of exposure, and the optimal dosage to reduce caries and improve the oral health of children. 3. encourages xylitol-containing products be labeled clearly with regard to their xylitol content to enable dentists and consumers to ensure therapeutic levels of exposure.31

References 1. 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. 2. Muhlemann HR, Regolati B, Marthaler TM. The effect on rat fissure caries of xylitol and sorbitol. Helv Odontol Acta 1970;14(1):48-50. 3. Scheinin A, Mäkinen KK, Tammisalo E, Rekola M. Turku sugar studies. XVIII. Incidence of dental caries in relation to 1-year consumption of xylitol chewing gum. Acta Odontol Scand 1975;33(5):269-78. 4. 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. 5. Mäkinen KK, Benett CA, Hujoel PP, et al. Xylitol chewing gums and caries rates: A 40-month cohort study. J Dent Res 1995;74(12):1904-13. 6. Mäkinen KK, Hujoel PP, Bennett CA, et al. A descriptive report of the effects of a 16-month xylitol chewing-gum programme subsequent to a 40-month sucrose gum programme. Caries Res 1998;32(2):107-12. 7. Milgrom P, Ly KA, Roberts M, Rothen M, Mueller G, Yamaguchi DK. Mutans Streptococci dose response to Xylitol chewing gum. J Dent Res 2006;85(2):177-81. 8. Hujoel PP, Mäkinen KK, Bennett CA, et al. The optimum time to initiate habitual xylitol gum-chewing for obtaining long-term caries prevention. J Dent Res 1999; 78(3):797-803. 9. Mäkinen KK. The rocky road of xylitol to its clinical application. J Dent Res 2000;79(6):1352-5.

10. Mäkinen KK, Chiego DJ Jr, Allen P, et al. Physical, chemical, and histologic changes in dentin caries lesions of primary teeth induced by regular use of polyol chewing gums. Acta Odontol Scand 1998;56(3):148-56. 11. Mäkinen KK, Mäkinen PL, Pape HR, et al. Conclusion and review of the Michigan Xylitol Programme (19861995) for the prevention of dental caries. Int Dent J 1996;46(1):22-34. 12. Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: A systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc 2008;139(12):1602-14. 13. Stecksén-Blicks C, Holgerson PL, Twetman S. Effect of xylitol and xylitol-fluoride lozenges on approximal caries development in high caries-risk children. Int J Paediatr Dent 2008;18(3):170-7. 14. Isokangas P. Xylitol chewing gum in caries prevention. A longitudinal study on Finnish school children. Proc Finn Dent Soc 1987;83(suppl 1):1-117. 15. Rekola M. Correlation between caries incidence and frequency of chewing gum sweetened with sucrose or xylitol. Proc Finn Dent Soc 1989;85(1):21-4. 16. Thaweboon S, Thaweboon B, Soo-Ampon S. The effect of xylitol chewing gum on mutans streptococci in saliva and dental plaque. Southeast Asian J Trop Med Public Health 2004;35(4):1024-7. 17. Scheie AA, Fijerskov O. Xylitol in caries prevention: What is evidence for clinical efficacy? Oral Dis 1998;4(4): 268-78. 18. Mäkinen KK. Dietary prevention of dental caries by xylitol – Clinical effectiveness and safety. J Appl Nutr 1992;44:16-28. 19. Akerblom HK, Koivukangas T, Puuka R, Mononen M. The tolerance of increasing amounts of dietary xylitol in children. Int J Vitam Nutr Res Suppl 1982;22:53-66. 20. Giertsen E, Emberland H, Scheie AA. Effects of mouth rinses with xylitol and fluoride on dental plaque and saliva. Caries Res 1999;33(1):23-31. 21. Salminen EK, Salminen SJ, Porkka L, Kwasowski P, Marks V, Koivistoinen PE. Xylitol vs glucose: Effect on the rate of gastric emptying and motilin, insulin, and gastric inhibitory polypeptide release. Am J Clin Nutr 1989; 49(6):1228-32. 22. Uhari M, Kontiokari T, Koskela M, Niemela M. Xylitol chewing gum in prevention of acute otitis media: Double blind randomized trial. Brit Med J 1996;313(7066): 1180-4. 23. Waler SM, Rolla G. [Xylitol, mechanisms of action and uses]. Nor Tannelaegeforen Tid 1990;100(4):140-3. 24. Trahan L, Mouton C. Selection for Streptococcus mutans with an altered xylitol transport capacity in chronic xylitol consumers. J Dent Res 1987;66(5):982-8.


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25. Trahan L, Söderling E, Dréan MF, Chevrier MC, Isokangas P. Effect of xylitol consumption on the plaquesaliva distribution of mutans streptococci and the occurrence and long-term survival of xylitol-resistant strains. J Dent Res 1992;71(11):1785-91. Erratum in: J Dent Res 1993;72(1):87-8. 26. Söderling E, Trahan L, Tammiala-Salonen T, Hakkinen L. Effects of xylitol, xylitol-sorbitol, and placebo chewing gums on the plaque of habitual xylitol consumers. Eur J Oral Sci 1997;105(2):170-7. 27. Söderling E, Isokangas P, Pienihakkinen K, Tenovuo J, Alanen P. Influence of maternal xylitol consumption on mother-child transmission of mutans streptococci: 6 year follow-up. Caries Res 2001;35(3):173-7. 28. Mäkinen KK, Alanen P, Isokangas P, et al. Thirty-nine month xylitol chewing gum programme in initially 8year-old school children: A feasibility study focusing on mutans streptococci and lactobacilli. Int Dent J 2008; 58(1):41-50.

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29. Machiulskiene V, Nyvad B, Baelum V. Caries preventive effect of sugar-substituted chewing gum. Community Dent Oral Epidemiol 2001;29(4):278-88. 30. Scheie AA, Fejerskov O, Danielsen B. The effects of xylitol-containing chewing gums on dental plaque and acidogenic potential. J Dent Res 1998;77(7):1547-52. 31. Van Loveren C. Sugar alcohols: What is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-93. 32. Ly KA, Milgrom P, Rothen M. Xylitol, sweeteners, and dental caries. Pediatr Dent 2006;28(2):154-63. Discussion 92-8. 33. Lynch H, Milgrom P. Xylitol and dental caries: An overview for clinicians. J Calif Dent Assoc 2003;31:205-9.


Policy on Interim Therapeutic Restorations (ITR) Originating Council

Council on Clinical Affairs Review Council


Revised 2004, 2008

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 circumstances do not permit traditional cavity preparation and/or placement of traditional dental restorations or when caries control is necessary prior to placement of definitive restorations, interim therapeutic restorations (ITR)1 may be beneficial and are best utilized as part of comprehensive care in the dental home.2,3 This policy will differentiate ITR from atraumatic/alternative techniques (ART)4 and describe the circumstances for its use.

Methods This policy is based upon a review of current dental literature. A MEDLINE search was performed using key words “dental caries”, “atraumatic restorative treatment”, and “glass ionomer cement”.

Background Atraumatic/alternative restorative technique (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 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 US. ITR may be used to restore and prevent further decalcification and caries in young patients, uncooperative patients, or patients with special health care needs or when traditional cavity preparation and/or placement of traditional dental restorations are not feasible and need to be postponed.5,6 Additionally, ITR may be used for step-wise excavation in children with multiple open carious lesions prior to definitive restoration of the teeth.7

The use of ITR has been shown to reduce the levels of cariogenic oral bacteria (eg, mutans streptococci, lactobacilli) in the oral cavity.8-10 The ITR procedure involves removal of caries using hand or slow speed 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 self-setting or resin-modified glass ionomer cement.11 ITR has the greatest success when applied to single surface or small 2 surface restorations.12,13 Inadequate cavity preparation with subsequent lack of retention and insufficient bulk can lead to failure.12 Follow-up care with topical fluorides and oral hygiene instruction may improve the treatment outcome in high caries-risk dental populations.

Policy statement The AAPD recognizes ITR as a beneficial provisional technique in contemporary pediatric restorative dentistry. ITR may be used to restore and prevent dental caries in young patients, uncooperative patients, patients with special health care needs, and situations in which traditional cavity preparation and/or placement of traditional dental restorations are not feasible. ITR may be used for caries control in children with multiple carious lesions prior to definitive restoration of the teeth.

References 1. American Academy of Pediatric Dentistry. Guideline on pediatric restorative dentistry. Pediatr Dent 2008:30 (suppl):163-9. 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. Pediatr Dent 2007;29(suppl):22-3. 4. 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.


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5. Louw AJ, Sarvan I, Chikte UME, Honkala E. One-year evaluation of atraumatic restorative treatment and minimum intervention techniques on primary teeth. South African Dent J 2002;57(9):366-71. 6. Lo ECM, Holmgren CJ. Provision of atraumatic restorative treatment (ART) restorations to Chinese preschool children: A 30-month evaluation. International J Paediatr Dent 2001;11(1):3-10. 7. 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. 8. Castro A, Feigal RF. Microleakage of a new improved glass ionomer restorative material in primary and permanent teeth. Pediatr Dent 2002;24(1):23-8.

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9. Grossman ES, Mickenautsch S. Microscope observations of ART excavated cavities and restorations. South African Dent J 2002;57(9):359-63. 10. Croll TP, Nicholson JW. Glass ionomer cements in pediatric dentistry: Review of the literature. Pediatr Dent 2002;24(5):423-9. 11. Berg JH. Glass ionomer cements. Pediatr Dent 2002;24 (5):430-7. 12. Castro A, Feigal RF. Microleakage of a new improved glass ionomer material in primary and permanent teeth. Pediatr Dent 2002;24(1):23-7.


Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies Originating Group A collaborative effort of the American Academy of Pediatric Dentistry and the American Academy of Pediatrics


Adopted 1978

Revised 1993, 1996, 2001, 2003, 2007, 2008

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes early childhood caries (ECC; formerly termed “nursing bottle caries”, “baby bottle tooth decay”) as a significant public health problem.1 The AAPD encourages oral health care providers and caregivers to implement preventive practices that can decrease a child’s risks of developing this devastating disease.

Methods This policy revision is based on a review of the current pediatric dental, medical, and public health literature related to ECC, including proceedings of the 2005 Symposium on the Prevention of Oral Diseases in Children and Adolescents, Chicago, Ill.1 A MEDLINE search was conducted using the terms “early childhood caries”, “nursing caries”, and “baby bottle caries”. Preventive recommendations were based primarily upon review of published studies and proceedings. In cases where the data did not appear sufficient or were inconclusive, recommendations were based upon expert and consensus opinion.

Background In 1978, the AAPD released “Nursing Bottle Caries”, a joint statement with the American Academy of Pediatrics, to address a severe form of caries associated with bottle usage.2 Initial policy recommendations were limited to feeding habits, concluding 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 2 decades, however, recognizing that this distinctive clinical presentation was not consistently associated with poor feeding practices and that caries was an infectious disease, AAPD adopted the term “early childhood caries” to reflect better its multifactoral etiology. Caries is a common, complex, chronic disease resulting from an imbalance of multiple risk factors and protective factors over time.3 Fundamentally, caries is biofilm (plaque)-induced acid demineralization of enamel or dentin, mediated by saliva.

Given time, the interaction of cariogenic microorganisms and fermentable carbohydrates (sucrose) may induce demineralization, which can progress to loss of tooth structure/cavitation.4 The disease of ECC has been defined as “the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces” in any primary tooth in a child 71 months of age or younger.5,6 In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC.7 Caries is a transmissible infectious disease; understanding the acquisition of cariogenic microbes is necessary to improving preventive strategies. Vertical transmission is the passing of microbes from caregiver to child, and the major reservoir from which infants acquire cariogenic bacteria [eg, mutans streptococci (MS)] is their mother’s saliva.4,8 The success of the transmission and resultant colonization of maternal MS may be related to several factors, including magnitude of the inoculum,9 frequency of small dose inoculations,10 and a minimum infective dose.11 Infants whose mothers have high levels of MS, a result of untreated caries, are at greater risk of acquiring the organism earlier than children whose mothers have low levels.9 Suppressing maternal reservoirs of MS via dental rehabilitation and antimicrobial treatments can prevent or delay infant inoculation.12,13 Ideally, these interventions would be initiated in the prenatal period.14 Horizontal transmission (eg, between members of a family or group such as daycare) of MS also occurs.8 Eliminating saliva-sharing activities (ie, sharing utensils, orally cleansing a pacifier) may help decrease an infant’s or toddler’s acquisition of cariogenic microbes. Recent studies have shown that MS can colonize the mouths of predentate infants.8 Oral cleanings following feedings, if not previously implemented, need to begin with eruption of the first primary tooth.14 Newly-erupted teeth, because of immature


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enamel, and teeth with enamel hypoplasia may be at higher risk of developing caries. Current best practice includes recommending twice-daily use of a fluoridated toothpaste for dentate children in optimally fluoridated and fluoride-deficient communities.15 Therapeutic use of fluoride for children needs to focus on regimens that maximize topical contact, preferably in lower-dose, higher-frequency approaches.15 Twice-daily use has benefits greater than once-daily brushing.15 A ‘smear’ of fluoridated toothpaste (see Figure 1) for children less than 2 years of age may decrease risk of fluorosis.16 A ‘pea-size’ amount of toothpaste is appropriate for children aged 2 through 5 years.16-18 Parents should dispense the toothpaste onto a soft, age-appropriate 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.16,19

Figure 1. Comparison of a smear (left) with a pea-sized (right) amount of toothpaste.

In addition to the establishment of oral flora, infants and young children have other unique caries-risk factors including development of dietary habits and childhood food preferences. High-risk dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood.20,21 The role of carbohydrates in caries initiation is unequivocal. Frequent bottle feeding at night, breastfeeding ad libitum, and extended and repetitive use of a no-spill training cup are associated with, but not consistently implicated in, ECC.22 While ECC may not arise from breast milk alone, breast feeding in combination with other carbohydrates has been found in vitro to be highly cariogenic.23 Frequent consumption of between-meal snacks and beverages containing fermentable carbohydrates (eg, juice, milk, formula, soda) increases the risk of caries due to prolonged contact between sugars in the consumed food or liquid and cariogenic bacteria on the susceptible teeth.24 The American Academy of Pediatrics has recommended children 1-6 years of age consume no more than 4-6 ounces of fruit juice per day, from a cup (ie, not a bottle or covered cup) and as part of a meal or snack.25 Children are at varying levels of risk for developing caries throughout life. Evidence increasingly suggests that to be successful at preventing dental disease, dentists must begin preventive interventions within the first year of life.26 Consequences

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of ECC include a higher risk of new carious lesions in both the primary and permanent dentitons,27-32 hospitalizations and emergency room visits,33-36 increased treatment costs and time,37,38 insufficient physical development (especially in height/ weight),39,40 loss of school days and increased days with restricted activity,41-43 diminished ability to learn,41,44-47 and diminished oral health-related quality of life.48-51

Policy statement The AAPD recognizes caries as a common, complex, chronic disease resulting from an imbalance of multiple risk factors and protective factors over time. To decrease the risk of developing ECC, a potentially devastating infectious disease, the AAPD encourages professional and at-home preventive measures including age-appropriate feeding practices that do not contribute to a child’s caries risk. These include: 1. Reducing the mother’s/primary caregiver’s/sibling(s) MS levels (ideally during the prenatal period) to decrease transmission of cariogenic bacteria. 2. Minimizing saliva-sharing activities (eg, sharing utensils) between an infant or toddler and his family/cohorts. 3. Implementing oral hygiene measures no later than the time of eruption of the first primary tooth. • If an infant falls asleep while feeding, the teeth should be cleaned before placing the child in bed. • Toothbrushing of all dentate children should be per formed twice daily with a fluoridated toothpaste and a soft, age-appropriate sized toothbrush. Parents should use a ‘smear’ of toothpaste to brush the teeth of a child less than 2 years of age. For the 2-5 year old, parents should dispense a ‘pea-size’ amount of toothpaste and perform or assist with their child’s toothbrushing. • Flossing should be initiated when adjacent tooth surfaces can not be cleansed by a toothbrush. 4. Establishing a dental home within 6 months of eruption of the first tooth and no later than 12 months of age to conduct a caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases. 5. Avoiding caries-promoting feeding behaviors. In particular: • Infants should not be put to sleep with a bottle con taining fermentable carbohydrates. • Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced. • Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle at 12 to 14 months of age. • Repetitive consumption of any liquid containing fer mentable carbohydrates from a bottle or no-spill training cup should be avoided. • Between-meal snacks and prolonged exposures to foods and juice or other beverages containing fermentable carbohydrates should be avoided.


References 1. American Academy of Pediatric Dentistry. Symposium on the prevention of oral disease in children and adolescents. Chicago, Ill; November 11-12, 2005: Conference papers. Pediatr Dent 2006;28(2);96-198. 2. American Academy of Pedodontics and American Academy of Pediatrics. Nursing bottle caries. January, 1978. Chicago, Ill. 3. Crall JJ. Rethinking prevention. Pediatr Dent 2006;28(2): 96-101. 4. Loescshe WJ. Dental caries: A treatable infection. Grand Haven, Mich; Automated Diagnostic Documentation, Inc.; 1993. 5. Kaste LM, Drury TF, Horowitz AM, Beltran E. An evaluation of NHANES III estimates of early childhood caries. J Public Health Dent 1999;59(3):198-200. 6. 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. 7. Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of early childhood caries. J Public Health Dent 1999;59(3):171-91. 8. Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent 2006;28(2):106-9. 9. Berkowitz RJ, Turner J, Green P. Maternal salivary levels of Streptococcus mutans and primary oral infection in infants. Arch Oral Biol 1981;26(2):147-9. 10. Loesche WJ. Role of Streptococcus mutans in human dental decay. Microbiol Rev 1986;50(4):353-80. 11. Van Houte J, Green DB. Relationship between the concentration of bacteria in saliva and colonization of teeth in humans. Infect Immun 1974;9(4):624-30. 12. Köhler B, Bratthall D, Krasse B. Preventive measures in mothers influence the establishment of the bacterium Streptococcus mutans in their infants. Arch Oral Biol 1983; 28(3):225-31. 13. Isokangas P, Söderling E, Pienihäkkinen K, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0 to 5 years of age. J Dent Res 2000;79(11):1885-9. 14. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2008;30(suppl):90-3. 15. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2): 133-42. 16. Scottish Intercollegiate Guideline Network. Prevention and Management of Dental Decay in the Pre-school Child. A National Guideline #83. November 2005;1-44. Available at: “http://www.sign.ac.uk/pdf/qrg83.pdf ”. Accessed March 30, 2008. 17. Pang DT, Vann WF Jr. The use of fluoride-containing toothpastes in young children: The scientific evidence for recommending a small quantity. Pediatr Dent 1992;14: 384-7.

18. Ramos-Gomez FJ, Crall JJ, 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. 19. Sjögren K, Birkhed D: Factors related to fluoride retention after toothbrushing and possible connection to caries activity. Caries Res 1993;27(6):474-7. 20. Douglass JM. Response to Tinanoff and Palmer: Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 2000; 60(3):207-9. 21. Kranz S, Smiciklas-Wright H, Francis LA. Diet quality, added sugar, and dietary fiber intake in American preschoolers. Pediatr Dent 2006;28(2)164-71. 22. Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Comm Dent Oral Epidem 1998;26(suppl 1):32-44. 23. Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent 1999;21(2):86-90. 24. Marino R, Bonze K, Scholl T, Anhalt H. Nursing bottle caries: Characteristics of children at risk. Clin Pediatr 1989;28(3):129-31. 25. American Academy of Pediatrics Committee on Nutrition. Policy statement: The use and misuse of fruit juices in pediatrics. Pediatrics 2001;107(5):1210-3. Reaffirmed October, 2006. 26. Lee JY, Bouwens TJ, Savage MF, Vann WF. Examining the cost-effectiveness of early dental visits. Pediatr Dent 2006;28(2):102-105, discussion 192-8. 27. Grindefjord M, Dahllöf G, Modéer T. Caries development in children from 2.5 to 3.5 years of age: A longitudinal study. Caries Res 1995;29(6):449-54. 28. O’Sullivan DM, Tinanoff N. The association of early childhood caries patterns with caries incidence in preschool children. J Public Health Dent 1996;56(2):81-3. 29. Johnsen DC, Gerstenmaier JH, DiSantis TA, Berkowitz RJ. Susceptibility of nursing-caries children to future approximal molar decay. Pediatr Dent 1986;8(3):168-70. 30. 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. 31. Gray MM, Marchment MD, Anderson RJ. The relationship between caries experience in deciduous molars at 5 years and in first permanent molars of the same child at 7 years. Community Dent Health 1991;8(1):3-7. 32. Heller KE, Eklund SA, Pittman J, Ismail AA. Associations between dental treatment in the primary and permanent dentitions using insurance claims data. Pediatr Dent 2000;22(6):469-74. 33. 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.


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34. Majewski RF, Snyder CW, Bernat JE. Dental emergencies presenting to a children’s hospital. J Dent Child 1988:55(5):339-42. 35. Fleming P, Gregg TA, Saunders ID. Analysis of an emergency dental service provided at a children’s hospital. Int J Paediatr Dent 1991;1(1):25-30. 36. Schwartz S. A one-year statistical analysis of dental emergencies in a pediatric hospital. J Can Dent Assoc 1994; 60(11):959-62, 966-8. 37. 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. 38. Ramos-Gomez FJ, Huang GF, Masouredis CM, Braham RL. Prevalence and treatment costs of infant caries in Northern California. ASDC J Dent Child 1996;63(2): 108-12. 39. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14(5):302-5. 40. Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight, and head circumference. J Clin Pediatr Dent 1996;20(3):209-12. 41. Reisine ST. Dental health and public policy: The social impact of disease. Am J Public Health 1985;75(1):27-30. 42. Gift HC, Reisine ST, Larach DC. The social impact of dental problems and visits. Am J Public Health 1992;82 (12):1663-8. 43. Hollister MC, Weintraub JA. The association of oral status with systemic health, quality of life, and economic productivity. J Dent Educ 1993;57(12):901-12.

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44. Peterson J, Niessen L, Nana Lopez G. Texas public school nurses’ assessment of children’s oral health status. J Sch Health 1999;69(2):69-72. 45. Schechter N. The impact of acute and chronic dental pain on child development. J Southeast Soc Pediatr Dent 2000;6:16. 46. Ramage S. The impact of dental disease on school performance. J Southeast Soc Pediatr Dent 2000;6:26. 47. National Center for Education in Maternal and Child Health and Georgetown University. Fact sheet: Oral health and learning. Arlington, Va: NCEMCH; 2001. 48. 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. 49. 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. 50. 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. 51. Filstrup SL, Inglehart MR, Briskie D, daFonseca M, Lawrence L, Wandera A. The effects on early childhood caries (ECC) and restorative treatment of children’s oral health-related quality of life (OHRQOL)–The parents’/ guardians’ and the child’s perspective [master’s thesis]. Ann Arbor, Mich: The University of Michigan; 2001.


Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options Originating Council Council on Clinical Affairs


Adopted 2000

Revised 2003, 2007, 2008

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 challenges and treatment options of this disease. This policy will not attempt to duplicate information found in the AAPD’s Guideline on Infant Oral Health Care.1

Methods The proceedings of the Conference on Early Childhood Caries held in Bethesda, Maryland in October, 1997 were reviewed. A MEDLINE search was conducted using the terms “early childhood caries”, “nursing caries”, and “bottle caries”. Recommendations were based primarily upon review of those proceedings and published studies. In cases where the data did not appear sufficient or were inconclusive, recommendations were based upon expert and consensus opinion.

Background Caries is biofilm (plaque)-induced acid demineralization of enamel or dentin, mediated by saliva. The disease of ECC is defined as “the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces” in any primary tooth in a child 71 months of age or younger.2 In children younger than 3 years of age, any sign of smoothsurface caries is indicative of severe early childhood caries (SECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or a decayed, missing, or filled score of >4 (age 3), >5 (age 4), or >6 (age 5) surfaces constitutes S-ECC.2 While the collective oral health of children has improved over the past several decades, between 1988-1994 and 19992004, prevalence of caries in primary teeth increased for youths aged 2 to 11 years.3 For 2 to 5 year olds, the prevalence increased from approximately 24% to 28%.3 ECC, a serious

public health problem, is prevalent in low socioeconomic groups, but also is found in the general population.3,4 ECC can be a particularly virulent form of caries, beginning soon after dental eruption, developing on smooth surfaces, progressing rapidly, and having a lasting detrimental impact on the dentition. Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in both the primary and permanent dentitions.5-8 Not only does ECC affect teeth, but consequences of this disease may lead to more widespread health issues.9,10 Infants with ECC grow at a slower pace than caries-free infants. Some young children with ECC may be severely underweight because of associated pain and the disinclination to eat. ECC also may be associated with iron deficiency.10 Prevention of ECC begins with intervention in the prenatal and perinatal periods.11 Women should be advised to optimize nutrition during the third trimester and the infant’s first year, when enamel is undergoing maturation. Enamel hypoplasia is common in children with low birthweight or systemic illness in the neonatal period.12,13 There is considerable presumptive evidence that malnutrition/undernutrition during the perinatal period causes hypoplasia.14 A consistent association exists between clinical hypoplasia and ECC.12,15 Cariogenic bacteria (specifically mutans streptococci) may be transmitted to the child; decreasing the mother’s/primary caregiver’s/ sibling(s)’ mutans streptococci levels may decrease the child’s risk of developing ECC.9,16-19 Motivational interviewing may help direct parents to improve home oral health habits.20,21 Frequent bottle feeding at night, ad libitum breast-feeding, and extended and repetitive use of a no-spill training cup are associated with, but not consistently implicated in, ECC.22 While ECC may not arise from breastmilk alone, breast-feeding in combination with other carbohydrates has been found to be highly cariogenic.23 The severity of ECC is associated with poor feeding habits.24 Because poor feeding practices alone will not cause caries, previously used terms such as “baby bottle tooth decay”, “bottle


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mouth”, and “nursing decay” are misleading. ECC is a term that better reflects the multifactorial etiologic process. 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, treatment should be specific for each individual patient. Areas of decalcification and hypoplasia can rapidly develop cavitation. The use of anticariogenic agents may reduce the risk of development and progression of caries. Interim therapeutic restorations (ITR), using materials such as glass ionomers that release fluoride, are efficacious in both preventive and therapeutic approaches.25,26 Stainless steel crowns are indicated to decrease the number of tooth surfaces at risk for new or secondary caries and are less likely than other restorations to require retreatment.27,28 Low levels of compliance with follow-up care and a high rate of children requiring additional treatment also can influence a practitioner’s decisions for a more definitive restorative management of ECC.29 The extent of the disease process as well as the patient’s developmental level and comprehension skills affect the practitioner’s behavior guidance approaches. To perform treatment effectively and efficiently while instilling a positive dental attitude, the practitioner caring for a child with ECC often must employ advanced behavior guidance techniques. These may include protective stabilization and/or sedation or general anesthesia. The success of restorations may be influenced by the child’s level of cooperation during treatment. General anesthesia may provide optimal conditions to perform restorative procedures. General anesthesia, under certain circumstances, may offer a cost-saving alternative to sedation for children with ECC.30

Policy statement The AAPD recognizes the unique and virulent nature of ECC. Health care providers who diagnose ECC should either provide therapy or refer the patient to an appropriately trained individual for treatment. Immediate intervention is medically necessary to prevent further destruction, as well as more widespread health problems. Because children who experience ECC are at greater risk for subsequent caries development, preventive and therapeutic measures such as optimizing home care, ITR, more frequent visits with regimented applications of topical fluoride, and full crown coverage often are necessary. 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 protective stabilization, sedation, or general anesthesia.

References 1. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2006;28(suppl): 69-72.

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2. Drury TF, Horowitz AM, Ismail AI, Haertens MP, Rozier RG, Selwitz RH. Diagnosing and reporting early childhood caries for research purposes. J Public Health Dent 1999;59(3):192-7. 3. 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. Vital Health Stat 11(248). Hyattsville, Md; 2007. 4. Tang JM, Altman DS, Robertson DC, O’Sullivan DM, Douglass JM, Tinanoff N. Dental caries prevalence and treatment levels in Arizona preschool children. Public Health Rep 1997;112(4):319-29. 5. Proceedings of the Conference on Early Childhood Caries, Bethesda, Md; October 1997. Community Dent Oral Epidemiol 1998;26(suppl):1-119. 6. Helfenstein V, Steiner M, Marthaler TM. Caries prediction on the basis of past caries including precavity lesions. Caries Res 1991;25(5):372-6. 7. Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an indicator of future caries: A longitudinal study. Pediatr Dent 2003;25(2):114-8. 8. Foster T, Perinpanayagam H, Pfaffenbach A, Certo M. Recurrence of early childhood caries after comprehensive treatment with general anesthesia and follow up. J Dent Child 2006;73(1):25-30. 9. Acs G, Lodolini G, Kaminshy S, Cisneros GJ. Effect of nursing caries on body weight in pediatric populations. Pediatr Dent 1992;14(5):302-5. 10. Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ, Judd P. Malnourishment in a population of young children with severe early childhood caries. Pediatr Dent 2006; 28(3):254-9. 11. Ismail AI. Prevention of early childhood caries. Community Dent Oral Epidemiol 1998;26(suppl):49-61. 12. Seow WK, Humphrys C, Tudehope DI. Increased prevalence of developmental dental defects in low-birthweight children: A controlled study. Pediatr Dent 1987;9(3):221-5. 13. Davies GN. Early childhood caries: A synopsis. Community Dent Oral Epidemiol 1998;26(suppl):106-16. 14. S eow WK. Biological mechanisms of early childhood caries. Community Dent Oral Epidemiol 1998;26 (suppl):8-27. 15. Horowitz HS. Research issues in early childhood caries. Community Dent Oral Epidemiol 1998;26(suppl):67-81. 16. C aufield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: Evidence for a discrete window of infectivity. J Dent Res 1993;72(1): 37-45. 17. Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci by infants from their mothers. J Dent Res 1995;74(2):681-5. 18. Köhler B, Bratthal D, Krasse B. Preventive measures in mothers influence the establishment of the bacterium Streptococcus mutans in their infants. Arch Oral Biol 1983; 28(3):225-31.


19. Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent 2006;28(2):106-9. 20. Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries: Confirming the beneficial effect of counseling. J Am Dent Assoc 2006;137(6):789-93. 21. Weinstein P. Provider versus patient-centered approaches to health promotion with parents of young children: What works/does not work and why. Pediatr Dent 2006; 28(2):172-6. 22. Tinanoff N. Introduction to early childhood caries conference: Initial description and current understanding. Communitry Dent Oral Epidemiol 1998;26(suppl):5-7. 23. Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent 1992;21(2):86-90. 24. Hallett KB, O’Rourke PK. Pattern and severity of early childhood caries. Community Dent Oral Epidemiol 2006; 34(1):25-35. 25. van’t Hof MA, Frencken JE, van Palenstein Helderman WH, Holmgren CJ. The atraumatic restorative treatment (ART) approach for managing dental caries: A metaanalysis. Int Dent J 2006;56(6):345-51.

26. American Academy of Pediatric Dentistry. Guideline on Restorative Dentistry. Pediatr Dent 2008;30(suppl):163-9. 27. Randall RC, Vrijhoef MM, Wilson NH. Efficacy of preformed metal crowns vs amalgam restorations in primary molars: A systematic review. J Am Dent Assoc 2000;131 (3):337-43. 28. Eidelman E, Faibis S, Peretz B. A comparison of restorations for children with early childhood caries treated under general anesthesia or conscious sedation. Pediatr Dent 2000;22(1):33-7. 29. 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. 30. Lee JY, Vann WF, Roberts MW. A cost analysis of treating pediatric dental patients using general anesthesia vs conscious sedation. Pediatr Dent 2000;22(1):27-32.


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Policy on Dietary Recommendations for Infants, Children, and Adolescents Originating Committee Clinical Affairs Committee


Adopted 1993

Revised 1999, 2002, 2005, 2006, 2008

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.

Methods The revision of this policy is based on a review of current dental and medical literature related to diet and nutrition for infants, children, and adolescents. A MEDLINE search was performed using the terms “body mass index”, “breast-feeding”, “caries”, “diabetes”, “hypertension”, “physical activity”, “nutrition”, and “obesity”. Expert opinions and best current practices also were relied upon for this policy.

Background Establishment of a dental home by 12 months of age allows the institution of appropriate caries-preventive strategies, including dietary recommendations and appropriate oral hygiene instruction, as the primary teeth begin to erupt.1 Dietary choices affect oral health as well as general health and well-being. Epidemiological research shows that human milk and breast-feeding 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.2 Human breast milk is uniquely superior in providing the best possible nutrition to infants and, by itself, has been shown to be noncariogenic.3 While early childhood caries (ECC) may not arise from breastfeeding alone, an in vitro study has shown that breast-feeding in combination with other carbohydrates is highly cariogenic.3 Frequent bottle-feeding at night, ad libitum breast-feeding, and extended and repetitive use of a no-spill training cup are associated with, but not consistently implicated in, ECC. ECC can be a particularly virulent form of caries, beginning soon after tooth eruption, developing on smooth surfaces, progressing

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rapidly, and having a lasting detrimental impact on the dentition.4 Consequences of this disease may lead to more widespread health issues.5 Caries and its sequelae are among the most prevalent health problems facing American infants, children, and adolescents. Frequent ingestion of sugars and other carbohydrates (eg, fruit juices, acidic beverages) and prolonged contact of these substances with teeth are particular risk factors in the development of caries. Along with increasing caries risk, increased consumption of sugar-sweetened beverages and snack foods also has been linked to obesity.6 Childhood overweight and obesity have reached epidemic proportions worldwide, and the prevalence among US youth has quadrupled in children ages 6 to 11 and nearly doubled in adolescents ages 12 to 19 in the past 25 years.7 Health risks associated with childhood overweight and obesity are strong indicators for predisposition to adult morbidity and mortality and include type 2 diabetes, cardiovascular disease (hypertension, hypercholesterolemia, and dyslipidemia), and psychological stress (depression and low self-esteem), as well as respiratory (obstructive sleep apnea and asthma), orthopedic (fractures), and hepatic (steatohepatitis) problems.8 To help the public make choices for a healthy diet, the US Department of Agriculture (USDA) and the Department of Health and Human Services (DHHS) published Dietary Guidelines for Americans.9 These guidelines include: 1. eating a variety of foods; 2. balancing foods eaten with physical activity to maintain a healthy body mass index; 3. maintaining a caloric intake adequate to support normal growth and development and to reach or maintain a healthy weight; 4. choosing a diet with plenty of vegetables, fruits, and whole grains and low in fat, saturated (especially trans-saturated) fat, and cholesterol; 5. using sugars and salt (sodium) in moderation.9


Food companies can encourage food and beverage selections that contribute to healthier lifestyles by increasing the prominence, simplicity, and uniformity of nutritional information on food packaging labels.

Policy statement The AAPD, in its efforts to promote optimal health for infants, children, and adolescents, supports the position of the American Dietetic Association (AmDA) that all children should have access to food and nutrition programs that ensure the availability of a safe and adequate food supply that promotes optimal physical, cognitive, and social growth and development.10 The AAPD recommends: 1. breast-feeding of infants to ensure the best possible health and developmental and psychosocial outcomes, with cessation of ad libitum breast-feeding as the first primary tooth begins to erupt and other dietary carbohydrates are introduced; 2. educating the public about the association between frequent consumption of carbohydrates and caries; 3. educating the public about other health risks associated with excess consumption of simple carbohydrates, fat, saturated fat, and sodium.

Furthermore, the AAPD encourages: 1. pediatric dentists and other health care providers who treat children to provide dietary and nutrition counseling (commensurate with their training and experience) in conjunction with other preventive services for their patients; 2. food and beverage manufacturers to make nutritional content on food labels more prominent and consumerfriendly and consumers to monitor the presence and relative amounts of carbohydrates and saturated fats as listed on food labels; 3. school health education programs and food services to promote nutrition programs that provide well-balanced and nutrient-dense foods of low caries-risk, in conjunction with encouraging increased levels of physical activity; 4. research, education, and appropriate legislation to promote diverse and balanced diets. Additional information on nutrition recommendations may be obtained from Web sites for the USDA11, USDA and DHHS9, and AmDA12.

References 1. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2007;29(suppl);22-3. 2. American Academy of Pediatrics. Policy statement: Breastfeeding and the use of human milk. Pediatrics 2005;115 (2):496-506. 3. Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent 1999;21(2):86-90. 4. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2007;29(suppl):81-4. 5. Acs G, Lodolini G, Kaminshy S, Cisneros GJ. Effect of nursing caries on body weight in pediatric populations. Pediatr Dent 1992;14(5):302-5. 6. Ludwig DS, Peterson KE, Gormaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet 2001;357(9255):505-8. 7. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA 2004; 291(23):2847-50. 8. American Academy of Pediatrics Committee on Nutrition. Policy statement on prevention of pediatric obesity and overweight. Pediatrics 2003;112(2):424-30. 9. US Dept of Agriculture, US Dept of Health and Human Services. Dietary Guidelines for Americans. 6 th ed. Washington, DC: US Dept of Agriculture and US Dept of Health and Human Services; 2005. Available at: “http:// www.health.gov/dietary guidelines/dga2005/document/”. Accessed December 23, 2007. 10. Stang J, Bayerl CT. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J Am Diet Assoc 2003;103(7):887-93. 11. US Dept of Agriculture. Available at: “http://www.my pyramid.gov”. Accessed December 23, 2007. 12. American Dietetic Association. Available at: “http://www. eatright.org”. Accessed December 23, 2007.


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Policy on Vending Machines in Schools Originating Council Council on Clinical Affairs


Adopted 2002

Revised 2005, 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that targeted marketing and easy access to sweetened foods and beverages (acidulated carbonated and noncarbonated) 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 The revision of this policy included a new systematic literature search of the MEDLINE/Pubmed database using the following parameters: Terms: “schools”, “vending machines”, AND “dental”; Fields: all fields; Limits: within the last 10 years, humans, English, and clinical trials. The update also included a review of the American Academy of Pediatrics’ policy on soft drinks in schools1 and the US Department of Agriculture’s policy on school meals.2 Fifty articles matched these criteria. Papers for review were chosen from these articles 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 There has been a reduction in untreated caries among certain demographic groups of children and adolescents in recent years.3 Frequent consumption of refined carbohydrates, however, can be a significant factor in the child and adolescent diet that contributes to the initiation and progression of caries.4 Vending machines provide ready access to highly-refined carbohydrates, especially soft drinks.* The acids present in carbonated beverages can have a greater deleterious effect (ie, erosion) on enamel than the acids generated by oral flora from the sugars present in sweetened drinks.5 Analysis of NHANES III data indicated that 13% of children aged 2 through 10 had diets high in consumption of carbonated softdrinks, and these children had a significantly higher dental

caries experience in the primary dentition than did children with other fluid consumption patterns.6 Many soft drinks also contain significant amounts of caffeine which, if consumed regularly, may lead to increased, even habitual, usage.7 There is growing concern that vending machine items with limited nutritional value are “competitive foods”, resulting in snack options that are considered to be of poor nutritional quality.8 A significant increase in caries scores has been reported for children who attended schools that had vending machines.9 An effort is underway to increase the healthy choices available in vending machines by replacing sugarsweetened drinks with bottled water, candy bars with nutrition bars, and potato chips with dried fruits and nuts.10 Increased consumption of refined carbohydrates by children and adolescents may have a negative impact on their overall nutrition by displacing foods with higher nutrient density.11 Nutrient density refers to the amount of nutrients in a food compared to the calories. Foods low in calories and high in nutrients are nutrient rich (dense). Foods high in calories and low in nutrients are of poor nutritional quality. As teenage girls have increased their consumption of soft drinks, their consumption of milk has decreased by 40%, which may contribute to a decrease in bone density, subsequent increase in fractures, and future risk of osteoporosis.12,13 Increased ingestion of sugar-sweetened drinks also has been linked to the increased incidence of childhood obesity.14 Many beverage and snack food products are targeted specifically and aggressively at the child and adolescent market. Vending machines containing these products are readily accessible to children and adolescents in schools. In exchange for money to the individual school or districts, “pouring rights contracts” give beverage companies exclusive rights to sell their products at school events and place vending machines on school property, along with other measures that increase student exposure to the beverages.15 Presently, several states have legislation and others are considering legislation to limit pouring rights contracts to healthier options.16,17

* For the purposes of this statement, the term soft-drinks refers to such beverages as sodas, fruit juices, and sports drinks.

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Policy statement The AAPD: 1. encourages collaboration with other dental and medical organizations, governmental agencies, education officials, parent and consumer groups, and corporations to increase public awareness of the negative effects of frequent and/or inappropriate intake of sweetened drinks (carbonated and noncarbonated) and low nutrient dense snack foods on infant, child, and adolescent oral health, nutrition, and general health; 2. opposes any arrangements that may decrease access to healthy nutritional choices for children and adolescents; 3. encourages school officials and parent groups to consider the importance of maintaining healthy choices in vending machines in schools and encourages the promotion of food and beverages of high nutritional value; bottled water and other more healthy choices should be available instead of soft drinks; 4. promotes educating and informing the public about the importance of good oral hygiene and nutritional habits as they pertain to consumption of items available in vending machines.

References 1. American Academy of Pediatrics. Policy statement: Soft drinks in schools. Pediatrics 2004;113(1Pt+1):152-4. 2. US Dept of Agriculture. Food and Nutrition Service. Available at: “http://www.fns.usda.gov/fncs”. Accessed December 7, 2008. 3. Brown LJ, Wall TP, Lazar V. Trends in total caries experience: Permanent and primary teeth. J Am Dent Assoc 2000;131(2):223-31. 4. Ismail IA, Burt BA, Eklund SA. The cariogenicity of soft drinks in the United States. J Am Dent Assoc 1984;109 (2):241-5. 5. 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: ADA; October 2001.

6. Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Research 2006;85(3):262-6. 7. Majewski R. Dental caries in adolescents associated with caffeinated carbonated beverages. Pediatr Dent 2001;23 (3):198-203. 8. US Government Accountability office. Report to Congressional Requests: School Meal Programs Competitive Foods are Widely Available and Generate Substantial Revenues for Schools. August 2005. Available at: “http:// www.gao.gov/new.items/d05563.pdf ”. Accessed December 7, 2008. 9. 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 Dental J 2006;201(7):441-4. 10. US Dept of Agriculture. Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation. National School Lunch Program Competitive Food Policies by State. Available at: “http://schoolmeals.nal.usda.gov/ Recipes/menuplan/menuplan.html”. Accessed December 7, 2008. 11. Freeman R, Sheiham A. Understanding decision-making processes for sugar consumption in adolescence. Community Dent Oral Epidemiol 1997;25(3):228-32. 12. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch Pediatr Adolesc Med 2000;154(6):610-3. 13. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet 2001;357(9255):505-8. 14. Fox K. Soft drinks under scrutiny. ADA News November 20; 2000:22. 15. Maihofer M. “Pouring wrongs”: MDA discourages pop deals. J Mich Dent Assoc 2000;82(2):10. 16. Berthold M. Michigan opposes school-soda deals. ADA News November 20, 2000:8. 17. National Council of State Legislatures. Available at: “http: //www.ncsl.org/programs/health/vending.htm”. Accessed December 7, 2008.


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Policy on Tobacco Use Originating Council Council on Clinical Affairs


Adopted 2000

Revised 2003, 2006, 2010

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 revision is based upon a review of current dental, medical, and public health literature related to tobacco use. An electronic search was conducted using the following parameters: Terms: “tobacco”, “teen tobacco use”, “tobacco use in children”, “smoking”, “smokeless tobacco”, “smokeless tobacco and oral disease”, “pregnancy and tobacco”, “secondhand smoke”, and “caries and smoking”; Field: all fields; Limits: within the last 10 years; humans, English; clinical trials; birth through age 19. Three hundred sixteen articles matched these criteria. Web sites for the American Lung Association, American Cancer Society, Centers for Disease Control and Prevention, Environmental Protection Agency, Campaign for Tobacco Free Kids, and US Department of Health and Human Services 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 Tobacco is a risk factor for 6 of the 8 leading causes of deaths in the world and kills up to one-half of its users.1 In the US, the Surgeon General’s report states that smoking is the single greatest avoidable cause of death.2 This report concludes that even in nonsmokers, secondhand smoke exposure causes disease and death. The Centers for Disease Control and Prevention (CDC) has conducted a National Youth Tobacco Survey (NYTS) for the years 1999, 2000, 2002, 2004 and 2006 as part of the Healthy People 2010 objectives on tobacco use.3 While middle school students showed a decrease in the use of cigarettes, cigars, and bidis (unfiltered cigarettes from India)4, they did

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not show a change in the use of smokeless tobacco, pipes, or kreteks (unfiltered cigarettes from India)4 between 2004 and 2006.4,5 Unfortunately during this same period, no significant change was seen in the tobacco use of high school students.4,5 Tobacco use among high school students is 20.0% or 3.5 million, while 19.8% of adults smoke.5,6 Smokeless tobacco use is seen in 13.4% of male high school students and 2.3% of females.5,6 Each day approximately 3,600 youth between 12-17 years of age try smoking with 1,100 a day becoming regular daily users.6,7 Signficant health consequences for tobacco use include 440,000 deaths per year from smoking and an additional 50,000 deaths per year from secondhand smoke.5,6 Other catastrophic sequelae are cardiovascular disease; reproductive effects; pulmonary disease; cancers of the cervix, kidney, pancreas, stomach, lung, larynx, bladder and esophagus; leukemia; cataracts; abdominal aortic aneurysm; bronchitis; and other lung diseases including pneumonia.7,8 Secondhand exposure to tobacco smoke imposes significant risks as well. Cardiovascular disease and lung cancer are increased by 25-30% in nonsmokers who inhale secondhand smoke.9 Infants and children who are exposed to smoke are at risk for sudden infant death syndrome (SIDS), acute respiratory infections, middle ear infections, bronchitis, pneumonia, asthma10, allergies11,12, and infections during infancy.13 Caries in the primary dentition also is related to secondhand smoke exposure.14-16 Enamel hypoplasia in both the primary and permanent dentition also is seen in children exposed to cigarette smoke.17 A new term, “thirdhand” smoke, has been proposed to describe the particulate residual toxins that are deposited in layers all over the home after a cigarette has been extinguished.18 These volatile compounds are deposited and “off gas” into the air over months.19,20 Since children inhabit these low-lying contaminated areas and because the dust ingestion rate in infants is more than twice that of an adult, they are even more susceptible to thirdhand smoke. Studies have shown that these children have associated cognitive defects in addition to the other associated risks of secondhand smoke exposure.21


Tobacco use can result in oral disease. Oral cancer,9 periodontitis,22-25 compromised wound healing, a reduction in the ability to smell and taste, smoker’s palate and melanosis, coated tongue, staining of teeth and restorations, implant failure, and leukoplakia26,27 are all seen in tobacco users. Smokeless tobacco is a risk factor for periodontal conditions28-30 and oral cancer.31 Initiation of tobacco use begins before age 19 for 90% of adult smokers.32 In fact, most studies show that people who do not use tobacco as a teen never use it.32 Aggressive marketing of tobacco products by manufacturers,33,34 smoking by parents,35 peer influence, a functional belief in the benefits and normalcy of tobacco,36 availability and price of tobacco products, low socioeconomic status, low academic achievement, lower self image, and a lack of behavioral skills to resist tobacco offers all contribute to the initiation of tobacco use during childhood and adolescence.37 Teens who use tobacco are more likely to use alcohol and other drugs and engage in high risk sexual behaviors.38 The monetary costs of this addiction and resultant morbidity and mortality is staggering. Annually, cigarette smoking costs the US $193 billion, based on lost productivity (more than $97 billion) and health care expenditures (more than $96 billion).7 Health care cost from the exposure to secondhand smoke is about $10 billion annually.7 Contrast this with tobacco industry expenditures on advertising and political influence of $13.11 billion in 2005.7 Current trends indicate that tobacco use will cause more than 8 million deaths a year by 2030.39 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 (ANDS), such as tobacco lozenges, nicotine water, nicotine lollipops, or “heated tobacco” cigarette substitutes. 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 environmental tobacco smoke (ETS) is a “known human carcinogen” and there is no evidence to date of a “safe” exposure level to ETS (secondhand or passive smoke),40 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 its members to: 1. promote and establish policies that ensure dental offices, clinics, and/or health care facilities, including property grounds, are tobacco free;

2. support tobacco-free school laws and policies as advocated by the American Dental Association;41,42 3. serve as role models by not using tobacco and urging staff members who use tobacco to stop; 4. routinely examine patients for oral signs of and changes associated with tobacco use; 5. determine and document tobacco use by patients and smoking status of their parents, guardians, and caregivers; 6. educate patients, parents, and guardians on the serious health consequences of tobacco use and exposure to ETS in the home; 7. provide both prevention and cessation services using evidence-based interventions identified as “best practice” for treating tobacco use and nicotine addiction; 8. work to ensure all third-party payors include “best practice” tobacco cessation counseling and pharmacotherapeutic treatments as benefits in health packages; 9. work with school boards to increase tobacco-free environments for all school facilities, property, vehicles, and school events; 10. work on the national level and within their state and community to organize and support anti-tobacco campaigns 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; 11. work with legislators, community leaders, and health care organizations to ban tobacco advertising, promotion, and sponsorships; 12. 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 employed; 13. establish and support education/training activities and prevention/cessation services throughout the community; 14. recognize the US Public Health Service Clinical Practice Guideline “Treating Tobacco Use and Dependence”43 as a valuable resource. References 1. World Health Organization. Tobacco key facts. Available at: “http://www.who.int/topics/tobacco/facts/en/index. html”. Accessed June 29, 2010. 2. US Dept of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. US Dept of Health and Human Services, CDC, National Center of Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available at: “http://www.surgeongeneral.gov/library/smokingconse quences/”. Accessed June 29, 2010. 3. US Dept of Health and Human Services. Healthy people 2010: Tobacco use and healthy people 2010 objectivesTobacco priority area. Washington, DC. Available at: “http://www.healthypeople.gov/document/HTML/ Volume2/27Tobacco.htm”. Accessed June 29, 2010.


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4. CDC. 2006 National Youth Tobaccao Survey and Key Prevalence Indicators. Available at: “http://www.cdc. gov/tobacco/data_statistics/fact_sheets/tobacco_industry/ bidis_kreteks/”. Accessed November 8, 2009. 5. CDC. Smoking and tobacco use: Surveys: 2006 National Youth Tobacco Survey and key prevalence indicators. Available at: “http://www.cdc.gov/tobacco/data_statis tics/surveys/nyts/pdfs/indicators.pdf ”. Accessed June 29, 2010. 6. CDC. Smoking and tobacco use: Youth and tobacco use: Current estimates. Available at: “http://www.cdc.gov/ tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/ index.htm#estimates”. Accessed June 29, 2010. 7. Campaign for Tobacco-Free Kids. Toll of tobacco in the United States of America. Tobacco use in the USA. Campaign for Tobacco-Free Kids, December 8, 2008. Available at: “http://www.tobaccofreekids.org/research/fact sheets”. Accessed August 6, 2009. 8. CDC. Smoking and tobacco use. Health effects of cigarette smoking. Updated December 1, 2009. Available at: “http://www.cdc.gov/tobacco/data_statistics/fact_sheets/ health_effects/effects_cig_smoking/index.htm”. Accessed June 29, 2010. 9. US Dept. of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon Gerneral. US Dept of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Ga. 2006. Available at: “http://www.surgeongeneral.gov/library/secondhand smoke/report/chapter1.pdf ”. Accessed June 29, 2010. 10. Dietert RR, Zelikoff JT. Early-life environment, developmental immunotoxicology, and the risk of pediatric allergic disease including asthma. Birth Defects Res B Dev Reprod Toxicol 2008;83(6):547-60. 11. Goodwin RD, Cowles RA. Household smoking and childhood asthma in the United States: A state-level analysis. J Asthma 2008;45(7):607-10. 12. 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. 13. Ladomenou F, Kafatos A, Galanakis E. Environmental tobacco smoke exposure as a risk factor for infections in infancy. Acta Paediatr 2009;98(7):1137-41. 14. Leroy R, Hoppenbrouwers K, Jara A, Declerck D. Parental smoking behavior and caries experience in preschool children. Community Dent Oral Epidemiol 2008;36(3): 249-57. 15. Hanioka T, Nakamura E, Ojima M, Tanaka K, Aoyama H. Dental caries in 3-year-old children and smoking status of parents. Paediatr Perinat Epidemiol 2008;22(6):546-50.

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16. Aligne CA, Moss ME, Auinger P, Weitzman M. Association of pediatric dental caries with passive smoking. JAMA 2003;289(10):1258-64. 17. 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. 18. 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. 19. 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. 20. Singer BC, Hodgson AT, Guevarra KS, Hawley EL, Nazaroff WW. Gas-phase organics in environmental tobacco smoke. 1. Effects of smoking rate, ventilation, and furnishing level on emission factors. Environ Sci Technol 2002;36(5):846-53. 21. Yolton K, Dietrich K, Auinger P, Lanphear BP, Hornung R. Exposure to environmental tobacco smoke and cognitive abilities among US children and adolescents. Environ Health Perspect 2005;113(1):98-103. 22. Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Periodontol 2004;75(2):196-209. 23. Bergström J, Eliasson S, Dock J. A 10-year prospective study of tobacco smoking and periodontal health. J Periodontol 2000;71(8):1338-47. 24. Albandar JM, Streckfus CF, Adesanya MR, Winn DM. Cigar, pipe, and cigarette smoking as risk factors for periodontal disease and tooth loss. J Periodontol 2000;71(2):1874-81. 25. Johnson GK, Slach NA. Impact of tobacco use on periodontal status. J Dent Educ 2001;65(4):313-21. 26. Vellappally S, Fiala Z, Smejkalová J, Jacob V, Somanathan R. Smoking related systemic and oral diseases. Acta Medica 2007;50(3):161-6. 27. Reibel J. Tobacco and oral diseases. Update on the evidence, with recommendations. Med Princ Pract 2003; 12(Suppl 1):22-32. 28. Montén U, Wennström JL, Ramberg P. Periodontal conditions in male adolescents using smokeless tobacco (moist snuff ). J Clin Periodontol 2006;33(12):863-8. 29. Kallischnigg G, Weitkunat R, Lee PN. Systematic review of the relation between smokeless tobacco and nonneoplastic oral diseases in Europe and the United States. BMC Oral Health 2008;8(PMCID:PMC2390522. Published online May 1. doi:10.1186/1472-6831-8-13): 13-33. 30. Bergström J, Keilani H, Lundholm C, Rådestad U. Smokeless tobacco (snuff ) use and periodontal bone loss. J Clin Periodontol 2006;33(8):549-54. 31. Rodu B, Jansson C. Smokeless tobacco and oral cancer: A review of the risks and determinants. Crit Rev Oral Biol Med 2004;15(5):252-63.


32. American Cancer Society. Child and Teen Tobacco Use. Available at: “http://www.cancer.org/docroot/PED/ content/PED_10_2X_Child_and_Teen_Tobacco_Use. asp?sitearea=PED”. Accessed June 29, 2010. 33. CDC. 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. 34. 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. 35. 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. 36. Song AV, Morrell HE, Cornell JL, et al. Perceptions of smoking-related risks and benefits as predictors of adolescent smoking initiation. Am J Public Health 2009; 99(3):487-92. 37. US Dept of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. US Dept of Health and Human Services, CDC, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Ga: 2000. Available at: “http:// www.cdc.gov/mmwr/preview/mmwrhtml/rr4916a1.htm”. Accessed June 29, 2010. 38. CDC. Best Practices for Comprehensive Tobacco Programs2007. US Dept. 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; Atlanta, Ga: October 2007. Available at: “http://www.cdc.gov/tobacco/tobacco_ control_programs/stateandcommunity/best_practices/ pdfs/2007/BestPractices_Complete.pdf ”. Accessed June 29, 2010. Errata notices available at: “http://www.cdc. gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/errata/index.htm” http://www.cdc.gov/ tobacco/tobacco_control_programs/stateandcommunity/ best_practices/errata/index.htm”. Accessed June 29, 2010. 39. World Health Organization. WHO report on the global tobacco epidemic, 2009. Available at: “http://whqlibdoc. who.int/publications/2009/9789241563918_eng_full. pdf\”. Accessed July 4, 2010. 40. US Dept of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. US Dept of Health and Human Services, 2007. Available at: “http://www.surgeongeneral. gov/library/secondhandsmoke/factsheets/factsheet7.html”. Accessed November 8, 2009. 41. Crozier S. Resolution directs ADA to support tobaccofree school policies. American Dental Association News, November 10, 2009. Available at: “http://www.ada/org/ news/528.aspx”. Accessed July 4, 2010. 42. American Dental Association. Tobacco Control. Available at: “http://www.ada.org/2788.aspx”. Accessed July 4, 2010. 43. US Dept of Health and Human Services. Treating Tobacco Use and Dependence: Clinical Practice Guidelines. 2008 Update. Available at: “http://www.ncbi.nlm.nih. gov/bookshelf/br.fcgi?book=hsahcpr&part=A28163”. Accessed June 29, 2010.


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Policy on Intraoral and Perioral Piercing Originating Council Council on Clinical Affairs


Adopted 2000

Revised 2003

Reaffirmed 2007

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes the importance of educating the public and health professionals on the health implications of oral and perioral piercings.

Methods This policy was based on a MEDLINE search using keywords “body piercing” and “oral piercing” and relevant articles from the dental and medical literature.

Background The use of intraoral jewelry and piercings of oral and perioral tissues have been gaining popularity among adolescents and young adults. Oral piercings involving the tongue, lips, cheeks, and uvula have been associated with pathological conditions including pain, infection, scar formation, tooth fractures, metal hyper-sensitivity reactions, localized periodontal disease, speech impediment, and nerve damage.1-13 Life-threatening complications associated with oral piercings have been reported, including bleeding, edema, and airway obstruction.14-16 Unregulated piercing parlors and techniques have been identified by the National Institutes of Health as a possible vector for disease transmission (eg, hepatitis, tetanus, tuberculosis) and as a cause of bacterial endocarditis in susceptible patients.1

Policy statement 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.

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References 1. National Institutes of Health. Management of hepatitis C and infectious disease. NIH Consensus Conference Statement 105. Section 5, paragraph 2; March 24-26, 1997. 2. American Dental Association. ADA statement on intraoral/perioral piercings and tongue splitting. Available at: “http://www.ada.org/prof/resources/positions/statements/ piercing.asp”. Accessed February 28, 2007. 3. Boardman R, Smith RA. Dental implications of oral piercing. J Calif Dent Assoc 1997;25:200-7. 4. Botchway C, Kuc I. Tongue piercing and associated tooth fracture. J Can Dent Assoc 1998;64(11):803-5. 5. Kretchmer MC, Moriarty JD. Metal piercing through the tongue and localized loss of attachment: A case report. J Periodontol 2001;72(6):831-3. 6. DeMoor RJ, DeWitte AM, Debuyne MA. Tongue piercing and associated oral and dental complications. Endod Dent Traumatol 2000;16(5):232-7. 7. Price SS, Lewis MW. Body piercing involving oral sites. J Am Dent Assoc 1997;128(7):1017-20. 8. Campbell A, Moore A, Williams E, Stephens J, Tatakis DN. Tongue piercing: Impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontol 2002;73(3):289-97. 9. Sardella A, Pedrinazzi M, Bez C, Lodi G, Carrassi A. Labial piercing resulting in gingival recession. A case series. J Clin Periodontol 2002;29(10):961-3. 10. Dibart S, DeFeo P, Surabian G, Hart A, Capri D, Su MF. Oral piercing and gingival recession: Review of the literature and a case report. Quintessence Int 2002;33(2): 110-2. 11. Ng KH, Siar CH, Ganesapillai T. Sarcoid-like foreign body reaction in body piercing: A report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84(1):28-31.


12. Kuczkowski KM, Benumof JL. Tongue piercing and obstetric anesthesia: Is there cause for concern? J Clin Anesth 2002;14(6):447-8. 13. Berenguer G, Forrest A, Horning GM, Towle HJ, Karpinia K. Localized periodontitis as a long-term effect of oral piercing: A case report. Compend Contin Educ Dent 2006;27(1):24-7.

14. Neiberger E. A large hypertrophic-keloid lesion associated with tongue piercing: A case report. Gen Dent 2006;54(1):46-7. 15. Perkins CS, Meisner J, Harrison JM. A complication of tongue piercing. Br Dent J 1997;182(4):147-8. 16. Brennan M, O’Connell P, O’Sullivan M. Multiple dental fractures following tongue barbell placement: A case report. Dent Traumatol 2006;22(1):41-3.


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Policy on Prevention of Sports-related Orofacial Injuries Originating Committee Clinical Affairs Committee


Adopted 1991

Revised 1995, 1999, 2002, 2006, 2010

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 is an update of the previous document, revised in 2006. The update included an electronic search using the following parameters: Terms: “sports injuries”, “injury prevention”, “dental injuries”, “orofacial injuries”, and “mouthguard”; Field: all fields; Limits: within the last 10 years; humans; English; clinical trials and literature reviews. The reviewers agreed upon the inclusion of 48 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.

Background The tremendous popularity of organized youth sports and the high level of competitiveness have resulted in a significant number of dental and facial injuries.1,2 Over the past decade, approximately 46 million youths in the United States were involved in “some form of sports”.3 It is estimated that 30 million children in the US participate in organized sport programs.4 All sporting activities have an associated risk of orofacial injuries due to falls, collisions, contact with hard surfaces, and contact from sports-related equipment. Sports accidents reportedly account for 10-39% of all dental injuries in children.5 Children are most susceptible to sports-related oral injury between the ages of 7 and 11 years.5-8 The administrators of youth, high school, and college football, lacrosse, and ice hockey have demonstrated that dental and facial injuries can be reduced significantly by introducing mandatory protective equipment. Popular sports such as baseball, basketball, soccer,

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softball, wrestling, volleyball, and gymnastics lag far behind in injury protection for girls and boys. Youths participating in leisure activities such as skateboarding, inline or roller skating, and bicycling also benefit from appropriate protective equipment.6,9-11 Studies of dental and orofacial athletic injuries are reported throughout the medical and dental literature.12,13 A review of literature published over the past 20 years showed that the injury rate varied greatly depending on the size of the sample, the sample’s geographic location, the ages of the participants, and the specific sports involved in the study.12,13 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.5,12-15 Consequences of orofacial trauma for children and their families are substantial because of potential for pain, psychological effects, and economic implications. Children with untreated trauma to permanent teeth exhibit greater impacts on their daily living than those without any traumatic injury.16,17 The yearly costs of all injuries, including orofacial injuries, sustained by young athletes have been estimated to be as high as 1.8 billion dollars.4 The National Youth Sports Safety Foundation in 2005 estimated the cost to treat an avulsed permanent tooth and provide followup care is between $5000 and $20,000 over a lifetime.18 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 noninsured children.19-22 The majority of sport-related dental and orofacial injuries affect the upper lip, maxilla, and maxillary incisors, with 5090% of dental injuries involving the maxillary incisors.5,12,13,23 Use of a mouthguard can protect the upper incisors. However, studies have shown that even with a mouthguard in place, up to 25% of dentoalveolar injuries still can occur.24 Identifying patients who participate in sports and recreational 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 to identify the risk factors involved in various sports. 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 exposure time, level of coaching and type of sports organization, whether the player is a focus of attention in a contact or noncontact sport, history of previous sports-related injury, and the situation (eg, practice vs game).15,25 Behavioral risk factors (eg, hyperactivity) also have been associated significantly with injuries affecting the face and/or teeth.26 The frequency of dental trauma is significantly higher for children with increased overjet and inadequate lip coverage.27,28 A dental professional may be able to modify these risk factors. Initiating preventive orthodontic treatment in early- to middlemixed dentition of patients with an overjet >3 mm has the potential to reduce the severity of traumatic injuries to permanent incisors.27 Although some sports-related traumatic injuries are unavoidable, most can be prevented.15,18,29,30 Helmets, facemasks, and mouthguards have been shown to reduce both the frequency and severity of dental and orofacial trauma.15 However, few sports have regulations that require their use. The National Federation of State High School Associations mandate mouthguards for only 4 sports: football, ice hockey, lacrosse, and field hockey.30 Several states have attempted to increase the number of sports which mandate mouthguard use, with various degrees of success and acceptance. Four New England states have been successful in increasing the number of sports requiring mouthguard use to include sports such as soccer, wrestling, and basketball.30,31 Initially used by professional boxers, the mouthguard has been used as a protective device since the early 1900’s.13,32 The mouthguard, also referred to as a gumshield or mouth protector, is defined as a “resilient device or appliance placed inside the mouth to reduce oral injuries, particularly to teeth and surrounding structures.”5 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 edentulous space.”33 The mouthguard works by “absorbing the energy imparted at the site of impact and by dissipating the remaining energy.”34 The American Society for Testing and Materials (ASTM) classifies mouthguards by 3 categories35: 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.5,15 The ASTM recommends that for maxixmum protection, cushioning, and retention, the mouthguard should cover all teeth in one arch, customarily the maxillary arch, less the third molar.35 A mandibular mouthguard is recommended for individuals with a Class III malocclusion.

The custom-fabricated type is superior in retention, protection, and comfort. 5,15,34,36,37 When this type is not available, the mouth-formed mouthguard is preferable to the stock or preformed mouthguard.32,38,39 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.5 Available commercially at department and sporting-good stores, these are the most commonly used among athletes but vary greatly in protection, retention, comfort, and cost.8,15 3. Type III – Stock mouthguards are purchased over-thecounter. They are designed for use without any modification and must be held in place by clenching the teeth together to provide a protective benefit.5,15 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.5,8,33,40 Despite these shortcomings, the stock mouthguard could be the only option possible for patients with particular clinical presentations (eg, use of orthodontic brackets and appliances, periods of rapidly changing occlusion during mixed dentition). The Academy for Sports Dentistry (ASD) “recommends the use of a properly fitted mouthguard. It encourages the use of a custom fabricated mouthguard 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.”41 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 distributing the force of impact.41 The practitioner also should consider the patient’s vertical dimension of occlusion, personal comfort, and breathing ability.39 By providng 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.8,42 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.43 Several block-out methods used in both the dental operatory and laboratory may incorporate space to accommodate for future tooth movement and dental development.43 By anticipating required space changes, a custom fabricated mouthguard may be made to endure several sports seasons.43 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 $285.44 In a study to determine the acceptance of the 3 types of mouthguards by 7- and 8-year old children playing soccer, only 24% of parents surveyed were willing to pay $25 for a custom mouthguard.45 Therefore, cost may be a barrier.44


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Attitudes of officials, coaches, parents, and players about wearing mouthguards influence their usage.46 Although coaches are perceived as the individuals with the greatest impact on whether or not players wear mouthguards, parents view themselves as equally responsible for maintaining mouthguard use.46,47 However, surveys of parents regarding the indications for mouthguard usage reveal a lack of complete understanding of the benefits of mouthguard use.46 Players’ perceptions of mouthguard use and comfort largely determine their compliance and enthusiasm.34,45 Therefore, the dental profession needs to influence and educate all stakeholders about the risk of sports-related orofacial injuries and available preventive strategies.32,44,48 Routine dental visits can be an opportunity to initiate patient/parent education and make appropriate recommendations for use of a properly-fitted athletic mouthguard.15

Policy statement The AAPD recommends: 1. dentists 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; 2. continuation of preventive practices instituted in youth, high school and college football, lacrosse, field hockey, and ice hockey; 3. for youth participating in organized baseball and softball activities, an ASTM-certified face protector be required (according to the playing rules of the sport); 4. mandating the use of properly-fitted mouthguards in other organized sporting activities that carry risk of orofacial injury; 5. prior to initiating practices for a sporting season, coaches/ administrators of organized sports consult a dentist with expertise in orofacial injuries for recommendations for immediate management of sports-related injuries (eg, avulsed teeth); 6. continuation of research in development of a comfortable, efficacious, and cost-effective sports mouthguard to facilitate more widespread use of this proven protective device; 7. dentists of all specialties, including pediatric and general dentists, provide education to parents and patients regarding prevention of orofacial injuries as part of the anticipatory guidance discussed during dental visits; 8. dentists should prescribe, fabricate, or provide an appropriate referral for mouthguard protection for patients at increased risk for orofacial trauma; 9. that third party payors realized the benefits of mouthguards for the prevention and protection from orofacial sports-related injuries and, furthermore, encourages them to improve access to these services; 10. the ASD and the International Association of Dental Traumatology be consulted as valuable resources for the professions and public.

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References 1. Castaldi CR. Sports-related oral and facial injuries in the young athlete: A new challenge for the pediatric dentist. Pediatr Dent 1986;8(4):311-6. 2. Castaldi CR. Athletic mouthguards: History and present status. Sports Med Digest 1988;10:1-2. 3. Barron M, Powell J. Fundamentals of injury prevention in youth sports. J Pediatr Dent Care 2005;11(2):10-2. 4. Adirim T, Cheng T. Overview of injuries in the young athlete. Sports Med 2003;33(1):75-81. 5. Newsome P, Tran D, Cooke M. The role of the mouthguard in the prevention of sports-related dental injuries: A review. Int J Paediatr Dent 2001;11(6):396-404. 6. Tesini DA, Soporowski NJ. Epidemiology of orofacial sportsrelated injuries. Dent Clin North Am 2000;44(1):1-18. 7. Rodd HD, Chesham DJ. Sports-related oral injury and mouthguard use among Sheffield school children. Community Dent Health 1997;14(1):25-30. 8. American Dental Association Council on Access, Prevention, and Interprofessional Relations and Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc 2006;137(12):1712-20. 9. Ranalli DN. Prevention of sports-related dental traumatic injuries. Dent Clin North Am 2000;44(1):35-51. 10. Finnoff JT, Laskowski ER, Altman KC, Diehl NW. Barriers to bicycle helmet use. Pediatrics 2001;108(1):4-10. 11. Fasciglione D, Persic R, Pohl Y, Fillippi A. Dental injuries in inline skating – Level of information and prevention. Dent Traumatol 2007;23(3);143-8. 12. Kumamoto D, Maeda Y. Global trends and epidemiology of sports injuries. J Pediatr Dent Care 2005;11(2):15-25. 13. Kumamoto D, Maeda Y. A literature review of sportsrelated orofacial trauma. Gen Dent 2004;52(3);270-80. 14. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Craniomaxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51-61. 15. Ranalli DN. Sports dentistry in general practice. Gen Dent 2000;48(2):158-64. 16. Cortes M, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14-year old children. Community Dent and Oral Epidemiol 2002;30(3):193-8. 17. Berger TD, Kenny DJ, Casas MJ, Barrett EJ, Lawrence HP. Effects of severe dentoalveolar trauma on the qualityof-life of children and parents. Dent Traumatol 2009; 25(5);462-9. 18. National Youth Sports Safety Foundation, Inc; 2005. Available at: “http://www.nyssf.org”. Accessed July 16, 2005. 19. Sane J, Ylipaavalniemi P, Turtola L, Niemi T, Laaka V. Traumatic injuries among university students in Finland. J Am Coll Health 1997;46(1);21-4 20. Ngyuyen PM, Kenny DJ, Barret EJ. Socio-economic burden of permanent incisor replantation on children and parents. Dent Traumatol 2004;20(3);123-33.


21. Gift HC, Reisine ST, Larach DC. The social impact of dental problems and visits. Am J Public Health 1992;82(12);1663-8. 22. McIntyre JD, Lee JY, Trope M, Vann WF. Elementary school staff knowledge about dental injuries. Dent Traumatol 2008;24(3);289-98. 23. Takeda T, Ishigami K, Nakajima K, et al. Are all mouthguards the same and safe to use? Part 2. The influence of anterior occlusion against a direct impact on maxillary incisors. Dent Traumatol 2008;24(3);360-5. 24. Onyeaso C, Adegbesan O. Knowledge and attitudes of coaches of secondary school athletes in Ibadan, Nigeria regarding orofacial injuries and mouthguard use by the athletes. Dent Traumatol 2003;19(5):204-8. 25. Fos P, Pinkham JR, Ranalli DN. Prediction of sportsrelated dental traumatic injuries. Dent Clin North Am 2000;44(1):19-33. 26. Lalloo R. Risk factors for major injuries to the face and teeth. Dent Traumatol 2003;19(1):12-14. 27. Bauss O, Rohling J, Schwestka-Polly R. Prevalence of traumatic injuries to the permanent incisors in candidates for orthodontic treatment. Dent Traumatol 2004;20(2):61-6. 28. Forsberg C, Tedestam G. Etiological and predisposing factors related to traumatic injuries to permanent teeth. Swed Dent J 1993;17(5):183-90. 29. 1st World Congress of Sports Injury Prevention. Abstracts. Br J Sports Med 2005;39:373-408. 30. Mills S. Can we mandate prevention? J Pediatr Dent Care 2005;11(2):7-8. 31. Kumamoto D. Establishing a mouthguard program in your community. Gen Dent 2000;48:160-4. 32. Patrick DG, van Noort R, Found MS. Scale of protection and the various types of sports mouthguard. Br J Sports Med 2005;39(5):278-81. 33. 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. 34. McClelland C, Kinirons M, Geary L. A preliminary study of patient comfort associated with customised mouthguards. Br J Sports Med 1999;33(3):186-9. 35. American Society for Testing and Materials. Standard practice for care and use of athletic mouth protectors. ASTM F697-00. Philadelphia, Pa: American Society for Testing and Materials; Reapproved 2006.

36. 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. 37. 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. 38. 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;68:430-42. 39. 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. 40. Ranalli DN. Prevention of craniofacial injuries in football. Dent Clin North Am 1991;35(4);627-45. 41. Academy for Sports Dentistry. Position statement: Mouthguard mandates. 2010. Available at: “http://www. academyforsportsdentistry.org/Organization/PositionStatement/tabid/58/Default.aspx”. Accessed June 23, 2010. 42. 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. 43. Croll T, Castaldi CR. Custom sports mouthguard modified for orthodontic patients and children in the transitional dentition. Pediatr Dent 2004;26(5):417-20. 44. Walker J. Parents plus: Getting mouthguards into kids’ mouths. J Pediatr Dent Care 2005;11(2):39-40. 45. 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. 46. Gardiner D, Ranalli DN. Attitudinal factors influencing mouthguard utilization. Dent Clin North Am 2000;44 (1):53-65. 47. Diab N, Mourino A. Parental attitudes toward mouthguards. Pediatr Dent 1997;19(8):455-60. 48. Woodmansey K. Athletic mouth guards prevent orofacial injuries: A review. Gen Dent 1999;47(1):64-9.


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Policy on the Use of Dental Bleaching for Child and Adolescent Patients Originating Council Council on Clinical Affairs


Adopted 2004

Revised 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that the desire for dental whitening in pediatric and adolescent patients has increased. This policy is intended to help professionals and patients make informed decisions about the indications, efficacy, and safety of internal and external bleaching of primary and young permanent teeth and incorporate such care into a comprehensive treatment plan.

Methods This revision included a new systematic literature search of the MEDLINE/Pubmed electronic database using the following parameters: Terms: “dental bleaching”, “dental whitening”, and “tooth bleaching”; Field: all fields; Limits: within the last 10 years, humans, English, clinical trials, and birth through age 18. Sixty-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, recommendations were based upon expert and/ or consensus opinion by experienced researchers and clinicians.

Background Through news stories and advertisements, the public has become more aware of advances in cosmetic dentistry. Both the variety and availability of bleaching products on the market have increased. Consequently, parents and the news media request information on dental whitening for children and adolescents with increasing frequency. Clinical indications for internal or external dental whitening for individual teeth may include discoloration resulting from a traumatic injury (ie, calcific metamorphosis, darkening with devitalization), irregularities in enamel coloration of a permanent tooth due to trauma or infection of the related primary tooth, or intrinsic discoloration/staining (eg, fluorosis, tetracycline staining).1-8 A negative self-image due to a discolored tooth or teeth can have serious consequences on adolescents and could be considered an appropriate indication for bleaching.9 Due to the

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difference in the thickness of enamel of primary and permanent teeth, tooth coloration within a dental arch 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. Dental whitening may be accomplished by using either professional or at-home bleaching modalities. Advantages of inoffice whitening include: 1. an initial professional examination to help identify causes of discoloration and clinical concerns with treatment (eg, existing restorations, side effects); 2. professional control, including use of accelerants (eg, lights, lasers) and soft-tissue protection; 3. patient compliance; 4. rapid results; 5. stability of results. The pretreatment professional assessment helps identify pulp pathology that may be associated with a single discolored 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.1,4,6,10-13 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 greater efficiency of bleaching agents. Over-the-counter products for at-home use include bleaching gels, whitening strips, and brush-on agents. 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% carbamide peroxide (equivalent to about 3% hydrogen peroxide) to 38% carbamide peroxide (equivalent to approximately 13% hydrogen peroxide). Carbamide peroxide is the most commonly used


active ingredient in dentist-dispensed home-use tooth-bleaching products.10 These agents sometimes are used sequentially. Inoffice 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.1-3,14-16 Many whitening toothpastes contain polishing or chemical agents to improve tooth appearance by removing surface stains through gentle polishing, chemically chelating, or other nonbleaching action.10 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.1-3,14-16 The more common side effects associated with bleaching vital teeth are tooth sensitivity and tissue irritation. Sensitivity affects 8% to 66% of patients and often occurs during the early stages of treatment.4,9,11,17-21 Tissue irritation, in most cases, results from an ill-fitting tray rather than the bleaching agents and no longer occurs once a more accurately fitted tray is used. Both sensitivity and tissue irritation usually are temporary and cease with the discontinuance of treatment.4,11,22 Another side effect associated with bleaching vital teeth is increased marginal leakage of an existing restoration.4,11,22 The more common side effects from internal bleaching of nonvital teeth are external root resorption12,23-26 and ankylosis. With external bleaching of nonvital teeth, the most common side effect is increased marginal leakage of an existing restoration.26-30 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 radical31-36 and the potential side effects of dental bleaching, minimizing exposure at the lowest effective concentration of hydrogen peroxide or carbamide peroxide is recommended. Current literature and clinical studies support the use of sodium perborate mixed with water for bleaching nonvital teeth.13,37 Studies have shown higher incidences of root resorption when hydrogen peroxide is mixed with sodium perborate12,38-41 or any mixture of sodium perborate is heated. 42 Therefore, the use of hydrogen peroxide and heating any mixture of sodium perborate are not recommended.

Policy statement The AAPD encourages: 1. the judicious use of bleaching for vital and nonvital teeth; 2. patients to consult their dentists to determine appropriate methods for and the timing of dental whitening within the context of an individualized, comprehensive, and sequenced treatment plan; 3. dental professionals and consumers to consider side effects when contemplating dental bleaching for child and adolescent patients; 4. further research of dental whitening agents in children.

The AAPD discourages full-arch cosmetic bleaching for patients in the mixed dentition.

References 1. 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. 2. Whitman FJ, Simon JF. A clinical comparison of two bleaching systems. J Calif Dent Assoc 1995;23(1):59-64. 3. Matis BA, Wang Y, Jiang T, Eckert GJ. Extended athome bleaching of tetracycline-stained teeth with different concentrations of carbamide peroxide. Quintessence Int 2002;33(9):645-55. 4. Matis BA, Cochran MA, Eckert G, Carlson TJ. The efficacy and safety of a 10% carbamide peroxide bleaching gel. Quintessence Int 1998;29(9):555-63. 5. Barnes DM, Kihn PW, Romberg E, George D, DePaola L, Medina E. Clinical evaluation of a new 10% carbamide peroxide tooth-whitening agent. Compend Contin Educ Dent 1998;19(10):968-72, 977-8. 6. Croll TP. Esthetic correction for teeth with fluorosis and fluorosis-like enamel dysmineralization. J Esthet Dent 1998;10(1):21-9. 7. Croll TP, Sasa IS. Carbamide peroxide bleaching of teeth with dentinogenesis imperfecta discoloration: Report of a case. Quintessence Int 1995;26(10):683-6. 8. Croll TP, Segura A. Tooth color improvement for children and teens: Enamel microabrasion and dental bleaching. J Dent Child 1996;63(1):17-22. 9. Donly KJ. The adolescent patient: Special whitening challenges. Compend Contin Educ Dent 2003;24(4A):390-6. 10. American Dental Association. Statement on the safety and effectiveness of tooth whitening products; June 2002. Available at: “http://www.ada.org/prof/resources/positions/ statements/whiten2.asp”. Accessed October 10, 2008. 11. Haywood VB, Leonard RH, Nelson CF, Brunson WD. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 1994;125(9):1219-26. 12. Haywood VB. Bleaching of vital and nonvital teeth. Curr Opin Dent 1992;2:142-9. 13. Fieldhouse J. Teeth whitening debate I. Br Dent J 2002; 193(6):300-1. 14. Kwon YH, Huo MS, Kim KH, Kim SK, Kim YJ. Effects of hydrogen peroxide on the light reflectance and morphology of bovine enamel. J Oral Rehabil 2002;29(5):473-7. 15. Slezak B, Santarpia P, Xu T, et al. Safety profile of a new liquid whitening gel. Compend Contin Educ Dent 2002; 11(suppl 1):4-11. 16. Kugel G, Aboushala A, Zhou X, Gerlach RW. Daily use of whitening strips on tetracycline-stained teeth: Comparative results after 2 months. Compend Contin Educ Dent 2002;23(1A):29-34; quiz 50.


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17. MacIsaac AM, Hoen CM. Intracoronal bleaching: Concerns and considerations. J Can Dent Assoc 1994;60(1): 57-64. 18. Donly KJ, Donly AS, Baharloo L, et al. Tooth whitening in children. Compend Contin Educ Dent 2002;23(1A): 22-28; quiz 49. 19. Donly KJ, Gerlach RW. Clinical trials on the use of whitening strips in children and adolescents. Gen Dent 2002;50(3):242-5. 20. Almas K, Albaker A, Felembam N. Knowledge of dental health and diseases among dental patients, a multicentre study in Saudi Arabia. Indian J Dent Res 2000;11(4): 145-55. 21. Marin PD, Heithersay GS, Bridges TE. A quantitative comparison of traditional and non-peroxide bleaching agents. Endod Dent Traumatol 1998;14(2):64-7. 22. Schulte JR, Morrissette DB, Gasior EJ, Czajewski MV. The effects of bleaching application time on the dental pulp. J Am Dent Assoc 1994;125(10):1330-5. 23. Szajkis S, Tagger M, Tamse A. Bleaching of root canal treated teeth and cervical external resorption: Review of the literature. Refuat Hashinayim 1986;4(2):10-2. 24. Lado EA, Stanley HR, Weisman MI. Cervical resorption in bleached teeth. Oral Surg Oral Med Oral Pathol 1983;55(1):78-80. 25. Heller D, Skriber J, Lin LM. Effect of intracoronal bleaching on external cervical root resorption. J Endod 1992;18(4):145-8. 26. Madison S, Walton R. Cervical root resorption following bleaching of endodontically treated teeth. J Endod 1990;16(12):570-4. 27. Haywood VB. Greening of the tooth-amalgam interface during extended 10% carbamide peroxide bleaching of tetracycline-stained teeth: A case report. J Esthet Restor Dent 2002;14(1):12-7. 28. Barkhordar RA, Kempler D, Plesh O. Effect of nonvital tooth bleaching on microleakage of resin composite restorations. Quintessence Int 1997;28(5):341-4. 29. Teixeira EC, Hara AT, Turssi CP, Serra MC. Effect of nonvital tooth bleaching on resin/enamel shear bond strength. J Adhes Dent 2002;4(4):317-22.

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30. Teixeira EC, Hara AT, Turssi CP, Serra MC. Effect of nonvital tooth bleaching on microleakage of coronal access restorations. J Oral Rehabil 2003;30(11):1123-7. 31. Anderson DG, Chiego DJ Jr, Clickman GN, McCauley LK. A clinical assessment of the effects of 10% carbamide peroxide gel on human pulp tissue. J Endod 1999;25(4): 247-50. 32. 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. 33. Rotstein I, Friedman S, Mor C, Katznelson J, Sommer M, Bab I. Histological characterization of bleaching-induced external root resorption in dogs. J Endod 1991;17(9): 436-41. 34. Weiger R, Kuhn A, Löst C. Radicular penetration of hydrogen peroxide during intra-coronal bleaching with various forms of sodium perborate. Int Endod J 1994; 27(6):313-7. 35. Li Y. [Safety of peroxide containing tooth whiteners]. Shanghai Kou Qiang Yi Xue 2001;10(2):97-9. 36. Li Y. Tooth bleaching using peroxide-containing agents: Current status of safety issue. Compend Contin Educ Dent 1998;19(3):783-6, 788, 790. 37. Macey-Dare LV, Williams B. Bleaching of a discoloured non-vital tooth: Use of a sodium perborate/water paste as the bleaching agent. Int J Paediatr Dent 1997;7(1):35-8. 38. Heithersay GS. Invasive cervical resorption following trauma. Aust Endod J 1999;25(2):79-85. 39. Heithersay GS. Treatment of invasive cervical resorption: An analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999;30(2):96-110. 40. Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors. Quintessence Int 1999;30(2):83-95. 41. Weiger R, Kuhn A, Lost C. In vitro comparison of various types of sodium perborate used for intracoronal bleaching of discolored teeth. J Endod 1994;20(7):338-41. 42. 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.


Policy on Minimizing Occupational Health Hazards Associated With Nitrous Oxide Originating Committee

Clinical Affairs Committee Review Council Council on Clinical Affairs

Adopted 1987

Revised 1993, 1996, 2000, 2003, 2008

Purpose The American Academy of Pediatric Dentistry (AAPD) recommends that exposure to ambient nitrous oxide be minimized to reduce occupational health hazards for dental personnel.

Methods This document is based on current dental, medical, and public health literature regarding the potential risks of ambient nitrous oxide exposure. A MEDLINE search was conducted using the terms “nitrous oxide”, “occupational exposure to nitrous oxide”, and “nitrous oxide and dentistry”. Guidelines and recommendations from the National Institute for Occupational Safety and Health (NIOSH) also were reviewed.1-2 Expert opinions and best current practices were relied upon when sufficient scientific data were not available.

Background Epidemiologic studies provide strong evidence that there are increased general health problems and reproductive difficulties among dental personnel chronically exposed to significant levels of ambient nitrous oxide.3-7 Nitrous oxide acts by oxidizing vitamin B12 from the active, reduced cobalamin to the inactive form. In turn, this inactivates the enzyme methionine synthetase, which requires both the active cobalamin and folate as cofactors. The inactivation of methionine synthetase decreases DNA production, thereby interfering with cell proliferation.8 Nitrous oxide has been linked epidemiologically to reproductive, hematologic, immunologic, neurologic, hepatic, and renal disorders; symptoms are time and dose dependent.9 Symptoms are reported most frequently in cases where scavenging has not been used or with chronic (recreational) abuse.9 Absolute occupational effects are still uncertain.9 Epidemiologic conclusions have been challenged.10 Adverse reproductive outcomes are linked to B12 deficient individuals and those exposed to “high nitrous oxide levels”.9 A maximum safe level of ambient nitrous oxide in the dental environment has not been determined.9-14 Reduction of ambient nitrous oxide through system maintenance, scavenging, ventilation, use of the minimal effective dose,

and patient management is critical to maintaining the lowest practical levels in the dental environment.1,2,14,15 Frequent and regular inspection and maintenance of the nitrous oxide delivery system, together with the use of a scavenging system, can reduce ambient nitrous oxide significantly.16,17 Using a well-fitted mask and an appropriate amount of suction via the scavenging system will minimize leakage, reducing ambient nitrous oxide levels.17 NIOSH has recommended that the exhaust ventilation of nitrous oxide from the patient’s mask be maintained at an air flow rate of 45 L/min and vented outside the building away from fresh air intakes.2 However, scavenging at this rate has been shown to reduce the level of pyschosedation achieved with nitrous oxide inhalation.20 Where possible, 100% clean outdoor air should be used for dental operatory ventilation.1 Supply and exhaust vents should be well separated to allow good mixing and prevent ‘short-circuiting’. 1 Appropriate patient selection is an important consideration in reducing ambient nitrous oxide levels.15 Patients who are unwilling or unable to tolerate the nasal hood and those with medical conditions (eg, obstructive respiratory diseases, emotional disturbances, drug dependencies) that contraindicate the use of nitrous oxide should be managed by other behavior guidance techniques.15 In the dental environment, patient behaviors such as talking, crying, and moving have been shown to result in significant increases in baseline ambient nitrous oxide levels despite the use of the mask-type scavenging systems.19 Use of supplemental measures, including a rubber dam and/or a high-volume dental aspirator, placed near or within 20 cm of the patient’s mouth, has been shown to reduce significantly ambient nitrous oxide levels.21-23 During the first 3-5 minutes after terminating nitrous oxide administration, a significant amount of the gas is exhaled by the patient.24 Once nitrous oxide administration is discontinued, the gas delivery system should be flushed by administering 100% oxygen to the patient for at least 5 minutes.2 This post-procedural oxygenation also decreases the risk of diffusion hypoxia to the patient. Diligent use of the above practices in the pediatric dental environment has allowed for the reduction of ambient nitrous oxide to the levels recommended oral he alth policies

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by NIOSH.14,23 Measurement of nitrous oxide levels in the dental operatory can be helpful in determining the type and extent of remediation necessary to decrease occupational exposure.

Policy statement The AAPD recommends that dentists and dental auxiliaries minimize their exposure to nitrous oxide by maintaining the lowest practical levels in the dental environment. Adherence to the recommendations below can help minimize occupational exposure to nitrous oxide. 1. Use scavenging systems that remove nitrous oxide during patient’s exhalation. 2. Ensure that exhaust systems adequately vent scavenged air and gases to the outside of the building and away from fresh air intake vents. 3. Use, where possible, 100% clean outdoor air for dental operatory ventilation. 4. Implement careful, regular inspection and maintenance of the nitrous oxide/oxygen delivery equipment. 5. Carefully consider patient selection criteria (ie, indications and contraindications) prior to administering nitrous oxide. 6. Select a properly-fitted mask size for each patient. 7. During administration, visually monitor the patient and titrate the flow/percentage to the minimal effective dose of nitrous oxide. 8. Encourage patients to minimize talking and mouth breathing during nitrous oxide administration. 9. Use rubber dam and high volume oral aspiration when possible. 10. Flush the delivery system of nitrous oxide after completion, by administering 100% oxygen to the patient for at least 5 minutes.

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. Rowland AS, Baird DD, Weinberg CR, Shore DL, Shy CM, Wilcox AJ. Reduced fertility among women employed as dental assistants exposed to high levels of nitrous oxide. N Engl J Med 1992;327(14):993-7. 4. Cohen EN, Brown BW Jr, Bruce DL, et al. A survey of anesthetic health hazards among dentists. J Am Dent Assoc 1975;90(6):1291-6. 5. Cohen EN, Gift HC, Brown BW Jr, et al. Occupational disease in dentistry and chronic exposure to trace anesthetic gases. J Am Dent Assoc 1980(1);101:21-31. 6. Brodsky JB, Cohen EN, Brown BW Jr, Wu ML, Whitcher CE. Exposure to nitrous oxide and neurologic disease among dental professionals. Anesth Analg 1981;60(5):297-301. 66


7. 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. 8. Emmanouil DE, Quock RM. Advances in understanding the actions of nitrous oxide. Anesth Prog 2007;54(1):9-18. 9. Louis-Ferdinand RT. Myelotoxic, neurotoxic, and reproductive adverse effects of nitrous oxide. Adverse Drug React Toxicol Rev 1994;13(4):193-206. 10. Clark MS, Renehan BW, Jeffers BW. Clinical use and potential biohazards of nitrous oxide/oxygen. Gen Dent 1997; 45(5):486-91. 11. Howard WR. Nitrous oxide in the dental environment: Assessing the risk and reducing the exposure. J Am Dent Assoc 1997;128(3):356-60. 12. 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. 13. Donaldson D, Meechan JG. The hazards of chronic exposure to nitrous oxide: An update. Br Dent J 1995;178(3):95-100. 14. Johnston J. Nitrous oxide: Your health not theirs. Br J Theatre Nurs 1993;3(6):29-30. 15. American Academy of Pediatric Dentistry. Guideline on appropriate use of nitrous oxide for pediatric dental patients. Pediatr Dent 2008;30(suppl):140-2. 16. Sass-Kortasak AM, Wheeler IP, Purdham JT. Exposure of operating room personnel to anaesthetic agents: An examination of the effectiveness of scavenging systems and the importance of maintenance programs. Can Anaesth Soc J 1981;28(1):22-8. 17. Flowerdew RM, Brummitt WM. Reduction of nitrous oxide contamination in a pediatric hospital. Can Anaesth Soc J 1979;26(5):370-4. 18. 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. 19. 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. 20. 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 inhalation. Pediatr Dent 1992;14(1):19-25. 21. 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. 22. Carlsson P, Ljungqvist B, Hallén B. The effect of local scavenging on occupational exposure to nitrous oxide. Acta Anaesthesiol Scand 1983;27(6):470-5. 23. 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. 24. Crouch KG, McGlothin JD, Johnston OE. A long-term study of the development of N2O controls at a pediatric dental facility. AIHAJ 2000;61(5):753-6.


Policy on the Use of Deep Sedation and General Anesthesia in the Pediatric Dental Office Originating Council Ad Hoc Committee on Sedation and Anesthesia


Adopted 1999

Revised 2004, 2007

Purpose The American Academy of Pediatric Dentistry (AAPD), as the advocate for oral health in infants, children, adolescents, and persons with special health care needs, recognizes that there exists a patient population for whom routine dental care using nonpharmacologic behavior guidance techniques is not a viable approach. It also recognizes that a population of patients, because of their need for extensive treatment, acute situational anxiety, uncooperative age-appropriate behavior, immature cognitive functioning, disabilities, or medical conditions, would benefit from deep sedation or general anesthesia.1

Background Pediatric dentists have long sought to provide dental care to their young and disabled patients in a manner which will promote excellence in quality of care and concurrently induce a positive attitude in the patient toward dental treatment. Behavior guidance techniques have allowed most children to receive treatment in the dental office with minimal discomfort and without expressed fear. Sedation has provided others with the ability to accept treatment. However, some children and developmentally disabled patients require general anesthesia to receive comprehensive dental care in a safe and humane fashion. Many pediatric dentists (and others who treat children) have sought to provide for the administration of general anesthesia by properly-trained individuals in their offices or other facilities (eg, outpatient care clinics) outside of the traditional hospital setting. In 1998, the AAPD established its Guideline on the Elective Use of Minimal, Moderate, and Deep Sedation and General Anesthesia in Pediatric Dental Patients.2 In an effort to unify guidelines for sedation used by medical and dental practitioners, the American Academy of Pediatrics and the AAPD in 2006 coauthored a statement entitled Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.3 This revised guideline reflects the current understanding of appropriate monitoring needs and, further, provide

definitions and characteristics of 3 levels of sedation (minimal, moderate, and deep) and general anesthesia involving pediatric patients. When deep sedation or general anesthesia is provided in a private pediatric dental office, the pediatric dentist must be responsible for evaluating the educational and professional qualifications of the general anesthesia or deep sedation provider (if it is other than himself ) and determining that the provider is in compliance with state rules and regulations associated with the provision of deep sedation and general anesthesia. The pediatric dentist is also responsible for establishing a safe environment that complies with local, state, and federal rules and regulations, as well as the Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures3 for the protection of the patient.

Educational requirements Deep sedation and general anesthesia must be provided only by qualified and appropriately-trained individuals and in accordance with state regulations. Such providers may include pediatric dentists who have completed advanced education in anesthesiology beyond their pediatric residency advanced training program, dental or medical anesthesiologists, certified registered nurse anesthetists, or anesthesia assistants. The expertise in providing deep sedation and general anesthesia cannot be gained through the undergraduate dental school curriculum or continuing education. Only dentists who have completed an advanced education program which meets the requirements of the American Dental Association (ADA) are considered qualified to provide deep sedation and general anesthesia in practice. This includes: 1. completion of an advanced training program in anes thesia and related subjects beyond the predoctoral dental curriculum that satisfies the requirements de scribed in Part Two of the ADA Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry4 at the time training was commenced; oral he alth policies

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2. completion of an ADA-accredited post-doctoral training program (eg, oral and maxillofacial surgery) which affords comprehensive and appropriate train ing necessary to administer and manage deep sedation/general anesthesia.

Risk management As stated above, the pediatric dentist is responsible for providing a safe environment for the in-office provision of deep sedation and general anesthesia. In addition to evaluating the qualifications of the anesthesia provider, he/she must be involved with the following aspects of care to minimize risks for the patient: 1. facilities and equipment; 2. monitoring and documentation; 3. patient selection utilizing medical history, physical status, and indications for anesthetic management; 4. preoperative evaluation; 5. appropriately-trained support personnel; 6. emergency medications, equipment, and protocols; 7. preoperative and postoperative patient instructions; 8. criteria and management of recovery and discharge.

Continuous quality improvement To reduce the chance of medical error and determine root cause, aspects of continuous quality improvement are applied in the outpatient setting during the administration of deep sedation and general anesthesia as described in the Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.3 Adverse events are recorded and examined for assessment of risk reduction and improvement in patient satisfaction.

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Policy statement The AAPD endorses the in-office use of deep sedation or general anesthesia on select pediatric dental patients administered either by a trained, credentialed, and licensed pediatric dentist, dental or medical anesthesiologist, nurse anesthetist, or anesthesia assistant in an appropriately-equipped and staffed facility.

References 1. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2006;28(suppl):97-105. 2. American Academy of Pediatric Dentistry. Guideline on the elective use of minimal, moderate, and deep sedation and general anesthesia in pediatric dental patients. Pediatr Dent 2004;26(suppl):95-103. 3. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatr Dent 2006;28(suppl):115-32. 4. American Dental Association. Guidelines for teaching the comprehensive control of anxiety and pain in dentistry. Chicago, Ill: ADA House of Delegates; 2005. Available at: “http://www.ada.org/prof/resources/positions/statements/ anxiety_guidelines.pdf ”. Accessed May 6, 2007.


Policy on Hospitalization and Operating Room Access for Dental Care of Infants, Children, Adolescents, and Persons With Special Health Care Needs Originating Committee

Dental Care Committee


Adopted 1989

Revised 1997, 2001, 2005, 2010

Reaffirmed 1993

Purpose The American Academy of Pediatric Dentistry (AAPD) advocates, when indicated, hospitalization and equal access to operating room facilities for dental care of infants, children, adolescents, and persons with special health care needs. The AAPD recognizes that barriers to hospital dental care for patients best treated in that setting need to be addressed.

Method This policy is an update of the previous document revised in 2005. An updated electronic search was performed using the parameters: Terms: “access to care for dental care in hospitals”, “operating room access for dental care”; Fields: all fields; Limits: within the last 10 years.

Background Pediatric dentists often treat patients who present special challenges related to their age, behavior, medical status, developmental disabilities, intellectual limitations, or special needs. Caries, periodontal diseases, and other oral conditions, if left untreated, can lead to pain, infection, and loss of function.1-4 These undesirable outcomes adversely can affect learning, communication, nutrition, and other activities necessary for normal growth and development.5-7 Many medical conditions (eg, hematological, oncological) are compounded by the presence of oral maladies and disease. To address these challenges and meet these treatment needs effectively, pediatric dentists have developed and employ a variety of management techniques, including accessing anesthesia services and/or the provision of dental care in a hospital setting with or without general anesthesia. Hospital dentistry is an integral part of the curriculum of all accredited advanced pediatric dental training

programs. Pediatric dentists are, by virtue of training and experience, qualified to recognize the indications for such an approach and to render such care.8 Pediatric dentists occasionally have experienced difficulty in gaining an equal opportunity to schedule operating room time, postponement/delay of nonemergency dental care, and economic credentialing. Economic credentialing (ie, the use of economic criteria not related to quality of care or professional competency) to determine qualifications for granting/renewing an individual’s clinical staff membership or privileges should be opposed.9 The AAPD and the American Dental Association urge hospital insurance carriers to include hospitalization benefits for dental treatment in both private and public insurance programs so that the resources of a hospital are available to patients whose condition, in the judgment of the dentist, warrants treatment in the operating room.10 The mutual objective of both the governing board and the medical staff is to improve the quality and efficiency of patient care in the hospital. Decisions regarding hospital privileges should be based upon the training, experience, and demonstrated competence of candidates, 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.11

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 dental care for patients best treated in those settings. The AAPD affirms that hospitals or


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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 to these facilities. The dental patient, as with any other patient, should have the right to be seen in a timely manner.

References 1. 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. 2. 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. 3. Milano M, Seybold SV. Dental care for special needs patients: A survey of Texas pediatric dentists. J Dent Child 2002;69(2):212-5. 4. American Academy of Pediatric Dentistry. Definition of dental disability. Pediatr Dent 2009;31(special issue):12. 5. American Academy of Pediatric Dentistry. Definition of dental neglect. Pediatr Dent 2009;31(special issue):11. 6. Kay L, Killian C, Lindemeyer R. Special Patients. In: Nowak AJ, Casamassimo PS, eds. Pediatric Dentistry: The Handbook. 3rd ed. Chicago, Ill: American Academy of Pediatric Dentistry; 2007:260.

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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 Dental Association Commission on Dental Accreditation. Accreditation standards for advanced specialty education programs in pediatric dentistry: Hospital and adjunctive experiences. Chicago, Ill; 1998:25-9. 9. American Medical Association. Policy H-230.975 Economic credentialing. Adopted 1991; reaffirmed 1998. Available at: “http://www.ama-assn.org/ama/pub/ physician-resources/legal-topics/medical-staff-topics/ economic-credentialing.shtml\”. Accessed Jun 22, 2010. 10. American Dental Association. Current policies, economic credentialing (1993:692). Available at: “http://www.ada. org/sections/about/pdfs/doc_policies.pdf ”. Accessed June 22, 2010. 11. American Medical Association. Policy E-4.07 Staff privileges. Issued July, 1983; updated June, 1994. Available at: “http://www.ama-assn.org/ama/pub/physician-resources/ medical-ethics/code-medical-ethics/opinion407.shtml”. Accessed June 22, 2010.


Policy on Hospital Staff Membership Originating Committee

Hospital Guidelines for Pediatric Dentistry Ad Hoc Committee Review Council Council on Clinical Affairs

Adopted 1977

Revised 1979, 1991, 1999, 2002, 2005, 2010

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that dentists have the 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.

Method This document is an update of the previous policy, revised in 2005. The update included an electronic search using the parameters: Terms: “hospital staff ” AND “dentistry”; Fields: all fields; 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 dental services to patients within an operating room setting. Additionally, the pediatric dentist can provide consultative and emergency services.1 “Team” (eg, cleft lip/palate, hemophilia) evaluations of patients often require dental input, and certain medical protocols (eg, 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 administrative 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 (previously known as board eligibility) increasingly is being 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 rotations, timely completion of medical records, and compliance with the rules and regula-

tions of the medical/dental staff and the policies and procedures of the hospital. Although hospital and medical/dental staffs have some individual latitude, the standards for all hospital services are issued by national commissions such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO).2 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. Economic credentialing (ie, the use of economic criteria not related to quality of care or professional competency) to determine qualifications for granting/renewing an individual’s clinical staff membership or privileges should be opposed. The mutual objective of both the governing board and the medical staff is to improve the quality and efficiency of patient care in the hospital. Decisions regarding privileges should be based upon the training, experience, and demonstrated competencies of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital, and especially the patient. Privileges should not be based on numbers of patients admitted to the facility or the patient’s economic or insurance status.4

Policy statement The AAPD: 1. 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. 2. Recognizes the American Dental Association as a corporate member of the JCAHO and further recognizes the standards for hospital governance, as established by the JCAHO.


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3. 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. 4. Is opposed to the use of economic credentialing to determine qualifications for granting/renewing a practitioner’s clinical staff membership or privileges.

References 1. Weddell JA, Jones JE. Hospital dental services for children and the use of general anesthesia. In: Dean JA, Avery DR, McDonald RE, eds. McDonald and Avery’s Dentistry for the Child and Adolescent. 9th ed. Maryland Heights, Mo: Mosby Elsevier; 2011:277.

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2. Joint Commission on Accreditation of Health Care Organizations. Medical staff chapter (MS). In: 2009 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Health Care Organizations; 2009. 3. American Medical Association. Policy H-230.975 Economic credentialing. Adopted 1991; reaffirmed 1998. Available at: “http://www.ama-assn.org/ama/pub/physicianresources/legal-topics/medical-staff-topics/economiccredentialing.shtml\”. Accessed Jun 22, 2010. 4. American Medical Association. Policy E-4.07 Staff privileges. Issued July, 1983; updated June, 1994. Available at: “http://www.ama-assn.org/ama/pub/physician-resources/ medical-ethics/code-medical-ethics/opinion407.shtml”. Accessed June 22, 2010.


Policy on Model Dental Benefits for Infants, Children, Adolescents, and Individuals With Special Health Care Needs Originating Councils Council on Dental Benefit Programs/Council on Clinical Affairs

Adopted 2008

Purpose

Policy Statement

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 decisions about the appropriateness of oral health care services for these patient populations.

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, 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 (ie, 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 Expected benefits of care should outweigh potential risks. Value of services is an important consideration, and all stakeholders should recognize that cost-effective care is not necessarily the least expensive treatment. Consistent with AAPD clinical guidelines, the following services should be included in health benefit plans.

Methods This policy is based upon a review of AAPD’s systematicallydeveloped oral health policies 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, in accordance with its vision and mission, advocates optimal oral health and health care for all infants, children, adolescents, and individuals with special health care needs. 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 life-long consequences in educational, social, and occupational environments. When oral health care is not accessible, the health implications, effects on quality of life, and societal costs are enormous.1 The AAPD’s oral health policies and clinical guidelines2 encourage the highest possible level of care to children and patients with special health care needs. The AAPD also sponsors a national consensus conference or symposium each year on pediatric oral health care and publishes those proceedings in a special issue of Pediatric Dentistry. Those documents,2-6 as well as clinical practice guidelines from other organizations with recognized professional expertise and stature,7-13 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.

A. Preventive services: (1) Initial and periodic examinations of the dentition and oral cavity, including medical and dental histories, furnished in accordance with the attached periodicity schedule15 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; (3) Age-appropriate anticipatory guidance and counseling on non-nutritive habits, injury prevention, and tobacco use/ substance abuse; (4) Application of topical fluoride at a frequency based upon caries risk factors; (5) Prescription of dietary fluoride supplement12 based upon a child’s age, caries risk, and fluoride level of the water supply or supplies; (6) Application of pit and fissure sealants based on caries risk factors, not based upon patient age or time lapsed since eruption;16 (7) Dental prophylactic services at a frequency based on caries and periodontal risk factors.


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B. Diagnostic procedures consistent with guidelines developed by organizations with recognized professional expertise and stature, including radiographs in accordance with recommendations by the US Food and Drug Administration and the American Dental Association.9 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.17 D. Orthodontic services including space maintenance and services to diagnose, prevent, intercept, and treat malocclusions, including management of children with cleft lip or palate and/or congenital or developmental defects. These services include, but are not limited to, initial appliance construction and replacement of appliances as the child grows. E. Dental and oral surgery which shall include sedation/general anesthesia and related medical services that shall be furnished on an inpatient basis when medically necessary. F. Periodontal services to resolve gingivitis, periodontitis, and other periodontal diseases or conditions in children. G. Prosthodontic services, including implants to restore oral function, that are consistent with guidelines developed by organizations with recognized professional expertise and stature. H. Diagnostic and therapeutic services related to the management of orofacial trauma. When the injury involves a primary tooth, benefits should cover complications for the developing succedaneous tooth. I. Drug prescription for preventive services, relief of pain, or treatment of infection. J. Medically necessary services for preventive and therapeutic care in patients with medical, physical, or behavioral conditions. 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 non-pharmacologic management techniques. L. Consultative services provided by a pediatric dentist when the dental home has been established with a general practitioner or when requested by another dental specialist or medical care provider.

References 1. US Dept of Health and Human Services. Oral health

in America: A report of the Surgeon General–Executive

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summary. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at: “http://www2.nidcr.nih.gov/sgr/execsumm.htm”. Accessed April 3, 2008. 2. American Academy of Pediatric Dentistry. Reference manual. Pediatric Dentistry Supplement. Chicago, Ill. Available at: “http://www.aapd.org/media/policies.asp”. Accessed June 7, 2008. 3. American Academy of Pediatric Dentistry. Pediatric dentistry restorative consensus conference. Pediatr Dent 2002; 24(5):374-516. 4. American Academy of Pediatric Dentistry. Symposium on behavior guidance. Pediatr Dent 2004;26(2):110-83. 5. American Academy of Pediatric Dentistry. Symposium on the prevention of oral disease in children and adolescents. Pediatr Dent 2006;28(2):96-198. 6. Proceedings of the Joint Symposium on Emerging Science in Pulp Therapy: New Insights into Dilemmas and Controversies. November 2-3, 2007. Chicago, Ill. Pediatr Dent 2008;30(3):190-267. 7. American Association of Endodontists. Guide to Clinical Endodontics. 4th ed. Chicago, Ill. American Association of Endodontists; 2004. 8. A merican Academy of Periodontology. Periodontal diseases of children and adolescents. J Periodontol 2003; 74:1696-704. 9. American Dental Association, US Dept of Health and Human Services. The Selection of Patients for X-Ray Examination: Dental Radiographic Examinations. Rockville, Md.: Food and Drug Administration, 2004; HHS Publication Number 88-8273. Available at: “http://www. ada.org/prof/resources/topics/radiography.asp”. Accessed April 3, 2008. 10. American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of patients with cleft lip/ palate or other craniofacial anomalies. Chapel Hill, NC: The Maternal and Child Health Bureau, Title V, Social Security Act, Health Resources and Services Administration, US Public Health Service, DHHS; November 2007. Grant # MCJ-425074. Available at: “http://www.acpacpf.org/teamcare/parameters07rev.pdf ”. Accessed April 1, 2008. 11. National Foundation for Ectodermal Dysplasias. Parameters of oral health care for individuals affected by ectodermal dysplasias. National Foundation for Ectodermal Dysplasias. Mascoutah, Ill. 2003. Available at: “http://www. nfed.org”. Accessed June 7, 2008. 12. American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation for children: Interim policy recommendations. Pediatrics 1995;95(5):777. 13. Casamassimo P, Holt K, eds. Bright Futures in Practice: Oral Health—Pocket Guide. Washington, DC: National Maternal and Child Oral Health Resource Center; 2004. 14. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2008;30(suppl):22-3.


15. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for infants, children, and adolescents. Pediatr Dent 2009;31(special issue):118-25.

16. Feigal RJ, Donly KJ. The use of pit and fissure sealants. Pediatr Dent 2006;28(2):143-50. 17. American Academy of Pediatric Dentistry. Guideline on pediatric restorative dentistry. Pediatr Dent 2008;30 (suppl):163-9.

Recommendations 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 (AAPD) 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 Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Infants, Children, and Adolescents ( www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf) for supporting information and references.

AGE

American Academy of Pediatric Dentistry

6 TO 12 MONTHS

12 TO 24 MONTHS

2 TO 6 YEARS

6 to 12 YEARS

12 YEARS AND OLDER

1

•

•

•

•

•

Assess oral growth and development

20

•

•

•

•

•

Caries-risk assessment

30

•

•

•

•

•

4

•

•

•

•

•

3,4

•

•

•

•

•

5

•

•

•

•

•

6 80

•

•

•

•

•

7

Parent

Parent

Patient/parent

Patient/parent

Patient

8 10

•

•

•

•

•

9

•

•

•

•

•

12 10

•

•

•

•

•

•

•

• •

•

•

•

•

•

•

•

•

•

Clinical oral examination

Radiographic assessment Prophylaxis and topical fluoride Fluoride supplementation Anticipatory guidance/counseling Oral hygiene counseling Dietary counseling Injury prevention counseling Counseling for nonnutritive habits Counseling for speech/language development Substance abuse counseling

1

Counseling for intraoral/perioral piercing Assessment and treatment of developing malocclusion

1 0

10

Assessment for pit and fissure sealants

11

Assessment and/or removal of third molars

10

•

Transition to adult dental care

•

1 First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child’s risk status/susceptibility to disease. Includes assessment of pathology and injuries. 2 By clinical examination. 3 Must be repeated regularly and frequently to maximize effectiveness. 4 Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease. 5 Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years. 6 Appropriate discussion and counseling should be an integral part of each visit for care. 7 Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child. 8 At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and childhood obesity. 9 Initially play objects, pacifiers, car seats; when learning to walk; then with sports and routine playing, including the importance of mouthguards. 10 At first, discuss the need for additional sucking: digits vs pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism. 11 For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.


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Policy on Third-party Reimbursement of Medical Fees Related to Sedation/General Anesthesia for Delivery of Oral Health Services Originating Committee

Dental Care Committee


Adopted 1989

Revised 1995, 2000, 2003, 2006

Reaffirmed 1993

Purpose The American Academy of Pediatric Dentistry (AAPD), to ensure that all children have access to the full range of oral health delivery systems, advocates that if sedation or general anesthesia and related facility fees are payable benefits of a health care plan, these same benefits shall apply for the delivery of oral health services.

Methods This policy 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. A MEDLINE search was conducted using the terms “general anesthesia/sedation costs”, “general anesthesia/sedation reimbursement”, and “general anesthesia/sedation insurance coverage”. Relevant policies and guidelines of the AAPD are included.

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 represents the only appropriate method to deliver necessary oral health care.1,2 The patient’s age, dental needs, disabilities, medical conditions, and/or acute situational anxiety may preclude the patient’s being treated safely in a traditional outpatient setting.3-8 These patients may be denied access to oral health care when insurance companies refuse to provide reimbursement for sedation/general anesthesia and related facility services. Most denials cite the procedure as not medically necessary. This determination appears to be based on arbitrary and inconsistent criteria.9-14 For instance, medical policies often provide 76


reimbursement for sedation/general anesthesia or facility fees related to myringotomy for a 3-year-old child, but deny these benefits when related to treatment of dental disease and/or infection for the same patient. American Dental Association (ADA) 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”.15

Policy statement The AAPD strongly believes that the dentist providing the oral health care for the patient determines the medical necessity of sedation/general anesthesia consistent with accepted guidelines on sedation and general anesthesia.1,7 The AAPD encourages third party payors to: 1. recognize that sedation and/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 discrimination between the “medical” or “dental” nature of the procedure; 3. end arbitrary and unfair refusal of reimbursement for sedation, general anesthesia, 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.16


References 1. American Academy of Pediatric Dentistry. Definition of medically necessary care. Pediatr Dent 2005;27(suppl):14. 2. American Academy of Pediatrics. Model contractual language for medical necessity for children. Pediatr 2005; 116(1):261-2. 3. 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. 4. Eidelman E, Faibis S, Peretz B. A comparison of restorations for children with early childhood caries treated under general anesthesia or conscious sedation. Pediatr Dent 2000;22(1):33-8. 5. 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. 6. Ferretti GA. Guidelines for outpatient general anesthesia to provide comprehensive dental treatment. Dent Clin North Am 1984;28(1):107-20. 7. American Academy of Pediatric Dentistry. Guideline on the elective use of minimal, moderate, and deep sedation and general anesthesia in pediatric dental patients. Pediatr Dent 2005;27(suppl):110-8. 8. Wilson S. Pharmacological management of the pediatric dental patient. Pediatr Dent 2004;26(2):131-6.

9. Patton LL, White BA, Field MJ. State of the evidence base for medically necessary oral health care. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(3):272-5. 10. Flick WG, Claybold S. Who should determine the medical necessity of dental sedation and general anesthesia? A clinical commentary supported by Illinois patient and practitioner surveys. Anesth Prog 1998;45(2):57-61. 11. Conway TE. What is currently available in terms of medically necessary oral care? Spec Care Dentist 1995;15 (5):187-91. 12. White BA. The costs and consequences of neglected medically necessary oral care [review]. Spec Care Dentist 1995;15(5):180-6. 13. Cameron CA, Litch CS, Liggett M, Heimberg S. National 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. American Dental Association. Transactions of the ADA: Benefits for services by qualified practitioners. Chicago, Ill; 1989:546. 16. American Dental Association. Transactions of the ADA: Standards for dental benefit plans. Chicago, Ill; 2000:458.


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Policy on Third-party Reimbursement for Oral Health Care Services Related to Congenital Orofacial Anomalies Originating Committee


Adopted 1996

Revised 2000, 2003, 2006

Purpose The American Academy of Pediatric Dentistry (AAPD), recognizing that patients with craniofacial 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 advocates compensation for provision of comprehensive oral health care services throughout life.

Methods This policy is based on review of current dental and medical literature, as well as policies and guidelines established by stakeholders in the health of infants, children, and adolescents affected by craniofacial anomalies. A MEDLINE search was conducted using the terms “orofacial anomalies”, “congenital anomalies”, “cleft lip/palate”, “third party reimbursement”, and “insurance”. Data is not available to determine the effectiveness of various insurance coverage or limitations of that coverage on children with craniofacial anomalies.

Background Congenital orofacial anomalies that result in malformed or missing teeth, such as but not limited to ectodermal dysplasia sia and cleft defects, can have significant negative functional, esthetic, and psychological effects on individuals and their families.1,2 Young children benefit from esthetic and functional restorative 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 have to be remade as the individual grows. These patients often are denied coverage for initial appliance construction and, more frequently, replacement of appliances as the child grows. Third-party payors legally may control the

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coverage of these services by limiting contractual benefits. The distinction between congenital anomalies involving the orofacial complex and those involving other parts of the body is often arbitrary and unfair. For instance, health care policies may provide reimbursement for the necessary prosthesis required for congenitally missing extremities 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 care services even when they clearly are associated with the complete habilitation of the craniofacial condition.3 Furthermore, clerical personnel and professional consultants employed by third-party payors often make benefit determinations based on arbitrary distinction between medical vs dental anomalies, ignoring important functional and medical relationships. Evaluation and care provided for an infant, child, or adolescent by a cleft lip/palate, orofacial, or craniofacial deformities team have been described as the optimal way to coordinate and deliver complex services.3 This approach may provide additional documentation to facilitate “medical necessity” of dental rehabilitation.4

Policy statement The AAPD strongly believes that the dentist providing the oral health care for the patient determines the medical indication and justification for treatment in these cases. The AAPD encourages third party payors to: 1. recognize that malformed and missing teeth and resultant anomalies of facial development seen in orofacial anomalies are congenital defects, just as the congenital absence of other body parts, requiring care over the lifetime of the patient;


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 examinations, and replacement of appliances; 3. end arbitrary and unfair refusal of compensation for oral health care services related to these facial and dental anomalies; 4. regularly consult the AAPD with respect to the development of benefit plans that best serve the oral health interests of infants, children, and adolescents with craniofacial anomalies.

References 1. American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Revised ed. Chapel Hill, NC: American Cleft Palate-Craniofacial Association; April 2000. 2. National Foundation for Ectodermal Dysplasias. Parameters of oral health care for individuals affected by ectodermal dysplasias. National Foundation for Ectodermal Dysplasias. Mascoutah, Ill; 2003:9. 3. Strauss RP. The organization and delivery of craniofacial services: The state of the art. Cleft Palate Craniofac J 1999; 36(3):189-95. 4. American Academy of Pediatrics. Policy statement: Model contractual language for medical necessity for children. Pediatr 2005;116(1):261-2.


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Policy on Third-party Reimbursement of Fees Related to Dental Sealants Originating Committee Clinical Affairs Committee


Adopted 1999

Revised 2000, 2006

Purpose

Recommendations

The American Academy of Pediatric Dentistry (AAPD) recognizes that the placement of sealants and their continued maintenance are scientifically-sound and cost-effective techniques for prevention of pit and fissure caries.

1. The dentition should be evaluated periodically for developmental defects and deep pits and fissures that may contribute to caries risk. Dental sealants should be placed on susceptible teeth and should be evaluated for repair or replacement as part of a periodic dental examination. 2. Third party coverage for sealants should not be based upon a patient’s age. Timing of the eruption of teeth can vary widely. Furthermore, caries risk may increase at any time during a patient’s life. 3. The AAPD shall work with other dental organizations, 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.

Methods This revision is based upon a review of current dental literature related to dental sealants. A MEDLINE search was conducted using the terms “dental sealants”, “indications”, and “insurance”.

Background According to national estimates, by 17 years of age, 78% of children in the United States have experienced caries.1 As much as 90% of all caries in school-aged children occurs in pits and fissures. The teeth at highest risk by far are permanent first and second molars where fluoride has its least preventive effect on the pits and fissures. Any tooth, including primary teeth and permanent teeth other than molars, may benefit from sealant application due to fissure anatomy and caries risk factors.2,3 Caries risk may increase due to changes in patient habits, oral microflora, or physical condition, and unsealed teeth subsequently might benefit from sealant application.2,3 Current data also show that, although initial sealant retention rates are high, sealant loss does occur.2 It is in the patient’s interest to receive periodic evaluation of sealants for maintenance or replacement. 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. With appropriate followup care, the success rate of sealants may be 80 to 90%, even after a decade.2 Although sealants are safe and effective, their use continues to be low.4 Sealants are particularly effective in preventing pit and fissure caries and providing cost savings if placed on patients during periods of greatest risk.5,6 However, initial insurance coverage for sealants often is denied, and insurance coverage for repair and/or replacement may be limited.7

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References 1. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 2. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent 2002;24(5):415-22. 3. American Academy of Pediatric Dentistry. Guideline on pediatric restorative dentistry. Pediatr Dent 2005;27 (suppl):122-9. 4. US Dept of Health and Human Services. Healthy people 2010. Rockville, Md: US Dept of Health and Human Services, National Institutes of Health; 2000. 5. Weintraub JA. Pit and fissure sealants in high-caries risk individuals. J Dent Educ 2001;65(10):1084-90. 6. American Dental Association Council on Access, Prevention, and Interprofessional Relations, American Dental Association Council on Scientific Affairs. Dental sealants. J Am Dent Assoc 1997;128(4):485-8. 7. American Dental Association. Statement on preventive coverage in dental benefits plans. Chicago, Ill; 1992:602; 1994:656.


Policy on the Role of Pediatric Dentists as Both Primary and Specialty Care Providers Originating Council Council on Clinical Affairs


Adopted 2003

Revised 2008

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 dentists play in the provision of professional oral health care, which includes both primary and specialty care services.

Methods

The AAPD respects the rights of employers to negotiate health care benefits for their employees. Unfortunately, thirdparty payors sometimes do not recognize pediatric dentists as primary care providers. This position restricts access to pediatric dentists for children who have reached a predetermined age.

Policy statement

This statement was based on a review of the accreditation standards for advanced specialty training programs in pediatric dentistry and the AAPD position paper on the role of pediatric dentists as primary and specialty care providers.1,2 A MEDLINE search was conducted using the terms “pediatric dentist”, “pediatric specialist”, “primary care provider”, and “specialty care provider”.

The AAPD recognizes that infants, children, adolescents, and individuals with special health care needs have the right to quality oral healthcare. 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.

Background

References

“Pediatric dentistry is an age-related specialty that provides both primary and comprehensive preventive and therapeutic oral health needs for infants and children through adolescence, 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.

1. American Dental Association Commission on Dental Ac-

creditation. Accreditation standards for advanced specialty education programs in pediatric dentistry. Chicago, Ill; 2000. 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; 2002.


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Policy on Patient Safety Originating Council


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 healthcare services and to implement practices that decrease a patient’s risk of injury or harm during the delivery of care. This policy is not intended to duplicate safety recommendations for medical facilities accredited by national commissions such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or those related to workplace safety such as Occupational Safety & Health Administration (OSHA).

Methods This guideline is based on a review of the current dental and medical literature related to patient safety. A MEDLINE literature search was conducted using the terms “patient safety”, “risk management”, “patient’s rights”, and “dentistry”.

Background All health care systems should be designed to promote patient health and protection. Dental practices must be in compliance with federal laws that help protect patients from misuse of personal information [eg, Health Insurance Portability and Accountability Act (HIPAA)]1-4 and potential dangers such as the transmission of disease. State and local laws help regulate potential chemical and environmental hazards (eg, radiation) and facilities (eg, fire prevention systems, emergency exits). Furthermore, state dental practice acts are intended to regulate the competency of and provision of services by dental health professionals. Designing health care systems that focus on preventing errors is critical to assuring patient safety. Some possible sources of error in the dental office are miscommunication, failure to review the patient’s medical history (eg, current drugs and medications), and lack of standardized records, abbreviations, and processes.5 Standardization helps assure clerical and clinical personnel execute their responsibilities in a safe and effective manner. Policy and procedure manuals that describe each facility’s established protocols serve as a valuable training tool for new employees and reinforce a consistent approach for safe, quality patient care. Identifying deviations from such protocols and studying patterns of occurrence can help reduce

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the likelihood of adverse events.6 Reducing clinical errors requires a careful examination of adverse events and root cause analysis of how the event could be avoided in the future. 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. Scientific knowledge and technology continually advance, and patterns of care evolve due, in part, to recommendations by organizations with recognized professional expertise and stature. Some recommendations can be based only on suggestive evidence or theoretical rationale (eg, infection control); other concerns of clinical practice remain in flux (eg, materials utilized in restorative dentistry). Consequently, the dental patient would benefit from a practitioner who follows current literature and participates in professional continuing education courses to increase awareness and knowledge of best current practices. The AAPD emphasizes safe, age-appropriate, nonpharmacological or pharmacological behavior guidance techniques for use with pediatric dental patients. It is important to base behavior guidance on each patient’s individual needs with goals of fostering a positive dental attitude, safety, and providing quality dental care.7 Appropriate diagnosis of behavior and safe and effective implementation of advanced behavior guidance techniques (ie, protective stabilization, sedation, general anesthesia) necessitate knowledge and experience that generally are beyond the core knowledge that students receive during predoctoral education.7

Policy Statement To promote patient health and protection, the AAPD recommends: 1. Professional continuing education by all licensed dental professionals to maintain familiarity with current regulations, technology, and clinical practices. 2. Compliance with federal laws such as HIPAA to protect patients against misuse of information identifiable to them.1 3. Compliance 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.2-4


4. Routine inspection of physical facility in regards to patient safety. This would include development of office emergency and fire safety protocols and routine inspection and maintenance of clinical equipment. 5. Recognition that informed consent by the parent is essential in the delivery of health care and effective relationship/ communication practices can help avoid problems and adverse events.8 The parent should be encouraged to be an active participant in the child’s care. 6. Accuracy of patient identification with the use of at least 2 patient identifiers, such as name and date of birth, when providing care, treatment, or services.5,9 7. An accurate and complete patient chart that can be interpreted by a knowledgeable third party.10 Standardizing abbreviations, acronyms, and symbols throughout the record is recommended. 8. An accurate, comprehensive, and up-to-date medical/ dental history including medications and allergy list to ensure patient safety during each visit.10 Ongoing communication with health care providers, both medical and dental, who manage the child’s health helps ensure comprehensive, coordinated care of each patient. 9. Appropriate staffing and supervision of patients treated in the dental office. 10. Adherence to AAPD recommendations on behavior guidance, especially as they pertain to use of advanced behavior guidance techniques (ie, protective stabilization, sedation, general anesthesia).7 11. Standardization and consistency of processes within the practice. A policies and procedures manual, with ongoing 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 (eg, rubber dam isolation)11 and minimize opportunity for injury during delivery of care (eg, protective eyewear). 12. Minimizing exposure to nitrous oxide by maintaining the lowest practical levels in the dental environment. This would include routine inspection and maintenance of nitrous oxide delivery equipment as well as adherence to clinical guidelines for patient selection and delivery of inhalation agents.12 13. Minimizing radiation exposure through adherence to ALARA (as low as reasonably achievable) principle, equipment inspection and maintenance, and patient selection criteria.13 14. 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.14 15. Dentists who utilize in-office anesthesia care 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 evaluation, and any prescriptions along with the instructions given for their use. The dentist and anesthesia care provider must communicate during treatment to share concerns about the airway or other details of patient safety.15 16. Ongoing quality improvement strategies. Routine assessment of risk, adverse events, and mistakes with a plan for reduction and improvement in patient safety and satisfaction.5

References 1. US Dept of Health and Human Services. Medical Privacy National Standards to Protect the Privacy of Personal Health Information: Available at: “http://www.hhs.gov/ocr/hipaa/”. Accessed July 30, 2007. 2. World Health Organization. WHO Guidelines On Hand Hygiene In Health Care (advanced draft): A Summary. Available at: “http://www.who.int/patientsafety/events/05/ HH_en.pdf ”. Accessed July 30, 2007. 3. Boyce JM, Pittet D. Guideline for Hand Hygiene in HealthCare Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task Force. Available at: “http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1. htm”. Accessed July 30, 2007. 4. American Academy of Pediatric Dentistry. Policy on Infection control. Pediatr Dent 2007;29(suppl):76. 5. Joint Commission on Accreditation of Health Care Organizations. 2008 National Patient Safety Goals Ambulatory Care Program. Available at: “http://www.jointcommission. org/PatientSafety/NationalPatientSafetyGoals/”. Accessed July 30, 2007. 6. American Academy of Pediatrics. Principles of Patient Safety in Pediatrics. Available at: “http://aappolicy.aap publications.org/cgi/content/full/pediatrics;107/6/ 1473”. Accessed July 30, 2007. 7. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2008;30(suppl):125-33. 8. American Academy of Pediatric Dentistry. Guideline on informed consent. Pediatr Dent 2008;30(suppl):234-5. 9. Joint Commission on Accreditation of Health Care Organizations. Implementation Expectations for the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. Available at: “http://www.joint commission.org/NR/rdonlyres/DEC4A816-ED52-4C04AF8C-FEBA74A732EA/0/up_guidelines.pdf ”. Accessed July 30, 2007. 10. American Academy of Pediatric Dentistry. Guideline on record-keeping. Pediatr Dent 2007;29(suppl):211-8. 11. American Academy of Pediatric Dentistry. Guideline on pediatric restorative dentistry. Pediatr Dent 2008;30 (suppl):163-9.


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12. American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated with nitrous oxide. Pediatr Dent 2008;30(suppl):64-5. 13. American Dental Association, US Dept of Health and Human Services. The Selection of Patients for X-Ray Examination: Dental Radiographic Examinations. Rockville, Md: Food and Drug Administration, 2004; HHS Publication No. 88-8273. Available at: “http://www. ada.org/prof/resources/topics/radiography.asp”. Accessed August 8, 2008.

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14. American Academy of Pediatric Dentistry, American Academy of Pediatrics. Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatr Dent 2007;29(suppl):134-51. 15. American Academy of Pediatric Dentistry. Guideline on use of anesthesia personnel in the administration of officebased deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2007;29(suppl):152-4.


Policy on the Ethical Responsibility to Treat or Refer Originating Council


Adopted 2003

Reaffirmed 2008

Purpose The American Academy of Pediatric Dentistry (AAPD) believes that all infants, children, adolescents, and individuals with special health care needs are entitled to oral health care that meets the treatment and ethical standards set by our specialty. If a dentist is unable to provide or fails to offer treatment for a diagnosed dental disease or condition, he or she has an ethical responsibility to refer the patient to a specific practitioner capable of providing the necessary care.

Methods Documents relating to principles of ethics of dental and medical organizations were reviewed. A MEDLINE search using the terms “ethics” and “dentistry” was performed. Experts on dental and medical ethics were consulted.

Background Dentists have an obligation to act in an ethical manner in the care of patients. Commonly accepted virtues of ethics include autonomy, beneficence, nonmaleficence, and justice.1,2 Autonomy reflects the patient’s or, if the patient is a minor, the parent’s or guardian’s right to be involved in treatment decisions. The caregiver must be informed of the problem and that treatment is recommended. Beneficence indicates the dentist has the obligation to act for the benefit of the patient in a timely manner, even when there may be conflicts 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.

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.

Policy statement Infants, children, and adolescents, 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.

References 1. American Dental Association. Principles of Ethics and Code of Professional Conduct. With official advisory opinions revised to January 2005. Available at: “http://www.ada.org/ prof/prac/law/code/index.asp”. Accessed July 15, 2007. 2. American College of Dentists. Ethics Handbook for Dentists. An Introduction to Ethics, Professionalism, and Ethical Decision Making. Gaithersburg, Md: American College of Dentists; 2004.


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Policy on Second Opinions for Pediatric Oral Health Care Originating Council


Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that second opinions are one avenue for additional information regarding health care issues. Parents frequently seek additional information and/or other opinions in order to address their child’s health care needs and make informed decisions. This policy is intended to provide guidance to the pediatric dentist by addressing what should be obtained and documented when providing a second opinion, as well as an understanding of the ethical and legal obligations involved in the process.

Methods This policy is based on a review of the current dental and medical literature related to the concept of second opinion in dentistry and medicine. An electronic search and a MEDLINE search was conducted using the search terms: “second opinion”, “medical second opinion”, and “dental second opinion”. Documents relating to principles of ethics of dental and medical organizations also were reviewed.

Background Patients today are more informed about their medical and dental problems and treatment options and are playing an active role in decision making with their doctors. Medical and dental knowledge and available treatment options are evolving at a rapid pace, and it is becoming increasingly difficult for health care providers to be fully aware of all the latest advances and information. As a result, patients and health care providers are seeking second opinions so that more informed decisions based on the risks and benefits can be made regarding the patient’s health care. For minor health problems, second opinions usually are unnecessary. However, a second opinion is recommended if the patient disagrees with or questions the diagnosis or the treatment plan of the health care provider, has multiple medical problems, or is diagnosed with a life-threatening disease such as cancer. Second opinions also are recommended when there is no improvement in the patient’s condition, when there is a communication barrier between the patient and the provider and, additionally, when extensive oral care needs or high cost may make treatment prohibitive. For health care practitioners, a second opinion or referral may be warranted if they

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are unsure of the diagnosis or the diagnosis/treatment is beyond the scope of their expertise. Furthermore, a second opinion may be necessary when required by a third party payor. There is a debate among health care providers about whether to provide a patient with a “blind” second opinion (ie, when medical/dental records, test results and first provider’s opinion are not made available to the second provider) or if the patient’s diagnostic information and diagnosis should be shared with the provider giving the second opinion. The advantage of the “blind” second opinion is that it cannot be influenced by previous information. The provider will develop his/her own unbiased opinion. The disadvantage is that the provider performing the second opinion may have to repeat diagnostic tests and the patient will incur additional costs. The second provider may not be able to explain to the patient why his/her opinion is different without knowing the patient’s previous history and the basis of the first provider’s opinion. A third option would be to provide test results, radiographs, and other information without the first doctor’s written diagnosis and treatment recommendations. This would allow for an unbiased opinion without having the patient incur unnecessary charges or radiation exposure from repeated radiographs. When presented with requests for second opinions, practitioners should consider the legal implications of such requests. Health care providers rendering second opinions could be unwarily 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 professional consulted does not mean that the provider is exempt from liability.1 A dissatisfied patient could file a lawsuit naming not only the treating doctor, but also the doctor rendering the second opinion as defendants. In addition, a colleague who believes his or her professional reputation has been damaged by statements made to a patient during a consultation could file a lawsuit for defamation of character. Patients should be advised of their health status without disparaging comments about their prior treatment or previous provider.

Policy statement The AAPD recognizes that: 1. A patient has a right to a second opinion. A provider who is trained and experienced in diagnosing and treating the condition should provide the second


opinion. Internet sites or a telephone conversation cannot be relied upon and should not constitute a second opinion.2 2. A health care practitioner has the right to request a second opinion from one or multiple practitioners/ specialists as deemed necessary to facilitate the optimal clinical outcome.3 3. Educating the patient regarding the diagnosis and available treatment options, including 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 on careful consideration of all the facts and with due attention given to current and previous states of the patient. Instances of gross or continual faulty diagnosis or treatment by other providers may require that the provider be reported to an appropriate reviewing agency as determined by the local component or constituent dental society.3 4. A provider has the ethical obligation 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.3 Health Insurance Portability and Accountability Act (HIPAA) privacy rules4 and state laws apply to all exchanges of health care information. 5. Second opinions may be mandatory by third party payors. The provider should be independent and the opinion should be based on best outcomes for the patient and not financial incentives.

6. Most second opinions are voluntary. It is the responsibility of the patient to check with his/her insurance carrier for specific policies and benefits regarding coverage of second opinions. 7. When presented with requests for second opinions, practitioners should consider the legal implications of such request. Patients should be fully advised of their health status without disparaging comments about their prior treatment or previous provider.

References 1. Machen DE. Legal aspects of orthodontic practice: Risk management concepts. Am J Orthod Dentofacial Orthop 1990;93(3)269-70. 2. US Dept of Health and Human Services, Office on Women’s Health. How to get a second opinion. Available at: “http://www.womenshealth.gov/tools/secondopinion. cfm”. Accessed July 8, 2010. 3. American Dental Association. Principles of ethics and code of professional conduct. With official advisory opinions revised to January, 2010. Available at: “http:// www.ada.org/sections/about/pdfs/ada_code.pdf ”. Accessed July 8, 2010. 4. US Dept of Health and Human Services. Health Information Privacy. Available at: “http://www.hhs.gov/ocr/ privacy/”. Accessed July 8, 2010.


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Policy on a Patient’s Bill of Rights and Responsibilities Originating Council


Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that pediatric oral health care should be rendered under conditions that are acceptable to both patient and dentist. The expectation is that oral health care providers, their staff, and patients/parents will support this policy, thereby enhancing patient care.

Methods This policy is based on a systematic literature search of the MEDLINE/Pubmed electronic database using the following parameters: Terms: “patient freedoms”, “patient’s Bill of Rights”, “Bill of Rights”, “Consumer Bill of Rights”; Fields: all fields; Limits: within the last 10 years and English. Eighty-one articles met these criteria. Papers for review were chosen from this list and from the references within selected articles. Documents of health care and public policy organizations relating to the concept of patient rights and responsibilities also were reviewed.1-3

Background AAPD is the leader in representing the oral health interests of infants, children, adolescents, and persons with special health care needs1. Effective oral health care requires collaboration between patients/parents and pediatric dentists and other health care professionals. Open and honest communication, respect for personal and professional values, and sensitivity to differences are integral to optimal patient care. The delivery of contemporary pediatric oral health care many times can be confusing to parents. It is normal for parents whose children have planned oral health care treatment to have a set of expectations about the proposed care. Likewise, it is desirable for these parents to have 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 decisionmaking capacity, or is legally incompetent. It articulates the positive rights that health care providers and facilities 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.

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The effectiveness of care and patient satisfaction with the course of treatment depend, in part, on the patient fulfilling certain responsibilities. As such, the American Academy of Pediatric Dentistry proposes this Policy on a Patient’s Bill of Rights and Responsibilities in the planning and delivery of pediatric oral health care.    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 may be necessary to ensure that patients and their families understand their rights and responsibilities.

Bill of Rights 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. The patient has the right to: 1. a dental home that provides comprehensive, considerate, and respectful care. 2. have oral health diagnoses made by a dentist. 3. a choice of oral health care provider. The parent has a right to designate a pediatric dentist as a primary oral health care provider for the child. 4. participate fully in all the decisions related to his/her care. 5. receive accurate, relevant, current, and easilyunderstood information concerning diagnosis, treatment, and prognosis. The patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risks involved, and the medically reasonable alternatives and their accompanying risks and benefits. Life threatening emergency care could be an exception. 6. 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 action. In case of such refusal, the patient is entitled to other appropriate care and services that the pediatric dentist offers or to transfer to another dentist. 7. consent to or decline to participate in proposed research studies affecting care and treatment or requiring direct patient involvement and to have those


8. 9. 10. 11.

12.

13. 14.

15.

16.

studies explained fully prior to consent. A patient who declines to participate in research is entitled to the most effective care that the pediatric dentist can otherwise provide. expect reasonable continuity of care. emergency care for acute dental trauma and odontogenic infections, as needed. know the identity, education, and training of the providers involved in his/her care, as well as when those involved are students, residents, or other trainees. know the immediate and long-term financial implications of treatment choices, insofar as they are known. 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. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in an organization. every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient’s privacy. expect that all communications and records pertaining to his/her care will be treated as confidential, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law. 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. ask and be informed of the existence of business relationships among institutions, other health care providers, or payors that may influence the patient’s treatment and care.

Bill of 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. 1. The patient is responsible for providing, to the best of his/her knowledge, accurate and complete information about past illnesses, hospitalizations, medications, and other matters related to his/her health status. 2. The patient must take responsibility for requesting additional information or clarification about his/her health status or treatment when he/she does not fully understand information and instructions. 3. The patient is responsible for his/her actions if he/she refuses treatment or does not follow the instructions of the provider. It is the patient’s responsibility to inform dentists and other caregivers of anticipated problems in following prescribed treatment, including follow-up treatment instructions. 4. The patient has a responsibility to keep appointments and when unable to do so, to notify the dental office as soon as possible. 5. The patient is responsible for being considerate of the rights of other patients and health care workers and for not interfering with the general functioning of the facility. 6. The patient is responsible for providing accurate insurance information and for accepting the financial obligations associated with the services rendered.

References 1. American Academy of Pediatric Dentistry. AAPD Vision Statement. Pediatr Dent 2008;29(suppl):3. 2. American Hospital Association. A Patient’s Bill of Rights. AHA 1992. Catalog no. 157759. 3. President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Consumer Bill of Rights and Responsibilities, 1998. Washington, DC. July 17, 1998. Available at: “http://www.hcqualitycommission. gov/final/append_a.html”. Accessed June 22, 2009.


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Policy on Stem Cells Originating Council


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. Adult mesenchymal stem cells, of which dental stem cells are a subset, display inherent plasticity, the ability to proliferate and differentiate into many cell lines. The most familiar application of adult stem cell therapy is bone marrow transplantation to treat hematopoietic cancers, metabolic disorders, and congenital immunodeficiency syndromes. Stem cell therapy is undergoing clinical testing for other conditions such as Parkinson’s disease, diabetes, and brain trauma/spinal cord injuries. Suggested applications related to oral health care have included healing and regeneration of dental and periodontal tissues as well as craniofacial structures (eg, repair of cleft lip/palate). Parents may elect to preserve umbilical cord blood of their child for future harvesting of stem cells if autologous regenerative

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therapies are indicated. Pulpal tissue of primary teeth and surgically removed third molars may serve as a source of adult mesenchymal stem cells. While sources of dental stem cells are readily accessible, those cells must be secured and stored properly to maintain the potential to proliferate and differentiate. The public is increasingly aware of this emerging science, and more parents are expressing interest in harvesting/banking dental stem cells. The American Academy of Pediatric Dentistry recognizes the emerging field of regenerative medicine and encourages dentists to follow future evidence-based literature in order to educate parents about the collection, storage, viability, and use of dental stem cells with respect to autologous regenerative therapies. 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.


Policy on Infection Control Originating Committee Clinical Affairs Committee - Infectious Disease Control Subcommittee

Review Council


Revised 1993, 2001, 2004, 2009

The American Academy of Pediatric Dentistry (AAPD) recognizes 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. The AAPD acknowledges Guidelines for Infection Control in the Dental Health-Care Setting—20031 and Guidelines for Disinfection and Sterilization in Healthcare Facilities—20082 as in-depth reviews of infection control measures for dental settings and supports the strategies therein. Aware that some recommendations are based only on suggestive evidence or theoretical rationale, and because many concerns regarding infection control in the dental setting remain unresolved, the AAPD

encourages dental practitioners to follow current literature and consider carefully infection control measures in their practices so as to minimize the risk of disease transmission.

Reference 1. Kohn WG, Collins AS, Cleveland JL, et al. CDC Guidelines for infection control in dental health-care settings— 2003. MMWR Recomm Rep 2003;52:(RR-17):1-61. 2. Rutula WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. CDC Guidelines for disinfection and sterilization in healthcare facilities—2008. Available at: “http://www.cdc.gov/ncidod/dhqp/pdf/ guidelines/Disinfection_Nov_2008.pdf ”. Accessed January 19, 2009.


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Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents Originating Committee


Adopted 1991

Revised 1992, 1996, 2000, 2003, 2007, 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) intends this guideline to help practitioners make clinical decisions concerning preventive oral health interventions, including anticipatory guidance and preventive counseling, for infants, children, and adolescents.

Methods This guideline is a compilation of related policies and guidelines developed by the AAPD, in addition to pediatric oral health literature and national reports and recommendations. The related policies and guidelines provide additional references for individual recommendations.

Background Professional care is necessary to maintain oral health.1 The AAPD emphasizes the importance of initiating professional oral health intervention in infancy and continuing through adolescence and beyond.1,2 The periodicity of professional oral health intervention and services is based on a patient’s individual needs and risk indicators.3,4 Each age group has distinct developmental needs to be addressed at specific intervals as part of a comprehensive evaluation.5-7 Continuity of care is based on the assessed needs of the individual patient and assures appropriate management of all oral conditions, dental disease, and injuries.8-10 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.11 Anticipatory guidance and counseling are essential components of the dental visit.5,7,11-18

Recommendations This guideline 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. An accurate, comprehensive, and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. Recommendations may be modified to meet the unique requirements of patients with special needs. 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.11 The developing dentition and occlusion should be monitored throughout eruption at regular clinical examinations. Unrecognized dental disease can result in exacerbated problems which lead to more extensive and expensive care,19-21 whereas early detection and management of oral conditions can improve a child’s oral health, general health and well-being, and school readiness.12,22-27 Early diagnosis of developing malocclusions may allow for timely therapeutic intervention.28 Components of a comprehensive oral examination include assessment of: • General health/growth • Pain • Extraoral soft tissue • Temporomandibular joint • Intraoral soft tissue • Oral hygiene and periodontal health • Intraoral hard tissue • The developing occlusion • Caries risk • Behavior of child Based upon the visual examination, the dentist may employ additional diagnostic aids (eg, radiographs, photographs, pulp testing, laboratory tests, study casts). The most common interval of examination is 6 months; however, some patients may require examination and preventive

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services at more frequent intervals, based upon historical, clinical, and radiographic findings.3,29-34 Caries and its sequelae are among the most prevalent health problems facing infants, children, and adolescents in America.1 Caries is cumulative and progressive and, in the primary dentition, is highly predictive of caries occurring in the permanent dentition.35,36 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 repetitive exposure to dental procedures, potentially allaying anxiety and fear for the apprehensive child or adolescent. Caries-risk assessment Risk assessment is the key element of contemporary preventive care for infants, children, adolescents, and persons with special health care needs. Its goal is to prevent disease by identifying and minimizing causative factors (eg, microbial burden, dietary habits, plaque accumulation) and optimizing protective factors (eg, fluoride exposure, oral hygiene, sealants).37 A caries-risk assessment tool (CAT) simplifies and clarifies the process.13 Sufficient evidence demonstrates certain groups of children at greater risk for development of early childhood caries (ECC) would benefit from infant oral health care.12,22,38,39 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. Children are most likely to develop caries if mutans streptococci are acquired at an early age.39,40 The characteristics of ECC and the availability of preventive methods support anticipatory guidance/counseling as an important strategy in addressing this significant pediatric health problem. ECC can be a costly, devastating disease with lasting detrimental effects on the dentition and systemic health.12,19-27 Adolescence can be a time of heightened caries activity due to an increased intake of cariogenic substances and inattention to oral hygiene procedures.41,42 Risk assessment can assure preventive care is tailored to each individual’s needs and direct resources to those for whom preventive interventions provide the greatest benefit. Because a child’s risk for developing dental disease can change over time due to changes in habits (eg, diet, home care), oral microflora, or physical condition, risk assessment must be repeated regularly and frequently to maximize effectiveness. Prophylaxis and topical fluoride treatment The interval for frequency of professional preventive services is based upon assessed risk for caries and periodontal disease. Gingivitis is nearly universal in children and adolescents43; it usually responds to thorough removal of bacterial deposits and improved oral hygiene.43,44 Self-administered plaque control programs without periodic professional reinforcement are inconsistent in providing long-term inhibition of gingivitis.44 Many patients lack the skill or motivation to become and remain plaque-free for a significant time.44 Hormonal fluctuations, including those occurring during the onset of puberty, can modify the gingival inflammatory response to dental plaque.43

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Children can develop any of the several forms of periodontitis, with aggressive periodontitis occurring more commonly in children and adolescents than adults.43 Caries risk may change quickly during active dental eruption phases. Newly erupted teeth may be at higher risk of developing caries, especially during the post-eruption maturation process. Children who exhibit higher risk of developing caries would benefit from recall appointments at greater frequency than every 6 months. This allows increased professional fluoride therapy application, microbial monitoring, antimicrobial therapy reapplication, and reevaluating behavioral changes for effectiveness.3,45,46 An individualized preventive plan increases the probability of good oral health by demonstrating proper oral hygiene methods/techniques and removing plaque, stain, calculus47, and the factors that influence their build-up.48-50 Professional topical fluoride treatments should be based on caries risk assessment.13,14,51-53 A pumice prophylaxis is not an essential prerequisite to this treatment.54 Appropriate precautionary measures should be taken to prevent swallowing of any professionally-applied topical fluoride. Children at moderate caries risk should receive a professional fluoride treatment at least every 6 months; those with high caries risk should receive greater frequency of professional fluoride applications (eg, every 3-6 months).52,55,56,57-62 Ideally, this would occur as part of a comprehensive preventive program in a dental home.11 Fluoride supplementation Fluoride contributes to the prevention, inhibition, and reversal of caries.53,62,63 The AAPD encourages optimal fluoride exposure for every child, recognizing fluoride in the community water supplies as the most beneficial and inexpensive preventive intervention. Fluoride supplementation should be considered when fluoride exposure is not optimal.62 Supplementation should be in accordance with the guidelines jointly recommended by the AAPD62, the American Academy of Pediatrics63, and the American Dental Association (ADA)64, and endorsed by the Centers for Disease Control and Prevention.14 Anticipatory guidance/counseling Anticipatory guidance is the process of providing practical, developmentally-appropriate information about children’s health to prepare parents for the significant physical, emotional, and psychological milestones.65 Appropriate discussion and counseling should be an integral part of each visit. Topics to be included are oral hygiene and dietary habits, injury prevention, nonnutritive habits, substance abuse, intraoral/perioral piercing, and speech/language development. Oral hygiene counseling involves the parent and patient. Initially, oral hygiene is the responsibility of the parent. As the child develops, home care is 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 preventive activities.3


High-risk dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood.66.67 Frequent bottle feeding at night, breastfeeding on demand, and extended and repetitive use of a no-spill training cup are associated with, but not consistently implicated in, ECC.68 The role of carbohydrates in caries initiation is unequivocal. Acids in carbonated beverages can have a deleterious effect (ie, erosion) on enamel. Excess consumption of carbohydrates, fats, and sodium contribute to poor systemic health. Dietary analysis and the role of dietary choices on oral health, malnutrition, and obesity should be addressed through nutritional and preventive oral health counseling at periodic visits.15 The US Department of Agriculture’s Food Pyramid69 and Center for Disease Control and Prevention/National Center for Health Statistics’ Growth Charts70 provide guidance for parents and their children and promote better understanding of the relationship between healthy diet and development. Facial trauma that results in fractured, displaced, or lost teeth can have significant negative functional, esthetic, and psychological effects on children.71 Practitioners should provide age-appropriate injury prevention counseling for orofacial trauma.16,17 Initially, discussions would include play objects, pacifiers, car seats, and electrical cords. As motor coordination develops, the parent/patient should be counseled on additional safety and preventive measures, including mouthguards for sporting activities. The greatest incidence of trauma to the primary dentition occurs at 2 to 3 years of age, a time of increased mobility and developing coordination. 72 The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports.73-76 Dental injuries could have improved outcomes if the public were aware of first-aid measures and the need to seek immediate treatment. Nonnutritive oral habits (eg, digital and pacifier habits, bruxism, abnormal tongue thrusts) may apply forces to teeth and dentoalveolar structures.18 Although early use of pacifiers and digit sucking are considered normal, habits of sufficient frequency, intensity, and duration can contribute to deleterious changes in occlusion and facial development. It is important to discuss the need for early additional sucking, then the need to wean from the habits before malocclusion or skeletal dysplasias occur. Early dental visits provide an opportunity to encourage parents to help their children stop sucking habits by age 3 years or younger. For school-aged children and adolescent patients, counseling regarding any existing habits (eg, fingernail biting, clenching, bruxism) is appropriate.18 Speech and language is an integral component of a child’s early development.77 Deficiencies and abnormal delays in speech and language production can be recognized early and referral made to address the concerns appropriately. Communication and coordination of appliance therapy with a speech and language professional can assist in the timely treatment of these disorders. Smoking and smokeless tobacco use almost always are initiated and established in adolescence.78-80 During this time period, children may be exposed to opportunities to experiment

with other substances that negatively impact their health and well-being. Practitioners should provide education regarding the serious health consequences of tobacco use and exposure to second hand smoke.81 The practitioner may need to obtain information regarding tobacco use and alcohol/drug abuse confidentially from an adolescent patient.6 When substance abuse has been identified, referral for appropriate intervention is indicated. Complications from intraoral/perioral piercings can range from pain, infection, and tooth fracture to life-threatening conditions of bleeding, edema, and airway obstruction.82 Although piercings most commonly are observed in the teenaged pediatric dental patient, education regarding pathologic conditions and sequelae associated with these piercings should be initiated for the preteen child/parent and reinforced during subsequent periodic visits. Radiographic assessment Appropriate radiographs are a valuable adjunct in the oral health care of infants, children and adolescents.29,30 Timing of initial radiographic examination should not be based upon the patient’s age.29 Rather, after review of an individual’s history and clinical findings, judicious determination of radiographic needs and examination can optimize patient care while minimizing radiation exposure.29,30 The US Food and Drug Administration/ ADA guidelines were developed to assist the dentist in deciding under what circumstances specific radiographs are indicated.30 Treatment of dental disease/injury Healthcare providers who diagnose oral disease or trauma should either provide therapy or refer the patient to an appropriatelytrained individual for treatment.83 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.19-21 Early intervention could result in savings of healthcare dollars for individuals, community health care programs, and third party payors. Treatment of developing malocclusion Guidance of eruption and development of the primary, mixed, and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients.28 Early diagnosis 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.84-87 Early treatment is beneficial for many patients, but may not be indicated for every patient. When there is a reasonable indication that an 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. Use of an appliance is indicated only when the child wants to stop the habit and would benefit from a reminder.28 At each stage of occlusal development, the objectives of intervention/treatment include: (1) reversing adverse growth;

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(2) preventing dental and skeletal disharmonies; (3) improving esthetics of the smile; (4) improving self-image; and (5) improving the occlusion.28 Sealants Sealants reduce the risk of pit and fissure caries in susceptible teeth and are cost-effective when maintained.88.89 They are indicated for primary and permanent teeth with pits and fissures that are predisposed to plaque retention. 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 (eg, dietary, home care), oral microflora, or physical condition, unsealed teeth subsequently might benefit from sealant application.88 The need for sealant placement should be reassessed at periodic preventive care appointments. Sealants should be monitored and repaired or replaced as needed. Third Molars Panoramic or periapical radiographic assessment is indicated during late adolescence to assess the presence, position, and development of third molars.29,30 A decision to remove or retain third molars should be made before the middle of the third decade.90 Consideration should be given to removal when there is a high probability of disease or pathology and/or the risks associated with early removal are less than the risks of later removal.10 Referral for regular and periodic dental 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 knowledgeable in adult oral 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.6,91 Until the new dental home is established, the patient should maintain a relationship with the current care provider and have access to emergency services. Proper communication and records transfer allow for consistent and continuous care for the patient. Recommendations by Age 6 to 12 months 1. Complete the clinical oral examination with adjunctive diagnostic tools (eg, 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. Provide oral hygiene counseling for parents, including the implications of the oral health of the caregiver. 3. Remove supragingival and subgingival stains or deposits as indicated. 4. Assess the child’s systemic and topical fluoride status (including type of infant formula used, if any, and exposure to fluoridated toothpaste) and provide counseling regarding fluoride. Prescribe systemic fluoride supplements,

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5. 6. 7. 8. 9. 10. 11. 12. 13.

if indicated, following assessment of total fluoride intake from drinking water, diet, and oral hygiene products. Assess appropriateness of feeding practices, including bottle and breast-feeding, and provide counseling as indicated. Provide dietary counseling related to oral health. Provide age-appropriate injury prevention counseling for orofacial trauma. Provide counseling for nonnutritive oral habits (eg, digit, pacifiers). Provide required treatment and/or appropriate referral for any oral diseases or injuries. Provide anticipatory guidance. Consult with the child’s physician as needed. Complete a caries risk assessment. Determine the interval for periodic reevaluation.

12 to 24 months 1. Repeat 6 to 12-month procedures every 6 months or as indicated by individual patient’s risk status/susceptibility to disease. 2. Assess appropriateness of feeding practices–including bottle, breast-feeding, and no-spill training cups–and provide counseling as indicated. 3. Review patient’s fluoride status–including any childcare arrangements which may impact systemic fluoride intake– and provide parental counseling. 4. Provide topical fluoride treatments every 6 months or as indicated by the individual patient’s needs. 2 to 6 years 1. Repeat 12- to 24-month procedures every 6 months or as indicated by individual patient’s risk status/susceptibility to disease. Provide age-appropriate oral hygiene instructions. 2. Scale and clean the teeth every 6 months or as indicated by individual patient’s needs. 3. Provide pit and fissure sealants for caries-susceptible primary molars and permanent molars, premolars, and anterior teeth. 4. Provide counseling and services (eg, mouthguards) as needed for orofacial trauma prevention. 5. Provide assessment/treatment or referral of developing malocclusion as indicated by individual patient’s needs. 6. Provide required treatment and/or appropriate referral for any oral diseases, habits, or injuries as indicated. 7. Assess speech and language development and provide appropriate referral as indicated. 6 to 12 years 1. Repeat 2- to 6-year procedures every 6 months or as indicated by individual patient’s risk status/susceptibility to disease. 2. Provide substance abuse counseling (eg, smoking, smokeless tobacco). 3. Provide counseling on intraoral/perioral piercing.


12 years and older 1. Repeat 6- to 12-year procedures every 6 months or as indicated by individual patient’s 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 and/or the risks associated with early removal are less than the risks of later removal. 3. At an age determined by patient, parent and pediatric dentist, refer the patient to a general dentist for continuing oral care.

References 1. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 2. Lewis DW, Ismail AI. Periodic health examination, 1995 Update: 2. Prevention of dental caries. The Canadian Task Force on the Periodic Health Examination. Can Med Assoc J 1995;152(6):836-46. 3. U S Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams and Wilkins; 1996. 4. Beirne P, Forgie A, Clarkson J, Worthington HV. Recall intervals for oral health in primary care patients. Evid Based Dent 2005;6(3):62-3. 5. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2009;31(special issue):95-9. 6. American Academy of Pediatric Dentistry. Guideline on adolescent oral health care. Pediatr Dent 2008;30(suppl): 94-101. 7. American Academy of Pediatric Dentistry. Guideline on the role of prophylaxis in pediatric dentistry. Pediatr Dent 2008;30(suppl):119-20. 8. A merican Academy of Pediatric Dentistry. Guideline on pediatric restorative dentistry. Pediatr Dent 2008;30 (suppl):169-9. 9. American Academy of Pediatric Dentistry. Guideline on acquired temporomandibular disorders in infants, children, and adolescents. Pediatr Dent 2008;30(suppl): 202-4. 10. American Academy of Pediatric Dentistry. Guideline on pediatric oral surgery. Pediatr Dent 2008;30(suppl):205-11. 11. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2008;30(suppl):22-3. 12. American Academy of Pediatric Dentistry. Policy on early childhood caries: Classifications, consequences, and preventive strategies. Pediatr Dent 2008;30(suppl):40-3. 13. A merican Academy of Pediatric Dentistry. Policy on the use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent 2008;30(suppl): 29-33.

14. CDC. Recommendations for using fluoride to prevent and control dental caries in the Unites States. MMWR Recomm Rep 2001;50(RR14):1-42. 15. American Academy of Pediatric Dentistry. Policy on dietary recommendations for infants, children, and adolescents. Pediatr Dent 2008;30(suppl):47-8. 16. American Academy of Pediatric Dentistry. Policy on prevention of sports-related orofacial injuries. Pediatr Dent 2008;30(suppl):58-60. 17. American Academy of Pediatric Dentistry. Guideline on management of acute dental trauma. Pediatr Dent 2008; 30(suppl):175-83. 18. American Academy of Pediatric Dentistry. Policy on oral habits. Pediatr Dent 2006;28(suppl):43. 19. 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. 20. Griffin SO, Gooch BF, Beltrán 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(1):21-7. 21. Ramos-Gomez FJ, Huang GF, Masouredis CM, Braham RL. Prevalence and treatment costs of infant caries in Northern California. ASDC J Dent Child 1996;63: 108-12. 22. American Academy of Pediatric Dentistry. Policy on early childhood caries: Unique challenges and treatment options. Pediatr Dent 2008;30(suppl):44-6. 23. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14(5):302-5. 24. Ramage S. The impact of dental disease on school performance. J Southeast Soc Pediatr Dent 2000;6:26. 25. National Center for Education in Maternal and Child Health. Oral health and learning. Bethesda, Md. National Center for Education in Maternal and Child Health and Georgetown University; 2001. 26. Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ, Judd P. Malnourishment in a population of young children with severe early childhood caries. Pediatr Dent 2006;28(3):254-9. 27. Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight, and head circum-ference. J Clin Pediatr Dent 1996;20(3):209-12. 28. American Academy of Pediatric Dentistry. Guideline on management of the developing dentition and occlusion in pediatric dentistry. Pediatr Dent 2009;31(special issue): 196-208. 29. American Academy of Pediatric Dentistry. Guideline on prescribing dental radiographs. Pediatr Dent 2009;31 (special issue):250-2. 30. American Dental Association, US Dept of Health and Human Services. The selection of patients for dental radiographic examinations – 2004. Available at: “http:// www.ada.org/prof/resources/topics/topics_radiography_examinations.pdf ”. Accessed June 16, 2009. clinical guidelines

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31. Greenwell H, Committee on Research, Science and Therapy American Academy of Periodontology. Guidelines for periodontal therapy. J Periodontol 2001;72(11):1624-8. 32. Flores MT, Andreasen JO, Bakland LK, et al. Guidelines for the evaluation and management of traumatic dental injuries (part 3 of the series). Dental Traumatol. 2001;17(3): 97-102. 33. Flores MT, Andreasen JO, Bakland LK, et al. Guidelines for the evaluation and management of traumatic dental injuries (part 4 of the series). Dental Traumatol 2001;17 (4):145-8. 34. Flores MT, Andreasen JO, Bakland LK, et al. Guidelines for the evaluation and management of traumatic dental injuries (part 5 of the series). Dental Traumatol 2001;17 (5):193-6. 35. Li Y, Wang W. Predicting caries in permanent teeth from caries in primary teeth: An eight-year cohort study. J Dent Res 2002;81(8):561-6. 36. Helfenstein V, Steiner M, Marthaler TM. Caries prediction on the basis of past caries including precavity lesions. Caries Res 1991;25(5):372-6. 37. Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137(9):1231-9. 38. Marino R, Bonze K, Scholl T, Anhalt H. Nursing bottle caries: Characteristics of children at risk. Clin Pediatr 1989;28(3):129-31. 39. 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): 71-85. 40. Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent 2006;28(2):106-9. 41. American Psychological Association. Developing adolescents: A reference for professionals. Washington, DC. American Psychological Association; 2002. 42. Macgregor ID, Regis D, Balding J. Self-concept and dental health behaviors in adolescents. J Clin Periodontol 1997;24(5):335-9. 43. Califano JV, Research Science and Therapy Committee American Academy of Periodontology. Periodontal diseases of children and adolescents. J Periodontol 2003;74 (11):1696-704. 44. Research Science and Therapy Committee American Aca-demy of Periodontology. Treatment of plaque-induced gingivitis, chronic periodontitis, and other clinical conditions. J Periodontol 2001;72:1790-800. Erratum J Periodontol 2003;74(10):1568. 45. Featherstone JDB. Caries prevention and reversal based on the caries balance. Pediatr Dent 2006;28(2);128-32. 46. Anderson MH, Shi W. A probiotic approach to caries management. Pediatr Dent 2006;28(2):151-3. 47. Clerehugh V, Tugnait A. Periodontal diseases in children and adolescents: 2. Management. Dent Update 2001;28 (6):274-81.

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48. Roulet JF, Roulet-Mehrens TK. The surface roughness of restorative materials and dental tissues after polishing with prophylaxis and polishing pastes. J Periodontol 1982;53(4):257-66. 49. Hosoya Y, Johnston JW. Evaluation of various cleaning and polishing methods on primary enamel. J Pedod 1989;13(3):253-69. 50. Quirynen M, Bollen CML. The influence of surface roughness and surface-free energy on supra- and subgingival plaque formation in man. A review of the literature. J Clin Periodontol 1995;22(1):1-14. 51. Facts about Fluoride. CDS Rev 2006;99(1):44. 52. American Dental Association Council on Scientific Affairs. Professionally-applied topical fluoride: Evidencebased clinical recommendations. J Am Dent Assoc 2006; 137(8):1151-9. 53. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2): 133-42. 54. Johnston DW, Lewis DW. Three-year randomized trial of professionally applied topical fluoride gel comparing annual and biannual applications with/without prior prophylaxis. Caries Res 1995;29(5):331-6. 55. Bader JD, Shugars DA, Bonito AJ. A systematic review of selected caries prevention and management methods. Community Dent Oral Epidemiol 2001;29(6):399-411. 56. Axelsson S, Söder B, Norderam G, et al. Effect of combined caries-preventive methods: A systematic review of controlled clinical trials. Acta Odontol Scand 2004;62 (3):163-9. 57. Källestål C. The effect of five years’ implementation of caries-preventive methods in Swedish high-risk adolescents. Caries Res 2005;39(1):20-6. 58. Featherstone JD, Adair SM, Anderson MH, et al. Caries management by risk assessment: Consensus statement, April 2002. J Calif Dent Assoc 2003;331(3):257-69. 59. Featherstone JD. The caries balance: The basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(suppl 1):259-64. 60. Bader JD, Shugars DA, Rozier G, et al. Diagnosis and management of dental caries. Evid Rep Technol Assess (Summ) 2001;36:1-4. 61. Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for indentifying carious lesions. J Public Health Dent 2002;62(4):201-13. 62. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent 2008;30(suppl):121-5. 63. American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation for children: Interim policy recommendations. Pediatrics 1995;95:777. 64. Meskin LH, ed. Caries diagnosis and risk assessment: A review of preventive strategies and management. J Am Dent Assoc 1995;126(suppl):1s-24s.


65. Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: A national survey. Pediatrics 2000;106(6):E84. 66. Douglass JM. Response to Tinanoff and Palmer: Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 2000; 60(3):207-9. 67. Kranz S, Smiciklas-Wright H, Francis LA. Diet quality, added sugar, and dietary fiber intakes in American preschoolers. Pediatr Dent 2006;28(2):164-71. 68. Reisine S, Douglass JM. Pyschosocial and behavorial issues in early childhood caries. Comm Dent Oral Epidem 1998;26(suppl):132-44. 69. US Dept of Agriculture. Food pyramid. Available at: “http://www.mypyramid.gov”. Accessed March 18, 2007. 70. CDC, National Center for Health Statistics. Growth charts. Available at: “http://www.cdc.gov/growthcharts/”. Accessed June 16, 2009. 71. Cortes MI, Marcenes W, Shelham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12- to 14-year old children. Comm Dent Oral Epidemiol 2002;30(3):193-8. 72. Flores MT. Traumatic injuries in the primary dentition. Dental Traumatol 2002;18(6):287-98. 73. Rocha MJdC, Cardoso M. Traumatized permanent teeth in Brazilian children assisted at the Federal University of Santa Catarina, Brazil. Dental Traumatol 2001;17(6): 245-9. 74. Caldas FA Jr, Burgos ME. A retrospective study of traumatic dental injuries in a Brazilian dental trauma clinic. Dental Traumatol 2001;17(6):250-3. 75. Skaare AB, Jacobsen I. Dental injuries in Norwegians aged 7-18 years. Dental Traumatol 2003;19(2):67-71. 76. Tapias MA, Jiménez-García R, Lamas F, Gil AA. Prevalence of traumatic crown fractures to permanent incisors in a childhood population: Mostoles, Spain. Dental Traumatol 2003;19(3):119-22. 77. American Speech-Language-Hearing Association. Available at: “http://www.asha.org/public/speech/development/ chart.htm”. Accessed June 16, 2009. 78. American Lung Association. Smoking and teen fact sheet – April 2006. Available at: “http://www.lungusa.org/ site/pp.asp?c=dvLUK9O0E&b=39871”. Accessed June 16, 2009.

79. CDC. Preventing tobacco use among young people: A report of the Surgeon General (executive summary). MMWR Recommend Reports 1994;43(RR-4):[inclusive page numbers]. 80. 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. 81. American Academy of Pediatric Dentistry. Policy on tobacco use. Pediatr Dent 2008;30(suppl):53-5. 82. American Academy of Pediatric Dentistry. Policy on intraoral and perioral piercing. Pediatr Dent 2008;30(suppl): 56-7. 83. American Academy of Pediatric Dentistry. Policy on ethical responsibility to treat or refer. Pediatr Dent 2008; 30(suppl):83. 84. Kanellis MJ. Orthodontic treatment in the primary dentition. In Bishara SE, ed. Textbook of orthodontics. Philadelphia, Pa: WB Saunders Co:2001;248-56. 85. Woodside DG. The significance of late developmental crowding to early treatment planning for incisor crowding. Am J Orthod Dentofacial Orthop 2000;117(5): 559-61. 86. Kurol J. Early treatment of tooth-eruption disturbances. Am J Orthod Dentofacial Orthop 2002;121(6):588-91. 87. Sankey WL, Buschang PH, English J, Owen AH III. Early treatment of vertical skeletal dysplasia: The hyperdivergent phenotype. Am J Orthod Dentofacial Orthop 2000;118(3):317-27. 88. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent 2002;24(5):415-22. 89. Feigal RJ, Donly KJ. The use of pit and fissure sealants. Pediatr Dent 2006;28(2):143-50. 90. American Association of Oral and Maxillofacial Surgeons. Parameters and Pathways: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParPath01). J Oral Maxillofac Surg 2001. 91. American Academy of Pediatric Dentistry. Guideline on management of persons with special health care needs. Pediatr Dent 2008;30(suppl):107-11.

clinical guidelines

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10

Injury prevention counseling

Counseling for nonnutritive habits

Counseling for speech/language development

7 Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.

6 Appropriate discussion and counseling should be an integral part of each visit for care.

5 Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years.

4 Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease.

11 For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.

10 At first, discuss the need for additional sucking: digits vs pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.

9 Initially play objects, pacifiers, car seats; when learning to walk; then with sports and routine playing, including the importance of mouthguards.

3 Must be repeated regularly and frequently to maximize effectiveness.

2 By clinical examination.

• • 8 At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and childhood obesity.

10

•

1 First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child’s risk status/susceptibility to disease. Includes assessment of pathology and injuries.

Transition to adult dental care

Assessment and/or removal of third molars

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•

•

•

•

•

•

•

•

Patient

•

•

•

•

•

•

•

12 YEARS AND OLDER

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•

•

•

Assessment for pit and fissure sealants

•

•

•

•

•

•

•

•

•

•

•

Patient/parent

Patient/parent •

•

•

•

•

•

•

•

6 to 12 YEARS

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•

•

•

•

•

•

2 to 6 YEARS

Assessment and treatment of developing malocclusion

Counseling for intraoral/perioral piercing

1 0

8

Dietary counseling

Substance abuse counseling

7

Oral hygiene counseling

•

•

•

6

Anticipatory guidance/counseling

•

•

•

Fluoride supplementation

•

•

•

5

Prophylaxis and topical fluoride

Parent

•

•

3,4

Radiographic assessment

Parent

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•

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•

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Assess oral growth and development

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12 to 24 MONTHS

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6 to 12 MONTHS

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American Academy of Pediatric Dentistry

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 (AAPD) emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. Refer to the text of this guideline for supporting information and references.

Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling reference manual 10 / 11


Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents Originating Council Council on Clinical Affairs


Adopted 2002

Revised 2006, 2010

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that caries-risk assessment and management protocols can assist clinicians with decisions regarding treatment based upon caries risk and patient compliance and are essential elements of contemporary clinical care for infants, children, and adolescents. This guideline is 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 diagnostic, fluoride, dietary, and restorative protocols.

Methods This guideline is an update of AAPD’s “Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents, Revised 2006” that includes the additional concepts of dental caries management protocols. The update used electronic and hand searches of English written articles in the medical and dental literature within the last 10 years using the search terms “caries risk assessment”, “caries management”, and “caries clinical protocols”. From this search, 1,909 articles were evaluated by title or by abstract. Information from 75 articles was used to update this document. When data did not appear sufficient or were inconclusive, 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 normally have sufficient data to accurately quantitate a person’s disease susceptibility and allow for preventive measures.1 Even though caries-risk data in dentistry still are not sufficient to quantitate the models, the process of determining risk should be a component in the clinical decision making process.2 Risk assessment: 1. fosters the treatment of the disease process instead of treating the outcome of the disease;

2. gives 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; and 4. anticipates caries progression or stabilization. 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.3-6 Caries risk assessment is the determination of the likelihood of the incidence of caries (ie, the number of new cavitated or incipient lesions) during a certain time period7 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 (ie, white spot lesions), health care providers can help prevent cavitation.8-10 Caries risk indicators are variables that are thought to cause the disease directly (eg, microflora) or have been shown useful in predicting it (eg, socioeconomic status) and include those variables that may be considered protective factors. Currently, there are no caries-risk factors or combinations of factors that have achieved high levels of both positive and negative predictive values.2 Although the best tool to predict future caries is past caries experience, it is not particularly useful in young children due to the importance of determining caries risk before the disease is manifest. Children with white spot lesions should be considered at high risk for caries since these are precavitated lesions that are indicative of caries activity.11 Plaque accumulation also is strongly associated with caries development in young children.12,13 As a corollary to the presence of plaque,14 a child’s mutans streptococci levels3 and the age at which a child becomes colonized with cariogenic flora15,16 are valuable in assessing risk, especially in preschool children. While there is no question that fermentable carbohydrates are a necessary link in the causal chain for dental caries, a systematic study of sugar consumption and caries risk has concluded that the relationship between sugar consumption and


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caries is much weaker in the modern age of fluoride exposure than previously thought.17 However, there is evidence that night-time use of the bottle, especially when it is prolonged, may be associated with early childhood caries.18 Despite the fact that normal salivary flow is an extremely important intrinsic host factor providing protection against caries, there is little data about the prevalence of low salivary flow in children.19,20 Sociodemographic factors have been studied extensively to determine their effect on caries risk. Children with immigrant backgrounds have 3 times higher caries rates than nonimmigrants.21 Most consistently, an inverse relationship between socioeconomic status and caries prevalence is found in studies of children less than 6 years of age.22 Perhaps another type of sociodemographic variable is the parents’ history of cavities and abscessed teeth; this has been found to be a predictor of treatment for early childhood caries.23,24 The most studied factors that are protective of dental caries include systemic and topical fluoride, sugar substitutes, and tooth brushing with fluoridated toothpaste. Teeth of children who reside in a fluoridated community have been shown to have higher fluoride content than those of children who reside in suboptimal fluoridated communities.25 Additionally, both pre- and post-eruption fluoride exposure maximize the caries-preventive effects.26,27 For individuals residing in nonfluoridated communities, fluoride supplements have shown a significant caries reduction in primary and permanent teeth.28 With regard to fluoridated toothpaste, studies have shown

consistent reduction in caries experience.29 Professional topical fluoride applications performed semiannually also reduce caries,30 and fluoride varnishes generally are equal to that of other professional topical fluoride vehicles.31 The effect of sugar substitutes on caries rates have been evaluated in several populations with high caries prevalence.32 Studies indicate that xylitol can decrease mutans streptococci levels in plaque and saliva and can reduce dental caries in young children and adults, including children via their mothers.33 With regard to toothbrushing, there only is a weak relationship between frequency of brushing and decreased dental caries, which is confounded because it is difficult to distinguish whether the effect is actually a measure of fluoride application or whether it is a result of mechanical removal of plaque.34 The dental home or regular periodic care by the same practitioner is included in many caries-risk assessment models because of its known benefit for dental health.35 Risk assessment tools can aid in the identification of reliable predictors and allow dental practitioners, physicians, and other nondental health care providers to become more actively involved in identifying and referring high-risk children. Tables 1, 2, and 3 incorporate available evidence into practical tools to assist dental practitioners, physicians, and other nondental health care providers in assessing levels of risk for caries development in infants, children, and adolescents. As new evidence emergences, these tools can be refined to provide greater predictably of caries in children prior to disease initiation.

Table 1. Caries-risk Assessment Form for 0-3 Year Olds 59,60 (For Physicians and Other Non-Dental Health Care Providers)

High Risk

Factors

Moderate Risk

Protective

Biological Mother/primary caregiver has active cavities Parent/caregiver has low socioeconomic status Child has >3 between meal sugar-containing snacks or beverages per day Child is put to bed with a bottle containing natural or added sugar Child has special health care needs Child is a recent immigrant

Yes Yes Yes Yes Yes Yes

Protective Child receives optimally-fluoridated drinking water or fluoride supplements Child has teeth brushed daily with fluoridated toothpaste Child receives topical fluoride from health professional Child has dental home/regular dental care

Yes Yes Yes Yes

Clinical Findings Child has white spot lesions or enamel defects Child has visible cavities or fillings Child has plaque on teeth

Yes Yes Yes

Circling those conditions that apply to a specific patient helps the health care worker and parent understand the factors that contribute to or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (eg, frequent exposure to sugar containing snacks or beverages, visible cavities) in determining overall risk.

Overall assessment of the child’s dental caries risk:

102


High 

Moderate 

Low 


Table 2. Caries-risk Assessment Form for 0-5 Year Olds 59,60 (For Dental Providers)

High Risk

Factors

Moderate Risk

Protective

Biological Mother/primary caregiver has active caries Parent/caregiver has low socioeconomic status Child has >3 between meal sugar-containing snacks or beverages per day Child is put to bed with a bottle containing natural or added sugar Child has special health care needs Child is a recent immigrant

Yes Yes Yes Yes Yes Yes

Protective Child receives optimally-fluoridated drinking water or fluoride supplements Child has teeth brushed daily with fluoridated toothpaste Child receives topical fluoride from health professional Child has dental home/regular dental care

Yes Yes Yes Yes

Clinical Findings Child has >1 decayed/missing/filled surfaces (dmfs) Child has active white spot lesions or enamel defects Child has elevated mutans streptococci levels Child has plaque on teeth

Yes Yes Yes Yes

Circling those conditions that apply to a specific patient helps the practitioner and parent understand the factors that contribute to or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (eg, frequent exposure to sugar-containing snacks or beverages, more than one dmfs) in determining overall risk.

Overall assessment of the child’s dental caries risk:

High 

Moderate 

Low 

Table 3. Caries-risk Assessment Form for >6 Years Olds 60-62 (For Dental Providers)

High Risk

Factors

Moderate Risk

Protective

Biological Patient is of low socioeconomic status Patient has >3 between meal sugar containing snacks or beverages per day Patient has special health care needs Patient is a recent immigrant

Yes Yes Yes Yes

Protective Patient receives optimally-fluoridated drinking water Patient brushes teeth daily with fluoridated toothpaste Patient receives topical fluoride from health professional Additional home measures (eg, xylitol, MI paste, antimicrobial) Patient has dental home/regular dental care

Yes Yes Yes Yes Yes

Clinical Findings Patient has >1 interproximal lesions Patient has active white spot lesions or enamel defects Patient has low salivary flow Patient has defective restorations Patient wearing an intraoral appliance

Yes Yes Yes Yes Yes

Circling those conditions that apply to a specific patient helps the practitioner and patient/parent understand the factors that contribute to or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (eg, >1 interproximal lesions, low salivary flow) in determining overall risk.

Overall assessment of the dental caries risk:

High 

Moderate 

Low 


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Furthermore, the evolution of caries-risk assessment tools and protocols 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.

Caries management protocols Clinical management protocols are documents designed to assist in clinical decision-making; they provide criteria regarding diagnosis and treatment and lead to recommended courses of action. The protocols are based on evidence from current

Table 4. Example of a Caries Management Protocol for 1-2 Year Olds Risk Category

Diagnostics

Interventions Fluoride

Restorative

Diet

Low risk

– Recall every 6-12 months – Baseline MS a

– Twice daily brushing with fluoridated toothpaste b

Counseling

– Surveillance χ

Moderate risk parent engaged

– Recall every 6 months – Baseline MS a

– Twice daily brushing with fluoridated toothpaste b – Fluoride supplements d – Professional topical treatment every 6 months

Counseling

– Active surveillance e of incipient lesions

Moderate risk parent not engaged

– Recall every 6 months – Baseline MS a

– Twice daily brushing with fluoridated toothpaste b – Professional topical treatment every 6 months

Counseling, with limited expectations

– Active surveillance e of incipient lesions

High risk parent engaged

– Recall every 3 months – Baseline and follow up MS a

– Twice daily brushing with fluoridated toothpaste b – Fluoride supplements d – Professional topical treatment every 3 months

Counseling

– Active surveillance e of incipient lesions – Restore cavitated lesions with ITRf or definitive restorations

High risk parent not engaged

– Recall every 3 months – Baseline and follow up MS a

– Twice daily brushing with fluoridated toothpaste b – Professional topical treatment every 3 months


– Active surveillance e of incipient lesions – Restore cavitated lesions with ITRf or definitive restorations

Table 5. Example of a Caries Management Protocol for 3-5 Year Olds Risk Category

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Diagnostics

Interventions Fluoride

Restorative

Diet

Sealants l

No

Yes

– Surveillance χ

Low risk

– Recall every 6-12 months – Radiographs every 12-24 months – Baseline MS a

– Twice daily brushing with fluoridated toothpaste g

Moderate risk parent engaged

– Recall every 6 months – Radiographs every 6-12 months – Baseline MS a

– Twice daily brushing with fluoridated toothpaste g – Fluoride supplements d – Professional topical treatment every 6 months

Counseling

Yes

– Active surveillance e of incipient lesions – Restoration of cavitated or enlarging lesions

Moderate risk parent not engaged

– Recall every 6 months – Radiographs every 6-12 months – Baseline MS a

– Twice daily brushing with fluoridated toothpaste g – Professional topical treatment every 6 months


Yes


High risk parent engaged

– Recall every 3 months – Radiographs every 6 months – Baseline and follow up MS a

– Brushing with 0.5% fluoride (with caution) – Fluoride supplements d – Professional topical treatment every 3 months

Counseling

Yes


High risk parent not engaged

– Recall every 3 months – Radiographs every 6 months – Baseline and follow up MS a

– Brushing with 0.5% fluoride (with caution) – Professional topical treatment every 3 months


Yes

– Restore incipient, cavitated, or enlarging lesions



Table 6. Example of a Caries Management Protocol for >6 Year-Olds Risk Category

Interventions

Diagnostics

Fluoride

Restorative

Diet

Sealants l

No

Yes

– Surveillance χ

Low risk

– Recall every 6-12 months – Radiographs every 12-24 months

– Twice daily brushing with fluoridated toothpaste m

Moderate risk patient/parent engaged

– Recall every 6 months – Radiographs every 6-12 months

– Twice daily brushing with fluoridated toothpaste m – Fluoride supplements d – Professional topical treatment every 6 months

– Counseling

Yes


Moderate risk patient/parent not engaged

– Recall every 6 months – Radiographs every 6-12 months

– Twice daily brushing with toothpastee m – Professional topical treatment every 6 months

– Counseling, with limited expectations

Yes


High risk patient/parent engaged

– Recall every 3 months – Radiographs every 6 months

– Brushing with 0.5% fluoride – Fluoride supplements d – Professional topical treatment every 3 months

– Counseling – Xylitol

Yes


High risk patient/parent not engaged

– Recall every 3 months – Radiographs every 6 months

– Brushing with 0.5% fluoride – Professional topical treatment every 3 months

– Counseling, with limited expectations – Xylitol

Yes

– Restore incipient, cavitated, or enlarging lesions

Legends for Tables 4-6 a Salivary mutans streptococci bacterial levels. χ Periodic monitoring for signs of caries progression. e Careful monitoring of caries progression and prevention program. γ Parental supervision of a “pea sized” amount of toothpaste. μ Less concern about the quantity of tooth paste.

b Parental supervision of a “smear” amount of tooth paste. d Need to consider fluoride levels in drinking water. f Interim Therapeutic Restoration.63 λ Indicated for teeth with deep fissure anatomy or developmental defects.

peer-reviewed literature and the considered judgment of expert panels, as well as clinical experience of practitioners. The protocols should be 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 intervention. Decisions for intervention often were learned from unstandardized dental school instruction, and then refined by clinicians over years of practice. Little is known about the criteria dentists use when making decisions involving restoration of carious lesions.36 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 management 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 arrestment or progression.

Caries management protocols 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 4, 5, 6). Such protocols should yield greater probability of success and better cost effectiveness of treatment than less standardized treatment. Additionally, caries management protocols free practitioners of the necessity for repetitive high level treatment decisions, standardize decision making and treatment strategies,36-38 eliminate treatment uncertainties, and guarantee morecorrect strategies.39 Content of the present caries management protocol is based on results of clinical trials, systematic reviews, and expert panel recommendations that give better understanding to, and recommendations for, diagnostic, preventive, and restorative treatments. The radiographic diagnostic guidelines are based on the latest guidelines from the American Dental Association (ADA).40 Systemic fluoride protocols are based on the Centers for Disease Control and Prevention’s (CDC) recommendations for using fluoride.29 Guidelines for the use of topical fluoride treatment are based on the ADA’s Council on Scientific Affairs’ recommendations for professionally-applied


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topical fluoride,41 the Scottish Intercollegiate Guideline Network guideline for the management of caries in pre-school children,42 a Maternal and Child Health Bureau Expert Panel,43 and the CDC’s fluoride guidelines.29 Guidelines for pit and fissure sealants are based on ADA’s Council on Scientific Affairs recommendations for the use of pit-and-fissure sealants.44 Guidelines on diet counseling to prevent caries are based on 2 review papers.45,46 Guidelines for the use of xylitol are based on the AAPD’s oral health policy on use of xylitol in caries prevention,32 a well-executed clinical trial on high caries-risk infants and toddlers,47 and 2 evidence-based reviews.48,49 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,50 that caries progression has diminished over recent decades,51 and that the majority of proximal lesions, even in dentin, are not cavitated.52 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 management protocols. For example, there are emerging trends to use calcium and phosphate remineralizing solution to reverse dental caries.53 Other fluoride compounds, such as silver diamine fluoride54 and stannous fluoride55, may be more effective than sodium fluoride for topical applications. There has been interest in antimicrobials to affect the caries rates, but evidence from caries trials is still inconclusive.56 However, some other proven methods, such as prescription fluoride drops and tablets, may be removed from this protocol in the future due to attitudes, risks, or compliance.57,58

Recommendations

1. Dental-caries risk assessment, based on a child’s age, biological factors, protective factors, and clinical find ings, 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, esti mating children at low, moderate, and high caries risk by a preponderance of risk and protective factors will enable a more evidence-based approach to medical provider referrals, as well as establish periodicity and intensity of diagnostic, preventive, and restorative services. 3. Clinical management protocols, based on a child’s age, caries risk, and level of patient/parent cooperation, provide health providers with criteria and protocols for determining the types and frequency of diagnos tic, preventive, and restorative care for patient speci fic management of dental caries.

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References 1. Lauer MS, Fontanarosa BP. Updated guidelines for cholesterol management. JAMA 2001;285(19):2486-97. 2. 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. 3. Litt MD, Reisine S, Tinanoff N. Multidimensional causal model of dental caries development in low-income preschool children. Public Health Reports 1995;110(4):607-17. 4. Nicolau B, Marcenes W, Bartley M, Sheiham A. A life course approach to assessing causes of dental caries experience: The relationship between biological, behavioural, socio-economic and psychological conditions and caries in adolescents. Caries Res 2003;37(5):319-26. 5. Featherstone JD. The caries balance: Contributing factors and early detection. J Calif Dent Assoc 2003;31(2): 129-33. 6. Featherstone JD. The caries balance: The basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(Suppl 1):259-64. 7. Reich E, Lussi A, Newbrun E. Caries-risk assessment. Int Dent J 1999;49(1):15-26. 8. Ismail AI, Nainar SM, Sohn W. Children’s first dental visit: Attitudes and practices of US pediatricians and family physicians. Pediatr Dent 2003;25(5):425-30. 9. Tsang P, Qi F, Shi W. Medical approach to dental caries: Fight the disease, not the lesion. Pediatr Dent 2006;28(2): 188-98. 10. Crall JJ. Development and integration of oral health services for preschool-age children. Pediatr Dent 2005;27(4): 323-30. 11. Vadiakas G. Case definition, aetiology and risk assessment of early childhood caries (ECC): A revisited review. European Arch Paed Dent 2008;9(9):114-25. 12. Alaluusua S, Malmivirta R. Early plaque accumulation – A sign for caries risk in young children. Community Dent Oral Epidemiol 1994;22(10):273-6. 13. Roeters J, Burgesdijk R, Truin GJ, van ’t Hof M. Dental caries and its determinants in 2- to-5-year old children. ASDC J Dent Child 1995;62(6):401-8. 14. Lee C, Tinanoff N, Minah G, Romberg E. Effect of Mutans streptococcal colonization on plaque formation and regrowth in young children – A brief communication. J Public Health Dent 2008;68(1):57-60. 15. Thibodeau EA, O’Sullivan DM, Tinanoff N. Mutans streptococci and caries prevalence in preschool children. Community Dent Oral Epidemiol 1993;21(5):288-91. 16. Grindefjord M, Dahllöf G, Nilsson B, Modéer T. Prediction of dental caries development in 1-year old children. Caries Res 1995;29(5):343-8. 17. Burt BA, Satishchandra P. The relationship between low birthweight and subsequent development of caries: A systematic review. J Dent Ed 2001;65(10):1017-23.


18. Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998;26(1 Suppl):45-8. 19. C ataldo WL, Oppenheim FG. Physical and chemical aspects of saliva as indicators of risk for dental caries in humans. J Dent Ed 2001;65(10):1054-62. 20. Vanobbergen J, Martens L, Lesaffre E, Bogaerts K, Declerck D. The value of a baseline caries risk assessment model in the primary dentition for the prediction of caries increment in the permanent dentition. Caries Res 2001;35(6): 442-50. 21. Nunn ME, Dietrich T, Singh HK, Henshaw MM, Kressin NR. Prevalence of early childhood caries among very young urban Boston children compared with US Children. J Public Health Dent 2009;69(3):156-62. 22. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc 1998;129(9):1229-38. 23. Southward LH, Robertson A, Edelstein BL, et al. Oral health of young children in Mississippi Delta child care centers: A second look at early childhood caries risk assessment. J Public Health Dent 2008;68(4):188-95. 24. Thitasomakul S, Piwat S, Thearmontree A, Chankanka O, Pithpornchaiyakul W. Madyusoh S. Risks for early childhood caries analyzed by negative binomial models. J Dent Res 2009;88(2):137-41. 25. Weatherell J, Deutsch D, Robinson C, Hallsworth AS. Assimilation of fluoride by enamel throughout the life of the tooth. Caries Res 1977;11(2):85-115. 26. Backer Dirks O, Houwink B, Kwant GW. The results of 6½ years of artificial fluoridation of drinking water in The Netherlands – The Tiel Cumemborg experiment. Arch Oral Biol 1961;5(12):284-300. 27. Singh KA, Spencer AJ, Armfield JM. Relative effects of pre-and posteruption water fluoride on caries experience of permanent first molars. J Pub Heath Dent 2003;63(1): 11-9. 28. Murray JJ, Naylor MN. Fluorides and dental caries. In: Murray JJ, ed. Prevention of Oral Disease. Oxford University Press, Oxford; 1996:32-67. 29. CDC. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50(RR14):1-42. 30. Ripa LW. A critique of topical fluoride methods (dentifrice, mouthrinses, operator-, and self-applied gels) in an era of decreased caries and increased fluorosis prevalence. J Pub Health Dent 1991;51(1):23-41. 31. Beltrán-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes: A review of their clinical use, cariostatic mechanism, efficacy and safety. J Am Dent Assoc 2000; 131(5):589-96. 32. American Academy of Pediatric Dentistry. Policy on use of xylitol in caries prevention. Pediatr Dent 2010;32 (special issue):36-8.

33. Ly KA, Milgrom P, Rothen M. Xylitol, sweeteners, and dental caries. Pediatr Dent 2006;28(2):154-63. 34. Reisine ST, Psoter W. Socioeconomic status and selected behavioral determinants and risk factor for dental caries. J Dent Ed 2001;65(10):1009-16. 35. Nowak AJ, Casamassimo PS. The dental home. A primary care oral health concept. J Am Dent Assoc 2002;133(1): 93-8. 36. Bader JD, Shugars DA. What do we know about how dentists make caries-related treatment decisions? Community Dent Oral Epidemiol 1997;25(1):97-103. 37. Anusavice K. Management of dental caries as a chronic infectious disease. J Dent Ed 1998;62(10):791-802. 38. Benn DK, Clark TD, Dankel DD, Kostewicz SH. Practical approach to evidence-based management of caries. J Am Coll Dent 1999;66(1):27-35. 39. White BA, Maupome G. Clinical decision-making for dental caries management. J Dent Ed 2001;65(10): 1121-5. 40. American Dental Association Council on Scientific Affairs. The use of dental radiographs. Update and recommendations. J Am Dent Assoc 2006;137(9):1304-12. 41. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: Evidencebased clinical recommendations. J Am Dent Assoc 2006; 137(8):1151-9. 42. Scottish Intercollegiate Guideline Network (SIGN). Prevention and management of dental decay in the preschool child. 2005. Available at: “http://www.sign.ac.uk/ pdf/sign83.pdf ”. Accessed July 2, 2010. 43. Maternal and Child Health Bureau Expert Panel. Topical fluoride recommendations for high-risk children: Development of decision support matrix. October 22–23, 2007, Altarum Institute, Washington, DC. Available at: “http://mohealthysmiles.typepad.com/Topical%20fl% 20recommendations%20for%20hi%20risk%20children. pdf ”. Accessed July 3, 2010. 44. American Dental Association Council on Scientific Affairs. Evidence-based clinical recommendations for the use of pit-and-fissure sealants. J Am Dent Assoc 2008;139(4):257-67. 45. Tinanoff N. Association of diet with dental caries in preschool children. Dental Clin North Am 2005;49(4): 725-7. 46. Burt BA, Pai S. Sugar consumption and caries risk: A systematic review. J Dent Ed 2001;65(10):1017-23. 47. Milgrom P, Ly KA, Tut OK, et al. Xylitol pediatric topical oral syrup to prevent dental caries. Arch Pediatr Adolesc Med 2009;163(7):601-7. 48. Maguire A, Rugg-Gunn AJ. Xylitol and caries prevention – Is it a magic bullet? British Dent J 2003;194(8):429-36. 49. Hayes C. The effect of non-cariogenic sweeteners on the prevention of dental caries: A review of the evidence. J Dent Ed 2001;65(10):1106-9.


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50. Parker C. Active surveillance: Toward a new paradigm in the management of early prostate cancer. Lancet Oncol 2004;5(2):101-6. 51. Warren JJ, Levy SM, Broffitt B, Kanellis MJ. Longitudinal study of non-cavitated carious lesion progression in the primary dentition J Public Health Dent 2006;66(2):83-7. 52. Anusavice KJ. Present and future approaches for the control of caries J Dent Ed 2005;69(5):538-54. 53. Hicks J, García-Godoy F, Flaitz C. Biological factors in dental caries: Role of remineralization and fluoride in the dynamic process of demineralization and remineralization. J Clin Ped Dent 2004;28(1):203-14. 54. Rosenblatt A, Stamford TCM, Niederman R. Silver diamine fluoride: A caries “silver-fluoride bullet”. J Dent Res 2009;88(2):116-25. 55. Tinanoff N. Progress regarding the use of stannous fluoride in clinical dentistry. J Clinical Dent 1995;6(Special issue):37-40. 55. Twetman S. Prevention of early childhood caries (ECC). Review of literature published 1998-2007. Europ Archives Paed Dent 2008;9(1):12-8. 56. Caufield PW, Desanayke AP, Li Y. The antimicrobial approach to caries management. J Dent Ed 2001;65(10): 1091-5. 57. Ismail AI, Hassen H. Fluoride supplements, dental caries and fluorosis. A systematic review. J Am Dent Assoc 2008;139(11):1457-68.

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58. Tinanoff N. Use of fluorides. In: Berg J, Slayton RL, eds. Early Childhood Oral Health. Wiley-Blackwell: Ames, Iowa; 2009:92-109. 59. 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. 60. American Dental Association Councils on Scientific Affairs and Dental Practice. Caries Risk Assessment Form (Ages 0-6). American Dental Association: Chicago, Ill; 2008. Available at: “http://www.ada.org/sections/professionalResources/docs/topics_caries_under6.doc”. Accessed July 3, 2010. 61. American Dental Association Councils on Scientific Affairs and Dental Practice. Caries Risk Assessment Form (Age >6). American Dental Association: Chicago, Ill; 2008. Available at: “http://www.ada.org/sections/ professionalResources/docs/topics_caries_over6.doc\”. Accessed July 3, 2010 62. Featherstone JDB, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessement in practice for age 6 through adult. J Calif Dent Assoc 2007;35(10): 703-13. 63. American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations. Pediatric Dent 2009;31(special issue):38-9.


Guideline on Perinatal Oral Health Care Originating Council Council on Clinical Affairs

Adopted 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that perinatal oral health, along with infant oral health, is one of 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. Aware that dentists, physicians, allied health professionals, and community organizations must be involved as partners to achieve this goal, the AAPD proposes recommendations for perinatal oral healthcare, including caries risk assessment, anticipatory guidance, preventive strategies, and appropriate therapeutic interventions, to be followed by the stakeholders in perinatal and pediatric oral health.

Method This guideline is based on a review of the current dental and medical literature related to perinatal oral health care. An electronic search was conducted using the following parameters: Terms: “early childhood caries”, “perinatal”, and “perinatal oral health”; Fields: all fields; Limits: within the last 10 years, humans, English, and clinical trials. Papers for review were chosen from the resultant 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 researchers and clinicians.

Background The perinatal period is defined as the period around birth, beginning with the completion of the 20-28th week of gestation and ending 7-28 days after birth.1-4 Perinatal oral health plays a crucial role in the overall health and well being of pregnant women.5 It is also essential for the health and well being of their newborn children. Many women do not seek dental care during their pregnancy, and those that do often confront unwillingness by dentists to provide care.6,7 Many expectant mothers are unaware of the implications of poor oral health for themselves, their pregnancy, and/or their unborn child. Research continues to show links between periodontal disease and adverse outcomes in pregnancy including preterm deliveries, low birth weight babies, and preeclampsia.8-14 Furthermore, mothers with poor oral health and high levels of cariogenic oral bacteria are at greater risk for infecting their children with the bacteria and increasing their children’s caries risk at an early age.15 Dental caries in infants is a disease that is,

by and large, preventable. Determining those mothers at highest risk for transferring cariogenic bacteria to their children improves opportunities for preventive intervention. The primary goal of perinatal oral health care, with regard to caries transmission, is to lower the numbers of cariogenic bacteria in an expectant mother’s mouth so that Mutans streptococci (MS) colonization of the infant can be delayed as long as possible.16 Timely delivery of educational information and preventive therapies to these parents can help prevent the later need for dental rehabilitation in their children. Physicians, nurses, and other health care professionals are far more likely to see expectant or new mothers and their infants than are dentists. Therefore, it is essential that these providers be aware of the infectious etiology and associated risk factors of caries and early childhood caries (ECC), make appropriate decisions regarding timely and effective interventions for pregnant women, and facilitate the establishment of a dental home.17-19

Perinatal Oral Health Caries Caries results from an overgrowth of specific organisms that are part of the normally-occurring human oral flora.20 MS is considered to be a principal indicator group of bacterial organisms responsible for dental caries.21 MS colonization of an infant has been shown to occur from the time of birth.22-28 While colonization had been thought to occur after dental eruption (as teeth provide non-shedding surfaces for adherence), current data show that other surfaces also may harbor MS.26,29-30 The furrows of the tongue appear to be an important ecological niche in harboring the bacteria in predentate infants.27,29 Vertical colonization of MS from mother to infant is well documented;31-33 genotypes of MS in infants appear identical to those present in mothers in approximately 71% of motherinfant pairs.34 The higher the levels of maternal salivary MS, the greater the risk of the infant being colonized.35 The success of transmission and resulting colonization of the mother’s salivary MS may be related to several factors including the magnitude of the inoculum, frequency of inoculation, and a minimum infective dose.36-38 Along with maternal salivary levels of MS, the mother’s oral hygiene, periodontal disease, snack frequency, and socioeconomic status also are associated with infant colonization.30 Recent reports have indicated that horizontal transmission (ie, transmission between members of a group) may be of concern. 39-41 Horizontal sources may include siblings of similar age or children in a daycare center. clinical guidelines

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Caries risk assessment can be performed to determine the patient’s relative risk for caries. Its goal is to prevent disease by identifying and minimizing causative factors (eg, microbial burden, dietary habits, plaque accumulation) and optimizing protective factors (eg, fluoride exposure, oral hygiene, sealants).42 Caries risk assessment tools can aid in the identification of reliable predictors and allow health care professionals to identify and refer high-risk patients.43 The early establishment of a dental home provides time-critical opportunities to implement preventive oral health practices, including a caries risk assessment, and reduces the risk of preventable oral/dental conditions or disease for children.44 Anticipatory guidance 45 Anticipatory guidance for the mother and/or other caregivers can help delay the onset and reduce the impact of MS colonization of the infant. Modification of the mother’s oral hygiene and diet and the use of topical chlorhexidine and/or fluoride can have a significant effect on MS levels and, correspondingly, the child’s caries rate.46-48 Perinatal anticipatory guidance includes the following: • Oral health education: The perinatal period is an opportune time to educate and perform dental treatment on expectant mothers.7,10,49,50 Pregnancy offers an opportunity to educate women regarding oral health by providing a “teachable moment” in self-care and future child-care.51 Early intervention and counseling during the perinatal period from all health care providers (eg, physicians, dentists, nurses) are essential to ensure good oral health for the mother and infant. • Oral hygiene: Tooth-brushing and flossing by the mother on a daily basis are important to help dislodge food and reduce bacterial plaque levels. Systematic literature reviews suggest an association between periodontal disease and an increased risk of adverse pregnancy outcomes, including preterm deliveries and low birth weight babies.52,53 Periodontal infections, which can be a reservoir for inflammatory mediators, can pose a threat to the placenta and fetus which can increase the likelihood of preterm delivery.54,55 Mothers with severe periodontitis have high levels of prostaglandin in their gingival crevicular fluid and blood. In turn, these increased levels of prostaglandins may be associated with uterine contractions leading to preterm deliveries.54,56 Fortunately, research shows that scaling and root planning during pregnancy can reduce the likelihood of preterm deliveries and low birth weight babies.8,57-61 These data thus emphasize the need for perinatal intervention. The effects of pregnancy negatively may affect oral health behaviors among pregnant women. Nausea and vomiting may lead to avoidance of tooth brushing, resulting in an increased caries rate. For a pregnant woman experiencing frequent vomiting, rinsing with a cup of water containing a teaspoon of baking soda and waiting an hour before brushing can help minimize dental erosion.7 Using a fluoridated toothpaste, chewing sugarless or 110

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xylitol-containing gum, and eating small amounts of nutritious food through out the day can help minimize their caries risk.7 Diet: Important components of the mother’s diet need to be discussed fully. A healthy diet is necessary to provide adequate amounts of nutrients for the mother-to-be and unborn child. Food cravings may lead to the consumption of foods that increase the mother’s caries risk. The caries potential of the mother’s diet, (ie, cariogenicity of certain foods, beverages, medicines) as well as its effect on her child, should be addressed. The frequency of consumption of cariogenic substances and resulting demineralization process also are important discussion topics. Fluoride: Daily use of a fluoridated toothpaste approved by the American Dental Association and rinsing nightly with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride have been suggested to help reduce plaque levels and help promote enamel remineralization.16 Professional oral health care: Routine professional dental care for the mother can help optimize her oral health. Every pregnant woman should have an oral evaluation, be counseled on proper oral hygiene, and be referred for preventive and therapeutic oral health care.7,10 Removal of active caries with subsequent restoration is important to suppress maternal MS reservoirs and has the potential to minimize the transfer of MS to the infant, thereby decreasing the infant’s risk of developing ECC.7 The safest time to perform dental treatment during pregnancy is in the second trimester, or the 14th–20th weeks.7,10,51,62 The risk of pregnancy loss is lower compared to that in the first trimester, and organogenesis is complete.7 Even though the second trimester is usually optimal, dental treatment can be accomplished safely at any time during pregnancy. Treatment options may include diagnostic x-rays,7,63-67 dental prophylaxis, periodontal treatment, and restorations68-73 with the administration of local anesthetics containing epinephrine.7,74 Amalgam may be considered as a restorative material in pregnant women. There is no evidence that fetal exposure to mercury releases from the mother’s existing amalgam restorations causes any adverse effects.68-70,72 Since mercury vapor released during removal and placement of amalgam restoration may be absorbed into the blood stream and cross the placental barrier, the use of rubber dam and high speed evacuation is recommended.72 Antibiotics and analgesics for treating infection and controlling pain may be administered.7 Acute conditions, such as pain and swelling, should be treated as soon as possible.7,75 Delay in necessary treatment could result in significant risk to the mother and indirectly to the fetus.7 The consequences of not treating an active infection during pregnancy outweigh the possible risks presented by most of the medications required for dental treatment.76 Due to patient positioning, comfort is a consideration for treatment during the third trimester. In these cases, elective treatment sometimes is best deferred until after delivery.


• Delay of colonization: Reducing maternal MS reservoirs, avoiding or delaying MS transmission, and implementing preventive practices for the child can help delay the colonization process.77-79 Maternal MS reservoirs can be suppressed by dietary counseling, reducing the frequency of simple carbohydrate intake, applying topical chlorhexidine and/or fluoride, removing and restoring active caries, and chewing xylitol-containing chewing gum.7 Evidence suggests that the use of xylitol chewing gum (4 pieces per day by the mother) has a significant impact on decreasing the child’s caries rate. 48,80,81 Avoidance or delay of MS transmission can be accomplished by educating the mother or caregiver on behaviors that directly pass saliva to the child (eg, sharing utensils or cups, cleaning a dropped pacifier by mouth).77,82,83 Routine preventive efforts should include toothbrushing, optimizing the child’s fluoride exposure, and limiting the child’s frequency of carbohydrate intake.

Recommendations The AAPD recommends: 1. Every expectant mother receive a comprehensive oral health evaluation from a dentist and, if not previously accomplished, establish a dental home as early as possible during pregnancy. The first visit should consist of review of medical, dental, and dietary histories, risk assessment for caries and periodontal disease, diagnosis of disease and other conditions, oral health education, and anticipatory guidance. Radiographic assessment and treatment of oral conditions should be performed with attention to maternal and fetal safety and patient comfort. 2. All primary health care professionals who serve pregnant women provide education on the etiology and prevention of ECC. Oral health counseling and referral for a comprehensive oral examination and treatment during pregnancy is especially important for the mother. 3. The curriculum of all medical, nursing, and allied health professional programs include education in perinatal oral health, including the infectious etiology of ECC, methods of oral health risk assessment, anticipatory guidance, and the need for early establishment of a dental home. 4. Parents/caregivers establish a dental home for infants by 12 months of age. 5. Legislators, policy makers and third party payors be educated about the benefits of perinatal intervention in order to support efforts that improve access to oral health care for pregnant women, including more frequent and comprehensive services.

References 1. Center for Cancer Education, University of Newcastle upon Tyne. Dictionary of Cell and Molecular Biology. Available at: “http://cancerweb.ncl.ac.uk/cgi-bin/omd? query=perinatal”. Accessed June 11, 2009. 2. Datasegment.com. Online dictionary. Available at: “http: //onlinedictionary.datasegment.com/word/perinatal”. Accessed June 11, 2009.

3. The Free Encyclopedia Wikimedia Foundation Inc. Wikipedia. Available at: “http://www.en.wikipedia.org/wiki/ Perinatal”. Accessed June 11, 2009. 4. Merriam-Webster Online Dictionary. Available at: “http:// www.merriam-webster.com/dictionary/perinatal”. Accessed June 11, 2009. 5. Brown A. Access or Oral Health Care During the Perinatal Period: A Policy Brief. National Maternal and Child Oral Health Resource Center. Georgetown University, Washington, DC; 2008. Available at: “http://www.mchoralhealth. org/PDFs/PerinatalBrief.pdf ”. Accessed August 30, 2009. 6. Gaffield ML, Gilbert BJ, Malvitz DM. Oral Health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc 2001;132(7):1009-16. 7. New York State Department of Health. Oral health care during pregnancy and early childhood: Practice Guidelines. August, 2006. Available at: “http://www.health.state. ny.us/publications/0824.pdf ”. Accessed December 29, 2008. 8. D asanayake AP, Gennaro S, Hendricks-Muñoz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs 2008;33(1):45-9. 9. Sacco G, Carmagnola D, Abati S, et al. Periodontal disease and preterm birth relationship: A review of the literature. Minerva Stomatol 2008;57(5):233-50. 10. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. Am Fam Physician 2008;77(8):1139-44. 11. Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy outcomes: A systematic review. BJOG 2006;113(2):135-43. 12. Siqueira FM, Cota LO, Costa JE, Haddad JP, Lana AM, Costa FO. Maternal periodontitis as a potential risk variable for preeclampsia: A case-control study. J Periodontol 2008;79(2):207-15. 13. Oettinger-Barak O, Barak S, Ohel G, et al. Severe pregnancy complication (preeclampsia) is associated with greater periodontal destruction. J Periodontol 2005;76 (1):134-7. 14. McKeown D. The link between periodontal disease and adverse birth outcomes. Toronto Staff Report 2006. Available at: “http://www.toronto.ca/legdocs/2006/agendas/com mittees/hl/hl060227/it002.pdf ”. Accessed June 23, 2006. 15. Ramos-Gomez FJ, Weintraub JA, Gansky SA, Hoover CI, Featherstone JD. Bacterial, behavioral and environmental factors associated with early childhood caries. J Clin Pedi Dent 2002;26(2):165-73. 16. American Academy of Pediatrics. Policy on oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;111(5Pt1):1113-6. 17. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am 2000;47(5):1043-66. 18. Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: A national survey. Pediatrics 2000;106(6):E84. clinical guidelines

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19. Harrison R. Oral health promotion for high-risk children: Case studies from British Columbia. J Can Dent Assoc 2003;69(5):292-6. 20. Loesche WJ. Clinical and microbiological aspects of chemotherapeutic agents used according to the specific plaque hypothesis. J Dent Res 1979;58(12):2404-12. 21. Ge Y, Caufield PW, Fisch GS, Li Y. Streptococcus mutans and Streptococcus sanguinis colonization correlated with caries experience in children. Caries Res 2008;42(6):444-8. 22. Stiles HM, Meyers R, Brunnelle JA, Wittig AB. Occurrence of Streptococcus mutans and Streptococcus sanguis in the oral cavity and feces of young children. In: Stiles M, Loesch WJ, O’Brien T, eds. Microbial Aspects of Dental Caries. Washington, DC: Information Retrieval; 1976:187. 23. Loesche WJ. Microbial Adhesion and Plaque. In: Dental Caries: A Treatable Infection. 2nd ed. Grand Haven, Mich. Automated Diagnostic Documentation, Inc; 1993:81-116. 24. Berkowitz RJ, Jordan HV, White G. The early establish-ment of Streptococcus mutans in the mouth of infants. Arch Oral Biol 1975;20(3):171-4. 25. Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. A longitudinal study of Streptococcus mutans colonization in infants after tooth eruption. J Dent Res 2003;82(7):504-8. 26. Wan AK, Seow WK, Walsh LJ, Bird P, Tudehope DI, Purdie DM. Association of Streptococcus mutans infection and oral developmental nodules in pre-dentate infants. J Dent Res 2001;80(10):1945-8. 27. Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent 2006;28(2):106-9; discussion 192-8. 28. Law V, Seow WK, Townsend G. Factors influencing oral colonization of mutans streptococci in young children. Aust Dent J 2007;52(2):93-100; quiz 159. 29. Tanner AC, Milgrom PM, Kent R Jr, et al. The microbiota of young children from tooth and tongue samples. J Dent Res 2002;81(1):53-7. 30. Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. Oral colonization of Streptococcus mutans in six-month-old predentate infants. J Dent Res 2001;80 (12):2060-5. 31. Davey AL, Rogers AH. Multiple types of the bacterium Streptococcus mutans in the human mouth and their intrafamily transmission. Arch Oral Biol 1984;29(6):453-60. 32. Berkowitz R, Jones P. Mouth-to-mouth transmission of the bacterium Streptococcus mutans between mother and child. Arch Oral Biol 1985;30(4):377-9. 33. Douglass JM, Li Y, Tinanoff N. Association of Mutans streptococci between caregivers and their children. Pediatr Dent 2008;29(5):375-87. 34. Li Y, Caufield PW. The fidelity of initial acquisition of Mutans streptococci by infants from their mothers. J Dent Res 1995;74(2):681-5. 35. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classifications, consequences, and prevention strategies. Pediatr Dent 2008;29(suppl):39-41. 112

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36. Acs G, Lodolini G, Kaminshy S, Cisneros GJ. Effect of nursing caries on body weight in pediatric populations. Pediatr Dent 1992;14(5):302-5. 37. Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ, Judd P. Malnourishment in a population of young children with severe early childhood caries. Pediatr Dent 2006;28 (3):254-9. 38. Ismail AI. Prevention of early childhood caries. Comm Dent Oral Epidemiol 1998;26(suppl):49-61. 39. Mattos-Graner RO, Li Y, Caufield PW, Duncan M, Smith JD. Genotypic diversity of Mutans streptococci in Brazilian nursery children suggests horizontal transmission. J Clin Microbiol 2001;39(6):2313-6. 40. Van Loveren C, Buijs JF, ten Cate JM. Similarity of bacteriocin activity profiles of Mutans streptococci within the family when the children acquire strains after the age of 5. Caries Res 2000;34(6):481-5. 41. Redmo Emanuelsson IM, Wang XM. Demonstration of identical strains of Mutans streptococci within Chinese families by genotyping. Eur J Oral Sci 1998;106(3):778-94. 42. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for infants, children, and adolescents. Pediatr Dent 2009;31(special issue):118-25. 43. American Academy of Pediatric Dentistry. Policy on the use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent 2009;30(suppl):29-33. 44. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2009;30(suppl):22-23. 45. Nowak AJ, Casamassimo PS. Using anticipatory guidance to provide early dental intervention. J Am Dent Assoc 1995;126(8):1156-63. 46. Köhler B, Andréen I, Jonsson B. The effects of cariespreventive measures in mothers on dental caries and the oral presence of the bacteria Streptococcus mutans and lactobacilli in their children. Arch Oral Biol 1984;29(11):879-83. 47. Brambilla E, Felloni A, Gagliani M, Malerba A, GarcíaGodoy F, Strohmenger L. Caries prevention during pregnancy: Results of a 30-month study. J Am Dent Assoc 1998;129(7):871-7. 48. Isokangas P, Söderling E, Pienihäkkinen K, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum: A follow-up from 0 to 5 years of age. J Dent Res 2000;79(11):1885-9. 49. Boggess KA, Society for Maternal-Fetal Medicine Publications Committee. Maternal oral health in pregnancy. Obstet Gynecol 2008;111(4):976-86. 50. De La Cruz GG, Rozier RG, Slade G. Dental screening and referral of young children by pediatric primary care providers. Pediatrics 2004;114(5):e642-52. 51. Boggess KA, Edelstein BL. Oral health in women during preconception and pregnancy: Implications for birth outcomes and infant oral health. Matern Child Health J 2006;10(5 suppl):S169-74. 52. Xiong X, Buekens P, Vastardis S, Yu SM. Periodontal disease and pregnancy outcomes: State-of-the-science. Obstet Gynecol Surv 2007;62(9):605-15.


53. Khader YS, Ta’ani Q. Periodontal diseases and the risk of preterm birth and low birth weight: A meta-analysis. J Periodontol 2005;76(2):161-5. 54. Offenbacher S, Katz V, Fertik G, et al. Periodontal infections as a possible risk factor for preterm low birth weight. J Periodontol 1996;67(suppl 10):1103-13. 55. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: Results of a prospective survey. J Am Dent Assoc 2001;132(7):875-80. 56. Offenbacher S, Jared HL, O’Reily PG, et al. Potential pathogenic mechanisms of periodontitis associated pregnancy complications. Ann Periodontol 1998;3(1):233-50. 57. López NJ, Da Silva I, Ipinza J, Gutiérrez J. Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol 2005;76(11 suppl):2144-53. 58. Jeffcoat MK, Hauth JC, Geurs NC, et al. Periodontal disease and preterm birth: Results of a pilot intervention study. J Periodontal 2003;74(8):1214-8. 59. Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy outcomes. A systemic review. Ann Periodontol 2003;8(1):70-8. 60. Dasanayake AP, Li Y, Wiener H, Ruby JD, Lee, MJ. Salivary actinomyces naeslundii genospecies 2 and lactobacillus casei levels predict pregnancy outcomes. J Periodontol 2005;76(2):171-7. 61. López NJ, Smith PC, Gutiérrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized controlled trial. J Periodontol 2002;73(8):911-24. 62. Gajendra S, Kumar JV. Oral health and pregnancy: A review. NY State Dent J 2004;70(1):40-4. 63. American College of Obstetrics and Gynecology. Committee Opinion, Number 299, September 2004 Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol 2004;104(3):647-51. 64. National Council on Radiation Protection and Measurement. Report No. 54: Medical radiation exposure of pregnant and potentially pregnant women. Bethesda, Md; 1977. 65. Toppenberg KS, Hill DA, Miller DP. Safety of radiographic imaging during pregnancy. Am Fam Physician 1999;59(7):1813-8, 1820. 66. Matteson SR, Joseph LP, Bottomley W, et al. The report of the panel to develop radiographic selection criteria for dental patients. Gen Dent 1991;39(4):264-70. 67. American Dental Association, US Dept of Health and Human Services. The selection of patients for x-ray examinations: Dental radiographic examinations. Rockville, Md. Food and Drug Administration, 2004; HHS Publication Number 88-8273. Available at: “http://www.ada.org/prof/ resources/topics/radiography.asp#radiographs”. Accessed December 30, 2008.

68. Life Sciences Research Office. Review and analysis of the literature on the potential adverse effects of dental amalgam. Bethesda, Md. December 9, 2004. Available at: “http: //www.lsro.org/presentation_files/amalgam/amalgam_pressrelease.pdf ”. Accessed June 15, 2009. 69. US Food and Drug Administration, Center for Devices and Radiological Health Consumer Information. Consumer Update: Dental Amalgam. Available at: “http://www.fda. gov/cdrh/consumer/amalgams.html”. Accessed December 30, 2008. 70. Hujoel PP, Lydon-Rochelle M, Bollen AM, Woods JS, Geurtsen W, del Aguila MA. Mercury exposure from dental filling replacement during pregnancy and low birth weight risk. Am J Epidemiol 2005;161(8):734-40. 71. March of Dimes. During your pregnancy: Things to avoid: Mercury. 2008. Available at: “http://www.marchofdimes. com/pnhec/159_15759.asp”. Accessed December 30, 2008. 72. Whittle KW, Whittle JG, Sarll DW. Amalgam fillings during pregnancy. Br Dent J 1998;185(10):500. 73. Olea N, Pulgar R, Perez P, et al. Estrogenicity of resin-based composites and sealants used in dentistry. Environ Health Perspect 1996;104(3):298-305. 74. Rosen MA. Management of anesthesia for the pregnant surgical patient. Anesthesiol 1999;91(4):1159-63. 75. Chiodo GT, Rosenstein DI. Dental treatment during pregnancy: A preventive approach. J Am Dent Assoc 1985; 110(3). 76. Moore PA. Selecting drugs for the dental patient. J Am Dent Assoc 1998;129(9):1281-6. 77. Berkowitz RJ. Causes, treatments and prevention of early childhood caries: A microbiologic perspective. J Can Dent Assoc 2003;69(5):304-7. 78. Kohler B, Andreen I. Influence of caries-preventive measures in mothers on cariogenic bacteria and caries experience in their children. Arch Oral Biol 1994;39(10): 907-11. 79. Li Y, Dasanayake AP, Caufield PW, Elliot RR. Butts JT III. Characterization of maternal Mutans streptococci transmission in an African American population. Dent Clin North Am 2003;47(1):87-101. 80. Söderling E, Isokongas P, Pienihäkkien K, Tenovuo J, Alanen P. Influence of maternal xylitol consumption on mother-child transmission of Mutans streptococci: 6-year follow-up. Caries Res 2001;35(3):173-7. 81. Gomez SS, Weber AA. Effectiveness of a caries preventive program in pregnant women and new mothers on their offspring. Int J Paediatr Dent 2001;11(2):117-22. 82. Berkowitz RJ. Acquisition and transmission of Mutans streptococci. J Calif Dent Assoc 2003;31(2):135-8. 83. Caufield PW, Wannemuehler YM, Hansen JB. Familial clustering of Streptococcus mutans cryptic plasmid strain in a dental clinic population. Infect Immun 1982;38(2): 907-11.

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Guideline on Infant Oral Health Care Originating Committee

Clinical Affairs Committee – Infant Oral Health Subcommittee Review Council Council on Clinical Affairs

Adopted 1986

Revised 1989, 1994, 2001, 2004, 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that infant oral health, along with perinatal oral health, is one of the foundations upon which preventive education and dental care must be built to enhance the opportunity for a lifetime free from preventable oral disease. Recognizing that allied health professionals and community organizations must be involved as partners to achieve this goal, the AAPD proposes recommendations for preventive strategies, oral health risk assessment, anticipatory guidance, and appropriate therapeutic interventions to be followed by the stakeholders in pediatric oral health.

Methods

This revision included a new systematic literature search of the MEDLINE/Pubmed electronic database using the following parameters: Terms: infant oral health, infant oral health care, and early childhood caries; Field: all fields; Limits: within the last 10 years, humans, English, and clinical trials. Papers for review were chosen from the resultant 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 researchers and clinicians.

Background Introduction The Centers for Disease Control and Prevention reports that caries is perhaps the most prevalent infectious disease in our nation’s children.1 More than 40% of children have caries by the time they reach kindergarten.2 Early childhood caries (ECC) can be a particularly virulent form of caries, beginning soon after tooth eruption, developing on smooth surfaces, progressing rapidly, and having a lasting detrimental impact on the dentition.3-8 This disease affects the general population but is 32 times more likely to occur in infants who are of low socioeconomic status, who consume a diet high in sugar, and whose mothers have a low education level.9 Caries in primary teeth can affect children’s growth, result in significant pain and potentially life-threatening infection, and diminish overall quality

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of life.10-17 Since physicians, nurses, and other health care professionals are far more likely to see new mothers and infants than are dentists, it is essential that they be aware of the infectious etiology and associated risk factors of ECC, make appropriate decisions regarding timely and effective intervention, and facilitate the establishment of the dental home.3,18-21 Caries Caries results from an overgrowth of specific organisms that are part of normally-occurring human oral flora.22 Mutans streptococci (MS) is considered to be a principal indicator group of bacterial organisms responsible for dental caries.23 MS colonization of an infant has been shown to occur from the time of birth.24-30 While colonization had been thought to occur after dental eruption (as teeth provided non-shedding surfaces for adherence), current data show that other surfaces also may harbor MS.28,31,32 For example, the furrows of the tongue appear to be an important ecological niche in harboring the bacteria in predentate infants.29,31 Vertical colonization of MS from mother to infant is well documented;33-35 genotypes of MS in infants appear identical to those present in mothers in approximately 71% of motherinfant pairs.36 The higher the levels of maternal salivary MS, the greater the risk of the infant being colonized.37 Along with salivary levels of MS, mother’s oral hygiene, periodontal disease, snack frequency, and socioeconomic status also are associated with infant colonization.32 Recent reports have indicated that horizontal transmission (ie, transmission between members of a group) also may be of concern.38-40 Horizontal sources may include siblings of similar age or children in a daycare center. Preventive strategies Caries is a disease that is, by and large, preventable. Early risk assessment allows for identification of parent-infant groups who are at risk for ECC and would benefit from early preventive intervention. The ultimate goal of early assessment is the timely delivery of educational information to populations at high risk for developing caries in order to prevent the need for later surgical intervention.


Oral health risk assessment An oral health risk assessment for infants by 6 months of age allows for the institution of appropriate preventive strategies as the primary dentition begins to erupt. Caries risk assessment can be used to determine the patient’s relative risk for caries. Even the most judiciously designed and implemented cariesrisk assessment tool, however, can fail to identify all infants at risk for developing ECC. In these cases, the mother may not be the colonization source of the child’s oral flora, the dietary intake of simple carbohydrates may be extremely high, or other uncontrollable factors may combine to place the patient at risk for developing caries. Therefore, screening for risk of caries in the parent and patient coupled with oral health counseling, although a feasible and equitable approach to ECC control, is not a substitute for the early establishment of the dental home.37 Whenever possible, the ideal approach to infant oral health care, including ECC prevention and management, is the early establishment of a dental home.21,41

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Anticipatory guidance42

General anticipatory guidance for the mother (or other intimate caregiver) includes the following: • Oral hygiene: Tooth-brushing and flossing by the mother on a daily basis are important to help dislodge food and reduce bacterial plaque levels. • Diet: Important components of dietary education for the parents include the cariogenicity of certain foods and beverages, role of frequency of consumption of these substances, and the demineralization/remineralization process. • Fluoride: Using a fluoridated toothpaste approved by the American Dental Association and rinsing every night with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride have been suggested to help reduce plaque levels and help enamel remineralization.18 • Caries removal: Routine professional dental care for the mothers can help keep their oral health in optimal condition. Removal of active caries with subsequent restoration is important to suppress maternal MS reservoirs and has the potential to minimize the transfer of MS to the infant, thereby decreasing the infant’s risk of developing ECC. 46 • Delay of colonization: Education of the parents, especially mothers, on avoiding saliva-sharing behaviors (eg, sharing spoons and other utensils, sharing cups, cleaning a dropped pacifier or toy with their mouth) can help prevent early colonization of MS in their infants. • Xylitol chewing gums: Evidence demonstrates that mothers’ use of xylitol chewing gum can prevent dental caries in their children by prohibiting the transmission of MS.47 General anticipatory guidance for the young patient (0 to 3 years of age) includes the following: • Oral hygiene: Oral hygiene measures should be implemented no later than the time of the eruption of the first primary tooth. Cleansing the infant’s teeth as soon as they erupt with either a washcloth or soft toothbrush will help

•

•

reduce bacterial colonization. Children’s teeth should be brushed twice daily with fluoridated toothpaste and a soft, age-appropriate sized toothbrush.37 A “smear” of toothpaste is recommended for children less than 2 years of age,48 while a “pea-size” amount of paste is recommended for children 2-5 years of age.48-50 Flossing should be initiated when adjacent tooth surfaces can not be cleansed with a toothbrush.37 Diet: High-risk dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood.51,52 Frequent night time bottle feeding, ad libitum breast-feeding, and extended and repeated use of a sippy or no-spill cup are associated with, but not consistently implicated in ECC.53 Likewise, frequent consumption of snacks or drinks containing fermentable carbohydrates (eg, juice, milk, formula, soda) also can increase the child’s caries risk.54 Fluoride: Optimal exposure to fluoride is important to all dentate infants and children. The use of fluoride for the prevention and control of caries is documented to be both safe and effective.55-59 Twice-daily brushing with fluoridated toothpaste is recommended for all children as a preventive procedure.55.60 Professionally-applied fluoride, as well as athome fluoride treatments, should be considered for children at high caries risk based upon caries risk assessment.55,58,59,61,62 Systemically-administered fluoride should be considered for all children drinking fluoride deficient water (6 mg/kg), prilocaine can the thickness of soft tissue is less than 20 mm. A long induce methemoglobinemia symptoms26 (eg, gray or slate needle may be used for a deeper injection into soft blue cyanosis of the lips, mucous membranes, and nails; tissue.21 Any 23- through 30-gauge needle may be used respiratory and circulatory distress).6 Prilocaine may be con for intraoral injections, since blood can be aspirated traindicated in patients with methemoglobinemia, sickle cell through all of them. Aspiration can be more difficult, anemia, anemia, or symptoms of hypoxia or in patients re21 however, when smaller gauge needles are used. An since both medica extra-short, 30-gauge is appropriate for infiltration ceiving acetaminophen or phenacetin, 23 tions elevate methemoglobin levels. 21 injections. Recommendations: 3. Needles should not be bent if they are to be inserted 1. Selection of local anesthetic agents should be based into soft tissue to a depth of >5 mm or inserted to upon: their hub for injections to avoid needle breakage.21 a. the patient’s medical history and mental/develop mental status; Anesthetic

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mg/1.7 ml or 1.8 ml cartridge

Vasoconstrictor/1.7 ml or 1.8 ml cartridge

American academy of pediatric dentistry

b. the anticipated duration of the dental procedure; c. the need for hemorrhage control; d. the planned administration of other agents (eg, nitrous oxide, sedative agents, general anesthesia); e. the practitioner’s knowledge of the anesthetic agent. 2. Use of vasoconstrictors in local anesthetics is recom mended to decrease the risk of toxicity of the anesthetic agent, especially when treatment extends to 2 or

more quadrants in a single visit. 3.

In cases of bisulfate allergy, use of a local anesthetic without a vasoconstrictor is indicated. A local anesthetic without a vasoconstrictor also can be used for shorter treatment needs but should be used with caution to minimize the risk of toxicity of the anesthetic agents. 4. The established maximum dosage for any anesthetic should not be exceeded. Documentation of local anesthesia

The patient record is an essential component of the delivery of competent and quality oral health care.27 Following each appointment, an entry is made in the record that accurately and objectively summarizes that visit. Appropriate documentation includes specific information relative to the administration of local anesthesia. Recommendations: 1. Documentation must include the type and dosage of local anesthetic. Dosage of vasoconstrictors, if any, must be noted. (For example, 34 mg lido with 0.017 mg epi or 34 mg lido with 1:100,000 epi).2 2. Documentation may include the type of injection(s) given (eg, infiltration, block, intraosseous), needle se lection, and patient’s reaction to the injection. 3. If the local anesthetic was administered in conjunc tion with sedative drugs, the doses of all agents must be noted on a time-based record. 4. In patients for whom the maximum dosage of local anesthetic may be a concern, the weight should be documented preoperatively. 5. Documentation should include that post-injection in structions were reviewed with the patient and parent. Local anesthetic complications Toxicity (overdose) Most adverse drug reactions develop either during the injection or within 5 to 10 minutes.12 Overdose of local anesthetic can result from high blood levels caused by a single inadvertent intravascular injection or repeated injections.3 Local anesthetic causes a biphasic reaction (eg, excitation followed by depression) in the central nervous system (CNS). Early subjective indications of toxicity involve the CNS and include dizziness, anxiety, and confusion. This may be followed by diplopia, tinnitis, drowsiness, 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.3 The cardiovascular system (CVS) response to local anesthetic toxicity also is biphasic. The CVS is more resistant to local anesthetics than the CNS.28 Initially, during CVS stimulation, 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 local anesthetic blood level.12 Local anesthetic toxicity can be prevented by careful injection technique, watchful observation of the patient, and knowledge of the maximum dosage based on weight. Practitioners should aspirate before every injection and inject slowly.12 After the injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect. Early recognition 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 is based on the severity of the reaction.3,12 Allergy to local anesthesia Allergic reactions are not dose dependant but are due to the patient’s heightened capacity to react to even a small dose. Allergies can manifest in a variety of ways, some of which include urticaria, dermatitis, angioedema, fever, photosensitivity, or anaphylaxis.12 Emergency management is dependent on the rate and severity of the reaction. Paresthesia Paresthesia is persistent anesthesia beyond the expected duration. Trauma to the nerve can produce paresthesia and, among other etiologies, trauma can be caused by the needle during the injection.29 The patient may experience an “electric shock” in the involved nerve distribution area. Paresthesia also can be caused by hemorrhage in or around the nerve.30 Risk of permanent paresthesia is 1:1,200,000 for 0.5%, 2%, and 3% local anesthetics and 1:500,000 for 4% local anesthetics.29 Reports of paresthesia are more common with articaine and prilocaine than expected from their frequency of use. Paresthesia unrelated to surgery most often involves the tongue, followed by the lip, and is more common with 4% solutions of articaine or prilocaine.30 Most cases resolve in 8 weeks.31 Postoperative soft tissue injury Self-induced soft tissue trauma is an unfortunate clinical complication of local anesthetic use in the oral cavity. Most lip- and cheek-biting lesions of this nature are self-limiting and heal without complications, although bleeding and infection possibly may result. The use of bilateral mandibular blocks does not increase the risk of soft tissue trauma when compared to unilateral mandibular blocks or ipsilateral maxillary infiltration.32 In fact, the frequency of soft tissue trauma was much

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higher than expected when only 1 side was anesthetized. Using mandibular infiltration vs blocks is not of great value in prevention of these injuries, since the duration of soft tissue anesthesia may not be reduced significantly. In addition, for some procedures, infiltration is not as effective as the mandibular block.33 Caregivers responsible for postoperative supervision should be given a realistic time for duration of numbness and informed of the possibility of 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 anesthesia. Use of phentolamine mesylate injections in patients over age 6 years or at least 15 kg has been shown to reduce the duration of effects of local anesthetic by about 47% in the maxilla and 67% in the mandible.34,35 However, there is no research demonstrating a relationship between reduction in soft tissue trauma and the use of shorter acting local anesthetics.36 Recommendations to reduce local anesthetic complications: 1. Practitioners who utilize any type of local anesthetic in a pediatric dental patient shall possess appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency. 2. Care should be taken to ensure proper needle place ment during the intraoral administration of local anesthetics. Practitioners should aspirate before every injection and inject slowly. 3. After the injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect. 4. Residual soft tissue anesthesia should be minimized in pediatric and special health care needs patients to de crease risk of self-inflicted postoperative injuries. 5. Practitioners should advise patients and their care givers regarding behavioral precautions (eg, do not bite or suck on lip/cheek, do not ingest hot substances) and the possibility of soft tissue trauma while anesthe sia persists. Placing a cotton roll in the mucobuccal fold may help prevent injury, and lubricating the lips with petroleum jelly helps prevent drying.36 Practi tioners who use pheytolamine mesylate injections to reduce the duration of local anesthesia still should follow these recommendations. Supplemental injections to obtain local anesthesia The majority of 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 (ie, periodontal ligament [PDL], intraligamentary, and peridental injection), “needleless” systems, and intraseptal or intrapulpal injection. These techniques may improve comfort of injection by better

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control of the administration rate, pressure, and location of anesthetic solutions and/or result in successful and more controlled anesthesia. Endocarditis prophylaxis is recommended for intraligamentary local anesthetic injections in patients at risk.37 Intraseptal injection for lingual anesthesia is a variation in technique after the buccal tissue is anesthetized. The needle is inserted through the buccal tissue to anesthetize the lingual/ palatal soft tissues. It can be used with the PDL injection to gain lingual anesthesia when postoperative soft tissue trauma is a concern.38 During pulpal therapy, administering local anesthetic directly into the pulp may be indicated when other methods fail to anesthetize the tooth.38 As with traditional methods of obtaining oral local anesthesia, the alternative methods generally are safe if the practitioner understands the principles for their use. Some of these techniques are desirable, especially in infants, children, adolescents, and special health care needs patients, since specific teeth may be anesthetized with less residual anesthesia (ie, avoid discomfort and potential self-mutilation of block anesthesia).38 The mandibular bone of a child usually is less dense than that of an adult, permitting more rapid and complete diffusion of the anesthetic.9 Mandibular buccal infiltration anesthesia is as effective as inferior nerve block anesthesia for some operative procedures.9,33 In patients with bleeding disorders, the PDL injection minimizes the potential for postoperative bleeding of soft tissue vessels.6 Intraosseus techniques may be contraindicated with primary teeth due to potential for damage to developing permanent teeth.30 Also, the use of the PDL injection or intraosseus methods is contraindicated in the presence of inflammation or infection at the injection site.38

Recommendation: Alternative techniques for the delivery of local anesthesia may be considered to minimize the dose of anesthetic used, improve patient comfort, and/or improve successful dental anesthesia. Local anesthesia with sedation, general anesthesia, and/or nitrous oxide/oxygen analgesia/anxiolysis Drugs that have the same mechanism of action often will have additive effects when used together. Local anesthetics and sedative agents both depress the CNS. An increase in toxic reactions of local anesthetics when combined with opioids has been demonstrated.39 Narcotics may decrease the amount of protein binding of local anesthetics and also elevate arterial carbon dioxide, both of which will increase CNS sensitivity to convulsions. In addition, narcotics such as meperidine have convulsant properties when excessive doses are administered. It has been suggested that the dose of local anesthesia be adjusted downward when sedating children with opioids.39 Using local anesthesia has been found to reduce the dosage of inhalation anesthetics for patients undergoing general anesthesia.40 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 hydrocarbons (eg, halothane).41 Local anesthesia

American academy of pediatric dentistry

also has been reported to reduce pain in the postoperative recovery period after general anesthesia.42 Recommendations: 1. Particular attention should be paid to local anesthetic doses used in children. To avoid excessive doses for the patient who is going to be sedated, a maximum re commended dose based upon weight should be cal culated. 2. The dosage of local anesthetic should not be altered if nitrous oxide/oxygen analgesia/anxiolysis is admi nistered. 3. When general anesthesia is employed, local anesthesia may be used to reduce the maintenance dosage of the anesthetic drugs. The anesthesiologist should be in formed of the type and dosage of the local anesthetic used. Recovery room personnel also should be in formed.

References 1. Nathan JE, Venham LL, West MS, Werboff J. The ef-

2. 3. 4. 5.

6. 7.

8.

9. 10.

fects of nitrous oxide on anxious young pediatric patients across sequential visits: A double-blind study. ASDC J Dent Child 1988;55(3):220-30. Malamed SF. Basic injection technique in local anesthesia. In: Handbook of Local Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004:159-69. Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc 2002;68(9):546-51. Malamed SF. Pharmacology of vasoconstrictors. In: Handbook of Local Anesthesia. 5 th ed. St. Louis, Mo: Mosby; 2004:41-54. Pérusse R, Goulet JP, Turcotte JY. Contraindications to vasoconstrictors in dentistry: Part II. Hyperthyroidism, diabetes, sulfite sensitivity, cortico-dependant asthma, and pheochromocytoma. Oral Surg Oral Med Oral Pathol 1992;74(5):687-91. Malamed SF. Physical and psychological evaluation. In: Handbook of Local Anesthesia. 5 th ed. St. Louis, Mo: Mosby; 2004:141-56. Goulet JP, Perusse R, Turcotte JY. Contraindications to vasoconstrictors in dentistry: Part III. Pharmacologic interactions. Oral Surg Oral Med Oral Pathol 1992;74(5): 692-7. Gielen M, Viering W. 3-in-1 lumbar plexus block for muscle biopsy in malignant hyperthermia patients: Amide local anesthetics may be used safely. Acta Anaesthesiol Scand 1986;30(7):581-3. Malamed SF. Local anesthetic considerations in dental specialties. In: Handbook of Local Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004:269, 274-5. Jeske AH, Blanton PL. Misconceptions involving dental local anesthesia. Part 2: Pharmacology. Tex Dent J 2002; 119(4):310-4.

11. Rosivack RG, Koenigsberg SR, Maxwell KC. An analysis of the effectiveness of two topical anesthetics. Anesth Prog 1990;37(6):290-2. 12. Malamed SF. Systemic complications. In: Handbook of Local Anesthesia. 5 th ed. St. Louis, Mo: Mosby; 2004: 311-25. 13. Malamed SF. Additional armamentarium. In: Handbook of Local Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004:120. 14. Graham JW. Profound, needle-free anesthesia in orthodontics. Clin Ortho 2006;40(12):723-4. 15. Kravitz ND. The use of compound topical anesthetics: A review. J Am Dent Assoc 2007;138(10)1333-9. 16. Kravits ND, Kusnoto B, Tsay TP, Hohlt WF. The use of temporary anchorage devices for molar intrusion. J Am Dent Assoc 2007;138(1):56-64. 17. US Food and Drug Administration. FDA public health advisory: Life-threatening side effect with the use of skin products containing numbing ingredients for cosmetic procedures. Available at: “http://www.fda.gov/cder/drug/ advisory/topical_anesthetics.htm”. Accessed November 15, 2008. 18. US Dept for Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research. Guidance for FDA staff and industry: Marketed unapproved drugs–Compliance policy guide. Sec 440.100 Marketed new drugs without approved NDAs or ANDAs. Available at “http://www.fda.gov/cder/guidance/6911fnl. pdf ”. Accessed November 15, 2008. 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. 20. American Dental Association Council on Dental Materials, 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 Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004:99-107. 22. Malamed SF. Local complications. In: Handbook of Local Anesthesia. 5 th ed. St. Louis, Mo: Mosby; 2004: 285-7. 23. Malamed SF. Clinical action of specific agents. In: Handbook of Local Anesthesia. 5th ed. St Louis, Mo: Mosby; 2004:55-81. 24. Haas DA, Harper DG, Saso MA, Young ER. Lack of differential effect by Ultracaine (articaine) and Citanest (prilocaine) in infiltration anaesthesia. J Can Dent Assoc 1991;57(3):217-23. 25. Bellamy MC, Hopkins PM, Hallsall PJ, Ellis FR. A study into the incidence of methaemoglobinaemia after “threein-one” block with procaine. Anaesthesia 1992;47(12): 1084-5.

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26. Hardwick FK, Beaudreau RW. Methemoglobinemia in renal transplant patient: Case report. Pediatr Dent 1995; 17(7):460-3. 27. American Academy of Pediatric Dentistry. Guideline on record-keeping. Pediatr Dent 2008;30(suppl):226-33. 28. Scott DB. Toxicity caused by local anesthetic drugs. Br J Anaesth 1981;53(6):553-4. 29. Haas DA. Local complications. In: Malamed SF, ed. Handbook of Local Anesthesia. 5th ed. St Louis, Mo: Mosby; 2004:288-9. 30. Haas DA, Lennon D. A 21-year retrospective study of reports of paresthesia following local anesthetic administration. J Can Dent Assoc 1995;61(4):319-20, 323-6, 329-30. 31. Nickel AA. A retrospective study of reports of paresthesia following local anesthetic administration. Anesth Prog 1990;37(1):42-5. 32. College C, Feigal R, Wandera A, Strange M. Bilateral vs unilateral mandibular block anesthesia in a pediatric population. Pediatr Dent 2000;22(6):453-7. 33. Oulis C, Vadiakas G, Vasilopoulou A, The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children. Pediatr Dent 1996;18(4):301-5. 34. Tavares M, Goodson MJ, Studen-Pavlovich D, et al. Reversal of soft-tissue local anesthesia with phentolamine mesylate in pediatric patients. J Am Dent Assoc 2008; 139(8):1095-104. 35. Hersh EV, Moore PA, Papas AS, et al. Reversal of softtissue local anesthesia with phentolamine mesylate in adolescents and adults. J Am Dent Assoc 2008;139(8): 1080-93.

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36. Malamed SF. Anatomical considerations. In: Handbook of Local Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004; 173-4 37. 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: “http://circ.ahajournals.org/cgi/ reprint/CIRCULATIONAHA.106.183095)”. Accessed March 30, 2008. Correction Circulation. 2007;116: e376-e377. Available at: “htttp://circ.ahajournals.org/cgi/ content/full/116/15/1736”. Accessed May 23, 2008. 38. Malamed SF. Supplemental injection techniques. In: Handbook of Local Anesthesia. 5th ed. St Louis, Mo: Mosby; 2004:256-68. 39. Moore PA. Adverse drug reactions in dental practice: Interactions associated with local anesthetics, sedatives, and anxiolytics. J Am Dent Assoc 1999;130(4):541-4. 40. Barash PG, Cullen BF, Stoelting RK. Clinical Anesthesia. 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1992:531. 41. Dionne RA, Phero JC, Becker DE. Management of Pain and Anxiety in the Dental Office. Philadelphia, Pa: WB Saunders; 2002:274-5. 42. Nick D, Thompson L, Anderson D, Trapp L. The use of general anesthesia to facilitate dental treatment. Gen Dent 2003;51(5):464-8.


Guideline on Use of Nitrous Oxide for Pediatric Dental Patients Originating Council Council on Clinical Affairs


Adopted 2005

Revised 2009

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 This guideline is based on a review of the current dental and medical literature related to nitrous oxide/oxygen analgesia/ anxiolysis in pediatric patients. A MEDLINE search was conducted using the terms “nitrous oxide”, “analgesia”, “anxiolysis”, “behavior management”, and “dental treatment”.

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 Analgesia/anxiolysis is defined as diminution or elimination of pain and anxiety in a conscious patient.2 The patient responds normally to verbal commands. 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.2 It also may allow the patient to tolerate unpleasant procedures by reducing or relieving anxiety, discomfort, or pain. The outcome of pharmacological approaches 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.

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 with little effect on the respiratory system.3 Nitrous oxide has multiple mechanisms of action. The analgesic effect of nitrous oxide appears to be initiated by neuronal release of endogeneous opioid peptides with subsequent activation of opioid receptors and descending Gamma-aminobutyric acid type A (GABAA) receptors and noradrenergic pathways that modulate nociceptive processing at the spinal level. The anxiolytic effect involves activation of the GABAA receptor either directly or indirectly through the benzodiazepine binding site.4 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. As nitrous oxide is 34 times more soluble than nitrogen in blood, diffusion hypoxia may occur. Studies5-7 have shown that children desaturate more rapidly than adolescents, and administering 100% oxygen to the patient for 3 to 5 minutes once the nitrous oxide in a closed system has been terminated is important.5 Nitrous oxide causes minor depression in cardiac output while peripheral resistance is slightly increased, thereby maintaining the blood pressure.3 This is of particular advantage in treating patients with cerebrovascular system disorders. Nitrous oxide is absorbed rapidly, allowing for both rapid onset and recovery (2-3 minutes). It causes minimal impairment of any reflexes, thus protecting the cough reflex.3 Although rare, silent regurgitation and subsequent aspiration need to be considered with nitrous oxide/oxygen sedation. The concern lies in whether pharyneal-laryngeal reflexes remain intact. This problem can be avoided by not allowing the patient to go into an unconscious state.8 It generally is acceptable to children and can be titrated easily. Most children are enthusiastic about the administration of nitrous oxide/oxygen; many children report dreaming or being on a “space-ride”.8 For some patients, however, the feeling of “losing control” may be troubling and

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claustrophobic patients may find the nasal hood confining and unpleasant.9 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. The objectives of nitrous oxide/oxygen inhalation include: 1. reduce or eliminate anxiety; 2. reduce untoward movement and reaction to dental treatment; 3. enhance communication and patient cooperation; 4. raise the pain reaction threshold; 5. increase tolerance for longer appointments; 6. aid in treatment of the mentally/physically disabled or medically compromised patient; 7. reduce gagging; 8. potentiate the effect of sedatives. Disadvantages of nitrous oxide/oxygen inhalation may include:3 1. lack of potency; 2. dependant largely on psychological reassurance; 3. interference of the nasal hood with injection to ante rior maxillary region; 4. patient must be able to breathe through the nose; 5. nitrous oxide pollution and potential occupational exposure health hazards.

Recommendations Patient selection Indications for use of nitrous oxide/oxygen analgesia/anxiolysis include: 1. a fearful, anxious, or obstreperous patient; 2. certain patients with special health care needs; 3. a patient whose gag reflex interferes with dental care; 4. a patient for whom profound local anesthesia cannot be obtained; 5. a cooperative child undergoing a lengthy dental pro cedure. 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: 1. allergies and previous allergic or adverse drug reac tions; 2. current medications including dose, time, route, and site of administration; 3. diseases, disorders, or physical abnormalities and pregnancy status; 4. previous hospitalization to include the date and purpose. Contraindications for use of nitrous oxide/oxygen inhalation may include: 1. some chronic obstructive pulmonary diseases; 2. severe emotional disturbances or drug-related depen dencies10; 3. first trimester of pregnancy11;

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4. treatment with bleomycin sulfate12; 5. methylenetetrahydrofolate reductase deficiency.13 Whenever possible, appropriate medical specialists should be consulted before administering analgesic/anxiolytic agents to patients with significant underlying medical conditions (eg, severe obstructive pulmonary disease, congestive heart failure, sickle cell disease,14 acute otitis media, recent tympanic membrane graft15, acute severe head injury16). Technique of nitrous oxide/oxygen administration Nitrous oxide/oxygen must be administered only by appropriately 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 5 to 6 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% oxygen for 1 to 2 minutes followed by titration of nitrous oxide in 10% intervals is recommended. During nitrous oxide/ oxygen analgesia/anxiolysis, the concentration of nitrous oxide should not routinely exceed 50%. Nitrous oxide concentration may be decreased during easier procedures (eg, restorations) and increased during more stimulating ones (eg, extraction, injection of local anesthetic). 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 psychological reassurance. Therefore, it is important to continue traditional behavior guidance techniques during treatment. Once the nitrous oxide flow is terminated, 100% oxygen should be delivered for 3 to 5 minutes.3 The patient must return to pretreatment responsiveness before discharge. Monitoring The response of patients to commands during procedures performed with anxiolysis/analgesia serves as a guide to their level of consciousness. Clinical observation of the patient must be done during any dental procedure. During nitrous oxide/oxygen analgesia/anxiolysis, continual clinical observation of the patient’s responsiveness, color, and respiratory rate and rhythm must be performed. Spoken responses provide an indication that the patient is breathing.2 If any other pharmacologic agent is used in addition to nitrous oxide/oxygen and a local anesthetic, monitoring guidelines for the appropriate level of sedation must be followed.17 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.18 Nausea and vomiting are the most common adverse effects, occurring in 0.5% of patients.19 A higher incidence is noted with longer administration of nitrous oxide/oxygen, fluctuations in nitrous oxide levels, and increased concentrations of nitrous oxide.3 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 2 hours prior to the administration of nitrous oxide.20 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 and disorientation and can be avoided by administering 100% oxygen after nitrous oxide has been discontinued.3 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 precautions, if indicated. In addition, the patient’s record should include indication for use of nitrous oxide/oxygen inhalation, nitrous oxide dosage (ie, 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 capacity for delivering 100%, and never less than 30%, oxygen concentration at a flow rate appropriate to the child’s size. Additionally, inhalation equipment must have a fail-safe system that is checked and calibrated regularly according to the practitioner’s state laws and regulations.17 If nitrous oxide/ oxygen delivery equipment capable of delivering more than 70% nitrous oxide and less than 30% oxygen is used, an inline oxygen analyzer must be used. The equipment must have an appropriate scavenging system. The practitioner who utilizes nitrous oxide/oxygen analgesia/anxiolysis for a pediatric dental patient shall possess appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency. 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. Emergency 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 positivepressure oxygen delivery system capable of administering >90% oxygen at a 10 L/min flow for at least 60 minutes (650 L, “E” cylinder) must be available. When a self-inflating

bag valvemask device is used for delivering positive 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.17 Where state law mandates equipment and facilities, such statutes should supersede this guideline.17 Occupational safety In an effort to reduce occupational health hazards associated with nitrous 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.21

References 1. American Dental Association. Position statement: The use of conscious sedation, deep sedation and general anesthesia in dentistry. Available at: “http://ada.org/prof/ resources/positions/statements/useof.asp”. Accessed November 24, 2008. 2. American Society of Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists: An updated report by the American Society of Anesthesiologists task force on sedation and analgesia by nonanesthesiologists. Anesthesiology 2002;96:1004-17. 3. Paterson SA, Tahmassebi JF. Pediatric dentistry in the new millennium: Use of inhalation sedation in pediatric dentistry. Dent Update 2003;30(7):350-6, 358. 4. Emmanouil DE, Quock RM. Advances in understanding the actions of nitrous oxide. Anesth Prog 2007;54(1):9-18. 5. Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and onset of desaturation in apnoeic children. Can J Anaesth 1994;41(9):771-4. 6. Patel R, Norden J, Hannallah RS. Oxygen administration prevents hypoxemia during post-anesthesia transport in children. Anesthesiology 1988;69(4):616-8. 7. Kinouci K, Tanigami H, Tashiro C, Nishimura M, Fukumitsu K, Takauchi Y. Duration of apnea in anesthetized infants and children required for desaturation of hemoglobin to 95%. Anesthesiology 1992;77(6):1105-7. 8. Hogue D, Ternisky M, Iranour B. The response to nitrous oxide analgesia in children. ASDC J Dent Child 1971;38 (2):129-33. 9. Stach DJ. Nitrous oxide sedation: Understanding the benefit and risks. Am J Dent 1995;8(1):47-50. 10. Clark MS, Brunkick AL. Nitrous Oxide and Oxygen Sedation. 3rd ed. St Louis, Mo; Mosby; 2008:94. 11. 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. 12. 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.

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13. Selzer R, Rosenblatt D, Laxova R, Hogan K. Adverse effect of nitrous oxide in a child with 5,10- methylenetetrahydrofolate reductase deficiency. N Engl J Med 2003; 349(1):45-50. 14. 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. 15. 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. 16. 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. 17. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: An update. Pediatr Dent 2008;30(suppl):143-59.

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18. Donaldson D, Meechan JG. The hazards of chronic exposure to nitrous oxide: An update. Br Dent J 1995;178(3): 95-100. 19. 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. 20. Hosey MT. UK National Clinical Guidelines in Paediatric Dentistry. Managing anxious children: The use of conscious sedation in paediatric dentistry. Int J Paediatr Dent 2002;12(5):359-72. 21. American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated with nitrous oxide. Pediatr Dent 2008;30(suppl):64-5.


Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures Developed and Endorsed by

American Academy of Pediatrics and the American Academy of Pediatric Dentistry Adopted 2006

Abstract The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical 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 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 tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation as well as an appreciation for 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, appropriate medications and reversal agents, sufficient numbers of people 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 presedation level of consciousness before discharge from medical supervision, and appropriate discharge instructions.

Introduction Invasive diagnostic and minor surgical procedures on pediatric patients outside the traditional operating room setting have increased in the last decade. 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 physician offices, dental offices, subspecialty procedure suites, imaging facilities, emergency departments, and ambulatory surgery centers also has markedly increased.1-37 In recognition of this need for both elective and emergency use of sedation in nontraditional settings, the American Academy of Pediatrics (AAP) and 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.38-42 The purpose of this updated statement is

to unify the guidelines for sedation used by medical and dental practitioners, add clarifications regarding monitoring modalities, provide new information from medical and dental literature, and suggest methods for further improvement in safety and outcomes. With the revision of this document, the Joint Commission on Accreditation of Healthcare Organizations, the American Society of Anesthesiologists (ASA), the AAP, and the AAPD will use similar language to define sedation categories and the expected physiologic responses.41-44 This revised statement reflects the current understanding of appropriate monitoring needs both during and after sedation for a procedure.4,5,12,19,21,22,26,45-53 The monitoring and care outlined in this guideline may be exceeded at any time, based on the judgment of the responsible practitioner. Although intended to encourage high-quality patient care, adherence to this guideline cannot guarantee a specific patient outcome. However, structured sedation protocols designed to incorporate the principles in this document have been widely implemented and shown to reduce morbidity.29,32-34,37,54,55 This guideline is proffered with the awareness that, regardless of the intended level of sedation or route of administration, the sedation of a pediatric patient represents a continuum and may result in respiratory depression and the loss of the patient’s protective reflexes.43,57-60 Sedation of pediatric patients has serious associated risks, such as hypoventilation, apnea, airway obstruction, laryngospasm, and cardiopulmonary impairment.2,6,22,45,46,54,60-69 These adverse responses during and after sedation for a diagnostic or therapeutic 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 conditions.54 Appropriate drug selection for the intended procedure as well as the presence of an individual with the skills needed to rescue a patient from an adverse response are essential. Appropriate physiologic monitoring and continuous observation by personnel not directly involved with the procedure allow for accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions.46,51,54

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The sedation of children is different from the sedation of adults. Sedation in children often is administered to control behavior to allow the safe completion of a procedure. A child’s ability to control his or her own behavior to cooperate for a procedure depends both on his or her chronologic and developmental age. Often, children younger than 6 years and those with developmental delay require deep levels of sedation to gain control of their behavior.57 Therefore, the need for deep sedation should be anticipated. Children in this age group are particularly vulnerable to the sedating medication’s effects on respiratory drive, patency of the airway, and protective reflexes.46 Studies have shown that it is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation.56,59,70 For older and cooperative children, other modalities, such as parental presence, hypnosis, distraction, topical local anesthetics, and guided imagery, may reduce the need for or the needed depth of pharmacologic sedation.31,71-81 The concept of rescue is 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,” practitioners must have the skills to rescue from “deep sedation”; if 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 necessary to provide appropriate cardiopulmonary support if needed. Sedation and anesthesia in a nonhospital environment (private physician or dental office or freestanding imaging facility) may be associated with an increased incidence of “failure to rescue” the patient should an adverse event occur, because the only backup in this venue may be to activate emergency medical services (EMS).46,82 Rescue therapies require specific training and skills.46,54,83,84 Maintenance of the skills needed to perform successful bagvalve-mask ventilation is essential to successfully rescue a child who has become apneic or developed airway obstruction. Familiarity with emergency airway management procedure algorithms is essential.83-87 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 patients are available.32,48,55,88-93 This guideline is intended for all venues in which sedation for a procedure might be performed (hospital, surgical center, freestanding imaging facility, dental facility, or private office). There are other guidelines for specific situations and personnel 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 departments of anesthesiology.94 Also, guidelines for the sedation

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of patients undergoing mechanical ventilation in a critical care environment or for providing analgesia for patients postoperatively, patients with chronic painful conditions, and hospice care are beyond the scope of this document. Definitions of Terms for This Report • “Pediatric patients”: all patients through 21 years of age, as defined by the AAP. • “Must” or “shall”: an imperative need or duty that is essential, indispensable, or mandatory. • “Should”: the recommended need and/or duty. • “May” or “could”: freedom or liberty to follow a suggested or reasonable alternative. • “Medical supervision” or “medical personnel”: a current, licensed practitioner in medicine, surgery, or dentistry trained in the administration of medications used for procedural sedation and the management of complications associated with these medications. • “Are encouraged”: a suggested or reasonable action to be taken. • “ASA Physical Status Classification”: guidelines for classifying the baseline health status according to the ASA (see Appendix B). • “Minimal sedation” (old terminology “anxiolysis”): a druginduced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. • “Moderate sedation” (old terminology “conscious sedation”or “sedation/analgesia”): a drug-induced depression of consciousness during which patients respond purposefully to verbal commands (eg,“open your eyes” either alone or accompanied by light tactile stimulation—a light tap on the shoulder or face, not a sternal rub). For older patients, this level of sedation implies an interactive state; for younger patients, age-appropriate behaviors (eg, crying) occur and are expected. Reflex withdrawal, although a normal response to a painful stimulus, is not considered as the only ageappropriate purposeful response (eg, it must be accompanied by another response, such as pushing away the painful stimulus so as to confirm a higher cognitive function). With moderate sedation, no intervention is required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. However, in the case of procedures that may themselves cause airway obstruction (eg, dental or endoscopic), the practitioner must recognize an obstruction and assist the patient in opening the airway. If the patient is not making spontaneous efforts to open his/her airway so as to relieve the obstruction, then the patient should be considered to be deeply sedated. • “Deep sedation” (“deep sedation/analgesia”): a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully (see discussion of reflex withdrawal above) after repeated verbal or painful stimulation


(eg, purposefully pushing away the noxious stimuli). The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. A state of deep sedation may be accompanied by partial or complete loss of protective airway reflexes. • “General anesthesia”: a drug-induced loss of consciousness 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. Cardiovascular function may be impaired.

Goals of Sedation The goals of sedation in the pediatric patient for diagnostic and therapeutic procedures are: 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 control behavior and/or movement so as to allow the safe completion of the procedure; and 5) to return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible (Appendix A). These goals can best be achieved by selecting the lowest dose of drug with the highest therapeutic index for the procedure. It is beyond the scope of this document to specify which drugs are appropriate for which procedures; however, the selection of the fewest number of drugs and matching drug selection to the type and goal of the procedure are essential for safe practice.53,88,91-93,95-97 For example, analgesic medications such as opioids are indicated for painful procedures. For nonpainful procedures, such as computed tomography or magnetic resonance imaging (MRI), sedatives/hypnotics are preferred. When both sedation and analgesia are desirable (eg, fracture reduction), either single agents with analgesic/sedative properties or combination regimens commonly are used. Anxiolysis and amnesia are additional goals that should be considered in selection of agents for particular patients. However, the potential for an adverse outcome may be increased when 3 or more sedating medications are administered.44,98 Knowledge of each drug’s time of onset, peak response, and duration of action is essential. Although the concept of titration of drug to effect is critical, one must know whether the previous dose has taken full effect before administering additional drug. Such management will improve safety and outcomes. Drugs with long durations of action (eg, chloral hydrate, intramuscular pentobarbital, phenothiazines) will require longer periods of observation even after the child achieves currently used recovery and discharge criteria.45,99,100 This concept is particularly important for infants and toddlers transported in car safety seats who are at risk of resedation after discharge because of residual prolonged drug effects with the potential for airway obstruction.45,46

General Guidelines Candidates Patients who are in ASA classes I and II are frequently considered appropriate candidates for minimal, moderate, or deep sedation (Appendix B). Children in ASA classes III and IV, children with special needs, and those with anatomic airway abnormalities or extreme tonsillar hypertrophy present issues that require additional and individual consideration, particularly for moderate and deep sedation.51 Practitioners are encouraged to consult with appropriate subspecialists and/or an anesthesiologist for patients at increased risk of experiencing 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 responsible person. It is preferable to have 2 or more 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.101 Facilities The practitioner who uses sedation must have immediately available facilities, personnel, and equipment to manage emergency and rescue situations. The most common serious complications of sedation involve compromise of the airway or depressed respirations resulting in airway obstruction, hypoventilation, hypoxemia, and apnea. Hypotension and cardiopulmonary arrest may occur, usually from inadequate recognition and treatment of respiratory compromise. Other rare complications may also include seizures and allergic reactions. Facilities providing pediatric sedation should monitor for, and be prepared to treat, such complications. Back-up Emergency Services A protocol for access to back-up emergency services shall be clearly identified, with an outline of the procedures necessary for immediate use. For nonhospital facilities, a protocol for ready access to ambulance service and immediate activation of the EMS system for life-threatening complications must be established and maintained. It should be understood that the availability of EMS services does not replace the practitioner’s responsibility to provide initial rescue in managing life-threatening complications. On-Site Monitoring and Rescue Equipment An emergency cart or kit must be immediately accessible. This cart or kit must contain equipment to provide the necessary age- and size-appropriate drugs and equipment 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 facility or to another area within a medical facility. All equipment and drugs must be checked and maintained on a scheduled basis (see Appendices C and D for suggested drugs and emergency life support equipment to consider before the need for rescue

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occurs). Monitoring devices, such as electrocardiography (ECG) machines, pulse oximeters (with size-appropriate oximeter probes), end-tidal carbon dioxide monitors, and defibrillators (with size-appropriate defibrillator paddles), must have a safety and function check on a regular basis as required by local or state regulation. Documentation Before Sedation Documentation shall include, but not be limited to, the guidelines that follow: 1. Informed consent. The patient record shall document that appropriate informed consent was obtained according to local, state, and institutional requirements.102 2. Instructions and information provided to the responsible person. The practitioner shall provide verbal and/or written instructions to the responsible person. Information shall include objectives of the sedation and anticipated changes in behavior during and after sedation. Special 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 so as to avoid airway obstruction. Transportation by 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 pentobarbital, or phenothiazine. 45,46,100,103 Consideration for a longer period of observation shall be given if the responsible person’s ability to observe the child is limited (eg, only 1 adult who also has to drive). Another indication for prolonged observation would be a child with an anatomic airway problem or a severe underlying medical condition. 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. Therefore, it is prudent that before sedation, the practitioner evaluate preceding food and fluid intake. It is likely that the risk of aspiration during procedural sedation differs from that during general anesthesia involving tracheal intubation or other airway manipulation.104,105 However, because the absolute risk of aspiration during procedural sedation is not yet known, guidelines for fasting periods before elective sedation generally should follow those used for elective general anesthesia. For emergency procedures in children who have not fasted, the risks of sedation and the possibility of aspiration must be balanced against the benefits of performing the procedure promptly (see below). Further research is needed to better elucidate the relationships between various fasting intervals and sedation complications.

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Before Elective Sedation Children receiving sedation for elective procedures should generally follow the same fasting guidelines as before general anesthesia (Table 1). It is permissible for routine necessary medications to be taken with a sip of water on the day of the procedure. For the Emergency Patient The practitioner must always balance the possible risks of sedating nonfasted patients with the benefits and necessity for completing the procedure. In this circumstance, the use of sedation must be preceded by an evaluation of food and fluid intake. There are few published studies with adequate statistical power to provide guidance to the practitioner regarding safety or risk of pulmonary aspiration of gastric contents during procedural sedation.104-109 When protective airway reflexes are lost, gastric contents may be regurgitated into the airway. Therefore, patients with a history of recent oral intake or with other known risk factors, such as trauma, decreased level of consciousness, extreme obesity, pregnancy, or bowel motility dysfunction, require careful evaluation before 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. The use of agents with less risk of depressing protective airway reflexes may be preferred.110 Some emergency patients requiring deep sedation may require protection of the airway before sedation. Use of Immobilization Devices Immobilization devices, such as papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction. The child’s head position and respiratory excursions 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 practitioner and reviewed by the sedation team at the time of treatment for possible interval changes. The purpose of this evaluation is not only to document baseline status but also to determine whether patients present specific risk factors that may warrant additional consultation before sedation. This evaluation will also screen out patients whose sedation will require more advanced airway or cardiovascular management skills or alterations in the doses or types of medications used for procedural sedation. A new concern for the practitioner is the widespread use of medications that may interfere with drug absorption or metabolism and, therefore, enhance or shorten the effect time of sedating medications. Herbal medicines (eg, St. John’s


wort, echinacea) may alter drug pharmacokinetics through inhibition of the cytochrome P450 system, resulting in prolonged drug effect and altered (increased or decreased) blood drug concentrations.111-116 Kava may increase the effects of sedatives by potentiating gamma-aminobutyric acid inhibitory neurotransmission, and valerian may itself produce sedation that apparently is mediated through modulation of gamma-aminobutyric acid neurotransmission and receptor function.117,118 Drugs such as erythromycin, cimetidine, and others also may inhibit the cytochrome P450 system, resulting in prolonged sedation with midazolam as well as other medications competing for the same enzyme systems. 119-122 Medications used to treat human immunodeficiency virus infection, some anticonvulsants, and some psychotropic medications also may produce clinically important drug-drug interactions.123-125 Therefore, a careful drug history is a vital part of the safe sedation of children. The clinician should consult various sources (a pharmacist, textbooks, online services, or handheld databases) for specific information on drug interactions.126 The health evaluation should include: • Age and weight • Health history, including: 1) allergies and previous allergic or adverse drug reactions; 2) medication/drug history, including dosage, time, route, and site of admi nistration for prescription, over-the-counter, herbal, or illicit drugs; 3) relevant diseases, physical abnormali ties, and neurologic impairment that might increase the potential for airway obstruction, such as a history of snoring or obstructive sleep apnea;127,128 4) preg nancy status; 5) a summary of previous relevant hospi talizations; 6) history of sedation or general anesthesia and any complications or unexpected responses; and 7) relevant family history, particularly related to anesthesia • Review of systems with a special focus on abnormali ties of cardiac, pulmonary, renal, or hepatic function that might alter the child’s expected responses to se dating/analgesic medications • Vital signs, including heart rate, blood pressure, res spiratory rate, 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 occurrence) • Physical examination, including a focused evaluation of the airway (tonsillar hypertrophy, abnormal anato my—eg, mandibular hypoplasia) to determine whether there is an increased risk of airway obstruction54,129,130 • Physical status evaluation (ASA classification [see Ap pendix B]) • Name, address, and telephone number of the child’s medical home For hospitalized patients, the current hospital record may suffice for adequate documentation of presedation health;

however, a brief note shall be written documenting that the chart was reviewed, positive findings were noted, and a management plan was formulated. If the clinical or emer gency condition of the patient precludes acquiring com plete 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 benefit of direct supervision by trained medical personnel. Administration of sedating medications at home poses an unacceptable risk, particularly for infants and preschool-aged children traveling in car safety seats.46 Documentation During Treatment The patient’s chart shall contain a time-based record that includes the name, route, site, time, dosage, 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 site of the procedure.43 During administration, the inspired concentrations of oxygen and inhalation sedation agents and the duration of their administration shall be documented. Before drug administrations, special attention must be paid to calculation of dosage (ie, mg/kg). 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, and oxygen saturation were monitored until the patient attained predetermined discharge criteria (see Appendix A). A variety of sedation scoring systems are available and may aid this process.70,100 Adverse events and their treatment shall be documented. Documentation After Treatment The time and condition of the child at discharge from the treatment area or facility shall be documented; this 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 recognized criteria (see Appendix A). 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 resedation,45,103,131,132 some patients might benefit from a longer period of less-intense observation (eg, a stepdown observation area) before discharge from medical supervision.133 Several scales to evaluate recovery have been devised and validated.70,134,135 A recently described and 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.100

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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.137-141 Therefore, each facility should maintain records that track adverse events, such as desaturation, apnea, laryngospasm, the need for airway interventions including jaw thrust, positive pressure ventilation, prolonged sedation, unanticipated use of reversal agents, unintended or prolonged hospital admission, and unsatisfactory sedation/ analgesia/anxiolysis. Such events can then be examined for assessment of risk reduction and improvement in patient satisfaction.

Preparation and Setting up for Sedation Procedures Part of the safety net of sedation is to use 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: S = Size-appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction) O = An adequate oxygen supply and functioning flow meters/ other devices to allow its delivery A = Airway: size-appropriate airway equipment (nasopharyngeal and oropharyngeal airways, laryngoscope blades [checked and functioning], endotracheal tubes, stylets, face mask, bag-valve-mask or equivalent device [functioning]) P = Pharmacy: all the basic drugs needed to support life during an emergency, including antagonists as indicated M = Monitors: functioning pulse oximeter with sizeappropriate oximeter probes141,142 and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, end-tidal carbon dioxide, ECG, stethoscope) E = Special equipment or drugs for a particular case (eg, defibrillator)

Specific Guidelines for Intended Level of Sedation Minimal Sedation Minimal sedation (old terminology “anxiolysis”) is a druginduced 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.57 Moderate Sedation “Moderate sedation” (old terminology “conscious sedation” or “sedation/analgesia”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal

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commands or following light tactile stimulation (see Definition of Terms for This Report). No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function usually is maintained. The caveat that loss of consciousness should be unlikely is a particularly important aspect of the definition of moderate sedation. The drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness highly unlikely. Because the patient who receives moderate sedation may progress into a state of deep sedation and obtundation, the practitioner should be prepared to increase the level of vigilance corresponding to what is necessary for deep sedation.57 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 provided in this guideline, and to manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bagvalve-mask ventilation so as to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged. Support Personnel The use of moderate sedation shall include 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 measures, if required. This individual may also be responsible for assisting with interruptible patientrelated tasks of short duration.44 This individual must be trained in and capable of providing pediatric basic life support. The support person shall have specific assignments in the event of an emergency and current knowledge of the emergency cart inventory. The practitioner and all ancillary personnel should participate in periodic reviews and practice drills of the facility’s emergency protocol to ensure proper function of the equipment and coordination of staff roles in such emergencies. Monitoring and Documentation Baseline Before administration of sedative medications, a baseline determination of vital signs shall be documented. For some children who are very upset or noncooperative, this may not be possible and a note should be written to document this happenstance. During the Procedure The practitioner shall document the name, route, site, time of administration, and dosage of all drugs administered. There shall be continuous monitoring of oxygen saturation and heart


rate and intermittent recording of respiratory rate and blood pressure; these should be recorded in a time-based record. Restraining devices 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 position should be checked frequently to ensure airway patency. A functioning suction apparatus must be present. After the procedure The child who has received moderate sedation must be observed in a suitably equipped recovery facility (eg, the facility must have functioning suction apparatus as well as the capacity to deliver more than 90% oxygen and positive-pressure ventilation—eg, bag and mask with oxygen capacity as described previously). The patient’s vital signs should be recorded at specific intervals. 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 A). 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 (eg, a step-down observation area where multiple patients can be observed simultaneously) before discharge from medical supervision (see also Documentation Before Sedation for instructions to families).45,103,131,132 A recently described and 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.100 Patients who have received reversal agents, such as flumazenil or naloxone, will also require a longer period of observation, because the duration of the drugs administered may exceed the duration of the antagonist, which can lead to resedation. Deep Sedation Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation (see Definition of Terms for This Report). The state and risks of deep sedation may be indistinguishable from those of general anesthesia.

Vascular Access Patients receiving deep sedation should have an intravenous line placed at the start of the procedure or have a person skilled in establishing vascular access in pediatric patients immediately available. Monitoring and Documentation A competent individual shall observe the patient continuously. The monitoring shall include all parameters described for moderate sedation. Vital signs, including oxygen saturation and heart rate, must be documented at least every 5 minutes in a timebased record. The use of a precordial stethoscope or capnograph for patients difficult to observe (eg, during MRI, in a darkened room) to aid in monitoring adequacy of ventilation is encouraged.143 The practitioner shall document the name, route, site, time of administration, and dosage of all drugs administered. The inspired concentrations of inhalation sedation agents and oxygen and the duration of administration shall be documented. Postsedation Care The facility and procedures followed for postsedation care shall conform to those described under “Moderate Sedation.”

Special Considerations Local Anesthetic Agents All local anesthetic agents are cardiac depressants and may cause central nervous system excitation or depression. Particular attention should be paid to dosage in small children.64,66 To ensure that the patient will not receive an excessive dose, the maximum allowable safe dosage (ie, mg/kg) should be calculated before administration. There may be enhanced sedative effects when the highest recommended doses of local anesthetic drugs are used in combination with other sedatives or narcotics (see Tables 2 and 3 for limits and conversion tables of commonly used local anesthetics).64,144-157 In general, when administering local anesthetic drugs, the practitioner should aspirate frequently so as to minimize the likelihood that the needle is in a blood vessel; lower doses should be used when injecting into vascular tissues.158

Personnel There must be 1 person available whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration. At least 1 individual must be present who is trained in, and capable of, providing advanced pediatric life support, and who is skilled in airway management and cardiopulmonary resuscitation; training in pediatric advanced life support is required.

Pulse Oximetry The new generation of pulse oximeters is less susceptible to motion artifacts and may be more useful than older oximeters that do not contain the updated software.159-163 Oximeters that change tone with changes in hemoglobin saturation provide immediate aural warning to everyone within hearing distance. It is essential that any oximeter probe is positioned properly; clip-on devices are prone to easy displacement, which may produce artifactual data (eg, under- or overestimation of oxygen saturation).141,142

Equipment In addition to the equipment previously cited for moderate sedation, an electrocardiographic monitor and a defibrillator for use in pediatric patients should be readily available.

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

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less-accessible locations, such as magnetic resonance imaging or computerized axial tomography devices or darkened rooms.47,49, 50,143,164-173 The use of expired carbon dioxide monitoring devices is encouraged for sedated children, particularly in situations where other means of assessing the adequacy of ventilation are limited. Several manufacturers have produced nasal cannulae that allow simultaneous delivery of oxygen and measurement of expired carbon dioxide values.164,165 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.166,168,173 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, and bag-mask-valve ventilation. Occasionally, endotracheal intubation is required for more prolonged ventilatory support. In addition to standard endotracheal intubation techniques, a number of new devices are available for the management of patients with abnormal airway anatomy or airway obstruction. Examples include the laryngeal mask airway (LMA), the cuffed oropharyngeal airway, and a variety of kits to perform an emergency cricothyrotomy. The largest clinical experience in pediatrics is with the LMA, which is available in a variety of sizes and can even be used in neonates. Use of the LMA is now being introduced into advanced airway training courses, and familiarity with insertion techniques can be life saving.174,175 The LMA also can serve as a bridge to secure airway management in children with anatomic airway abnormalities.176,177 Practitioners are encouraged to gain experience with these techniques as they become incorporated into pediatric advanced life support courses. An additional emergency device with which to become familiar is the intraosseous needle. Intraosseous needles also are available in several sizes and can be life saving in the rare situation when rapid establishment of intravenous access is not possible. Familiarity with the use of these adjuncts for the management of emergencies can be obtained by keeping current with resuscitation courses, such as Pediatric Advanced Life Support and Advanced Pediatric Life Support or other approved programs. Patient Simulators Advances in technology, particularly patient simulators that allow a variety of programmed adverse events (eg, apnea, bronchospasm, laryngospasm), response to medical interventions, and printouts of physiologic parameters, are now available. The use of such devices is encouraged to better train medical professionals to respond more appropriately and effectively to rare events.178-180

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Monitoring During MRI The powerful magnetic field and the generation of radiofrequency emissions necessitate the use of special equipment to provide continuous patient monitoring throughout the MRI scanning procedure. Pulse oximeters capable of continuous function during scanning should be used in any sedated or restrained pediatric patient. Thermal injuries can result if appropriate precautions are not taken; avoid coiling the oximeter wire and place the probe as far from the magnetic coil as possible to diminish the possibility of injury. Electrocardiogram monitoring during magnetic resonance imaging has been associated with thermal injury; special MRI-compatible ECG pads are essential to allow safe monitoring.181-184 Expired carbon dioxide monitoring is strongly encouraged in this setting. 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 to oxygen and that has a delivery system that covers the mouth and nose must be used in conjunction with a calibrated and functional oxygen analyzer. All nitrous oxideto-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.185 Newly constructed or reconstructed treatment facilities, especially those with piped-in nitrous oxide and oxygen, must have appropriate 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.15,186-210 The use of nitrous oxide for minimal sedation is defined as the administration of nitrous oxide (50% or less) with the balance as oxygen, without any other sedative, narcotic, 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 maintain verbal communication throughout the procedure. It should be noted that although local anesthetics have sedative properties, for purposes of this guideline, they are not considered sedatives in this circumstance. If nitrous oxide in oxygen is combined with other sedating medications, such as chloral hydrate, midazolam, or an opioid, or if nitrous oxide is used in concentrations greater than 50%, the likelihood for moderate or deep sedation increases.211,212 In this situation, the clinician must be prepared to institute the guidelines for moderate or deep sedation as indicated by the patient’s response.213


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, clear tea, black coffee

2

Breast milk

4

Infant formula

6

Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period

6

Light meal: a light meal typically consists of toast and clear liquids. 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.

6

* 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. A Report of the American Society of Anesthesiologists. Available at: “http://www.asahq.org/publicationsAndServices/npoguide.html”.

Table 2. Commonly Used Local Anesthetic Agents: Doses, Duration, and Calculations* Maximum Dose with Epinephrine (mg/Kg)† Local Anesthetic

Duration of Action (min) ‡

Medical

Dental

Procaine

10.0

6

Chloroprocaine

20.0

12

30-60

1.5

1

180-600

Lidocaine

7.0

4.4

90-200

Mepivacaine

7.0

4.4

120-240

Bupivacaine

3.0

1.3

180-600

Levobupivacaine

3.0

2

180-600

Ropivacaine

3.0

2

180-600

7

60-230

Esters

Tetracaine

60-90

Amides

Articaine

* Maximum recommended doses and duration of action. Note that lower doses should be used in very vascular areas. † These are maximum doses of local anesthetics combined with epinephrine; lower doses are recommended when used without epinephrine. Doses of amides should be decreased by 30% in infants younger than 6 months. When lidocaine is being administered intravascularly (eg, during intravenous regional anesthesia), the dose should be decreased to 3 to 5 mg/kg; long-acting local anesthetic agents should not be used for intravenous regional anesthesia. ‡ Duration of action is dependent on concentration, total dose, and site of administration; use of epinephrine; and the patient’s age.

Table 3. Local Anesthetic Percent Concentration: Conversion to mg/mL Concentration (%)

mg/mL

3.0

30.0

2.5

25.0

2.0

20.0

1.0

10.0

0.5

5.0

025

2.5

0.125

1.25

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Appendix A. Recommended Discharge Criteria 1. 2. 3. 4. 5. 6.

Cardiovascular function and airway patency are satisfactory and stable. The patient is easily arousable, and protective reflexes are intact. The patient can talk (if age appropriate). The patient can sit up unaided (if age appropriate). For a very young or handicapped child incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved. The state of hydration is adequate.

Appendix B. ASA Physical Status Classification Class I Class II Class III Class IV Class V

A normally healthy patient. A patient with mild systemic disease (eg, controlled reactive airway disease). A patient with severe systemic disease (eg, a child who is actively wheezing). A patient with severe systemic disease that is a constant threat to life (eg, a child with status asthmaticus). A moribund patient who is not expected to survive without the operation (eg, a patient with severe cardiomyopathy requiring heart transplantation).

Appendix C. Drugs* That May Be Needed to Rescue a Sedated Patient44 Albuterol for inhalation Ammonia spirits Atropine Diphenhydramine Diazepam Epinephrine (1:1000, 1:10 000) Flumazenil Glucose (25% or 50%) Lidocaine (cardiac lidocaine, local infiltration) Lorazepam Methylprednisolone Naloxone Oxygen Fosphenytoin Racemic epinephrine Rocuronium Sodium bicarbonate Succinylcholine * The choice of emergency drugs may vary according to individual or procedural needs.

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Appendix D. Emergency Equipment † That May Be Needed to Rescue a Sedated Patient ‡ Intravenous Equipment Assorted IV catheters (eg, 24-, 22-, 20-, 18-, 16-gauge) Tourniquets Alcohol wipes Adhesive tape Assorted syringes (eg, 1-, 3-, 5-, 10-mL) IV tubing Pediatric drip (60 drops/mL) Pediatric burette Adult drip (10 drops/mL) Extension tubing 3-way stopcocks IV fluid Lactated Ringer solution Normal saline solution D5 0.25 normal saline solution Pediatric IV boards Assorted IV needles (eg, 25-, 22-, 20-, and 18-gauge) Intraosseous bone marrow needle Sterile gauze pads Airway Management Equipment Face masks (infant, child, small adult, medium adult, large adult) Breathing bag and valve set Oropharyngeal airways (infant, child, small adult, medium adult, large adult) Nasopharyngeal airways (small, medium, large) Laryngeal mask airways (1, 1.5, 2, 2.5, 3, 4, and 5) Laryngoscope handles (with extra batteries) Laryngoscope blades (with extra light bulbs) Straight (Miller) No. 1, 2, and 3 Curved (Macintosh) No. 2 and 3 Endotracheal tubes (2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, and 6.0 uncuffed and 6.0, 7.0, and 8.0 cuffed) Stylettes (appropriate sizes for endotracheal tubes) Surgical lubricant Suction catheters (appropriate sizes for endotracheal tubes) Yankauer-type suction Nasogastric tubes Nebulizer with medication kits Gloves (sterile and nonsterile, latex free) † The choice of emergency equipment may vary according to individual or procedural needs. ‡ The practitioner is referred to the SOAPME acronym described in the text in preparation for sedating a child for a procedure.


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169. Roelofse J. Conscious sedation: Making our treatment options safe and sound. SADJ 2000;55:273-6. 170. Wilson S, Creedon RL, George M, Troutman K. A history of sedation guidelines: Where we are headed in the future. Pediatr Dent 1996;18:194-9. 171. Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxide monitoring during procedural sedation. Acad Emerg Med 2002;9:275-80. 172. Vascello LA, Bowe EA. A case for capnographic monitoring as a standard of care. J Oral Maxillofac Surg 1999;57: 1342-7. 173. Iwasaki J, Vann WF Jr, Dilley DC, Anderson JA. An investigation of capnography and pulse oximetry as monitors of pediatric patients sedated for dental treatment. Pediatr Dent 1989;11:111-7. 174. Berry AM, Brimacombe JR, Verghese C. The laryngeal mask airway in emergency medicine, neonatal resuscitation, and intensive care medicine. Int Anesthesiol Clin 1998;36: 91-109. 175. Patterson MD. Resuscitation update for the pediatrician. Pediatr Clin North Am 1999;46:1285-303. 176. Selim M, Mowafi H, Al Ghamdi A, Adu-Gyamfi Y. Intubation via LMA in pediatric patients with difficult airways. Can J Anaesth 1999;46:891-3. 177. Munro HM, Butler PJ, Washington EJ. Freeman-Sheldon (whistling face) syndrome. Anaesthetic and airway management. Paediatr Anaesth 1997;7:345-8. 178. Rowe R, Cohen RA. An evaluation of a virtual reality airway simulator. Anesth Analg 2002;95:62-6. 179. Medina LS, Racadio JM, Schwid HA. Computers in radiology. The sedation, analgesia, and contrast media computerized simulator: A new approach to train and evaluate radiologists’ responses to critical incidents. Pediatr Radiol 2000;30:299-305. 180. Blike G, Cravero J, Nelson E. Same patients, same critical events-different systems of care, different outcomes: Description of a human factors approach aimed at improving the efficacy and safety of sedation/analgesia care. Qual Manag Health Care 2001;10:17-36. 181. Kanal E, Shellock FG, Talagala L. Safety considerations in MR imaging. Radiology 1990;176:593-606. 182. Shellock FG, Kanal E. Burns associated with the use of monitoring equipment during MR procedures. J Magn Reson Imaging 1996;6:271-2. 183. Shellock FG. Magnetic resonance safety update 2002: Implants and devices. J Magn Reson Imaging 2002;16: 485-96. 184. Dempsey MF, Condon B, Hadley DM. MRI safety review. Semin Ultrasound CT MR. 2002;23:392-401 185. National Institute for Occupational Safety and Health (NIOSH). Criteria for a Recommended Standard: Occupational Exposure to Waste Anesthetic Gases and Vapors. Cinncinnati, Oh. Publication 77-140. 1977. Ref Type: Statute.

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186. O’Sullivan I, Benger J. Nitrous oxide in emergency medicine. Emerg Med J 2003;20:214-7. 187. 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; 6:11-31. 188. Frampton A, Browne GJ, Lam LT, Cooper MG, Lane LG. Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department. Emerg Med J 2003;20:410-3. 189. Everitt I, Younge P, Barnett P. Paediatric sedation in emergency department: What is our practice? Emerg Med (Fremantle) 2002;14:62-6. 190. Krauss B. Continuous-flow nitrous oxide: Searching for the ideal procedural anxiolytic for toddlers. Ann Emerg Med 2001;37:61-2. 191. Otley CC, Nguyen TH. Conscious sedation of pediatric patients with combination oral benzodiazepines and inhaled nitrous oxide. Dermatol Surg 2000;26:1041-4. 192. 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;15:388-92. 193. Burton JH, Auble TE, Fuchs SM. Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children. Acad Emerg Med 1998;5:112-7. 194. Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J Pediatr Orthop 1996;16:187-91. 195. Hennrikus WL, Shin AY, Klingelberger CE. Selfadministered nitrous oxide and a hematoma block for analgesia in the outpatient reduction of fractures in children. J Bone Joint Surg Am 1995;77:335-9. 196. Hennrikus WL, Simpson RB, Klingelberger CE, Reis MT. Self-administered nitrous oxide analgesia for pediatric fracture reductions. J Pediatr Orthop 1994;14:538-42. 197. Wattenmaker I, Kasser JR, McGravey A. Self-administered nitrous oxide for fracture reduction in children in an emergency room setting. J Orthop Trauma 1990;4:35-8. 198. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med 1989;18:177-81. 199. 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] [article in French]. Arch Pediatr 2002;9:1213-5. 200. Michaud L, Gottrand F, Ganga-Zandzou PS, et al. Nitrous oxide sedation in pediatric patients undergoing gastrointestinal endoscopy. J Pediatr Gastroenterol Nutr 1999; 28:310-4.


201. Baskett PJ. Analgesia for the dressing of burns in children: A method using neuroleptanalgesia and Entonox. Postgrad Med J 1972;48:138-42. 202. Veerkamp JS, van Amerongen WE, Hoogstraten J, Groen HJ. Dental treatment of fearful children, using nitrous oxide. Part 1: Treatment times. ASDC J Dent Child 1991; 58:453-7. 203. 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;60:175-82. 204. 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;59:115-9. 205. 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;60:372-6. 206. Houpt MI, Limb R, Livingston RL. Clinical effects of nitrous oxide conscious sedation in children. Pediatr Dent 2004;26:29-36. 207. 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;14:167-70.

208. Primosch RE, Buzzi IM, Jerrell G. Effect of nitrous oxideoxygen inhalation with scavenging on behavioral and physiological parameters during routine pediatric dental treatment. Pediatr Dent 1999;21:417-20. 209. 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: 35-41. 210. Wilson S, Matusak A, Casamassimo PS, Larsen P. The effects of nitrous oxide on pediatric dental patients sedated with chloral hydrate and hydroxyzine. Pediatr Dent 1998;20:253-8. 211. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Breathing patterns and levels of consciousness in children during administration of nitrous oxide after oral midazolam premedication. J Oral Maxillofac Surg 1997;55:1372-7. 212. Litman RS, Kottra JA, Verga KA, Berkowitz RJ, Ward DS. Chloral hydrate sedation: The additive sedative and respiratory depressant effects of nitrous oxide. Anesth Analg 1998;86:724-8. 213. American Academy of Pediatric Dentistry. Guideline on appropiate use of nitrous oxide for pediatric dental patients. Pediatr Dent 2005;27(suppl ):107-9.

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Guideline on Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/ General Anesthesia to the Pediatric Dental Patient Originating Committee

Clinical Affairs Committee – Sedation and General Anesthesia Subcommittee Review Council Council on Clinical Affairs

Adopted 2001

Revised 2005, 2007, 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) recognizes that there are pediatric dental patients for whom routine dental care using nonpharmacologic behavior guidance techniques is not a viable approach.1 The AAPD intends this guideline to assist the dental practitioner who elects to use anesthesia personnel 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 surgicenter. This document discusses personnel, facilities, documentation, and quality assurance mechanisms necessary to provide optimal and responsible patient care.

Methods The revision of this guideline is based upon a review of current dental and medical literature pertaining to deep sedation/general anesthesia of dental patients, including the 2006 guideline on pediatric sedation co-authored by the American Academy of Pediatrics (AAP) and the AAPD.2 A MEDLINE search was performed using the terms “office-based anesthesia”, “pediatric sedation”, and “dental sedation”.

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 patient attitude toward dental treatment. Behavior guidance techniques have allowed many pediatric dental patients to receive treatment in the office with minimal discomfort and without expressed fear. Minimal or moderate sedation has allowed others who are less compliant to receive treatment. There are some children and special needs patients with extensive treatment needs, acute situational anxiety, uncooperative age-appropriate behavior, immature

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cognitive functioning, disabilities, or medical conditions that require deep sedation/general anesthesia to receive dental treatment in a safe and humane fashion. Access to hospital-based anesthesia services may be limited for a variety of reasons, including restriction of coverage of by third party payors. Pediatric dentists and others who treat children can provide for the administration of deep sedation/general anesthesia by properly trained individuals in their offices or other facilities outside of the traditional surgical setting. Deep sedation/general anesthesia in the dental office can provide benefits for the patient and the dental team. Access to care may be improved. The treatment may be scheduled more easily and efficiently. Facility charges and administrative procedures may be less than those associated with a surgical center. Complex or lengthy treatment can be provided comfortably while minimizing patient memory of the dental procedure. Movement by the patient is decreased, and the quality of care may be improved. The dentist can use his/her customary inoffice delivery system with access to supplemental equipment, instrumentation, or supplies should the need arise. The use of anesthesia personnel to administer deep sedation/general anesthesia in the pediatric dental population is an accepted treatment modality.2-6 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.1,2,6 In many cases, the patient may be treated in an appropriate out-patient facility (including the dental office) because the extensive medical resources of a hospital are not necessary. This guideline does not supercede, nor is it to be used in deference to, federal, state, and local credentialing and licensure laws, regulations, and codes. It cannot and does not predict nor guarantee a specific patient outcome.


Recommendations Personnel Office-based deep sedation/general anesthesia techniques require at least 3 individuals. The anesthesia care provider’s responsibilities are to administer drugs or direct their administration and to observe constantly the patient’s vital signs, airway patency, cardiovascular and neurological status, and adequacy of ventilation.2 In addition to the anesthesia care provider, the operating dentist and other staff shall be trained in emergency procedures. It is the obligation of treating practitioners, when employing anesthesia personnel to administer deep sedation/general anesthesia, to verify their credentials and experience. 1. The anesthesia care provider must be a licensed dental and/or medical practitioner with appropriate and current state certification for deep sedation/general anesthesia. 2. The anesthesia care provider must have completed a 1- or 2-year dental anesthesia residency or its equivalent, as approved by the American Dental Association (ADA), and/ or medical anesthesia residency, as approved by the American Medical Association (AMA). 3. The anesthesia care provider currently must be licensed by and in compliance with the laws of the state in which he/ she practices. Laws vary from state to state and may supercede any portion of this document. 4. If state law permits a certified registered nurse anesthetist or anesthesia assistant to function under the supervision of a dentist, the dentist is required to have completed training in deep sedation/general anesthesia and be licensed or permitted, as appropriate to state law. The dentist and anesthesia care provider must be compliant with the AAP/AAPD’s Guideline on Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures2 or other appropriate guideline(s) of the ADA, AMA, and their recognized specialties. The recommendations in this document may be exceeded at any time if the change involves improved safety and is supported by currently-accepted practice and/or is evidence-based. The dentist and anesthesia personnel must work together to enhance patient safety. Effective communication is essential. The dentist introduces the concept of deep sedation/general anesthesia to the parent and provides appropriate preoperative instructions and informational materials. The dentist or his/her designee coordinates medical consultations when necessary. The anesthesia care provider explains potential risks and obtains informed consent for sedation/anesthesia. Office staff should understand their additional responsibilities and special considerations (eg, loss of protective reflexes) associated with office-based deep sedation/general anesthesia. Advanced training in recognition and management of pediatric emergencies is critical in providing safe sedation and anesthetic care. Although it is appropriate for the most experienced professional (ie, the anesthesia provider) to assume responsibility in managing anesthesia-related emergencies, the operating dentist and clinical staff need to maintain current

expertise in basic life support. An individual experienced in recovery care must be in attendance in the recovery facility until the patient, through continual monitoring, exhibits respiratory and cardiovascular stability and appropriate discharge criteria2 have been met. In addition, the staff of the treating dentist must be well-versed in rescue and emergency protocols (including cardiopulmonary resuscitation) and have contact numbers for emergency medical services and ambulance services. Emergency preparedness must be updated and practiced on a regular basis. Facilities A continuum exists that extends from wakefulness across all levels of sedation. Often these levels are not easily differentiated, and patients may drift through them. 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 also should comply 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.3 The treatment room must accommodate the dentist and 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, the Guideline on Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures2 should be followed as the minimum requirements. For deep sedation, there shall be continuous monitoring of oxygen saturation and heart rate and intermittent time-based recording of respiratory rate and blood pressure. When adequacy of ventilation is difficult to observe, use of a precordial stethoscope or capnograph is encouraged.2 An electrocardiographic monitor should be readily available for patients undergoing deep sedation. In addition to the monitors previously mentioned, a temperature monitor and pediatric defibrillator are required for general anesthesia.2 Emergency equipment must be readily accessible and should include suction, drugs necessary for rescue and resuscitation (including 100% oxygen capable of being delivered by positive pressure at appropriate flow rates for up to 1 hour), and age-/ size-appropriate equipment to resuscitate and rescue a nonbreathing and/or unconscious pediatric dental patient and provide continuous support while the patient is being transported to a medical facility.2,7 The treatment facility should

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have medications, equipment, and protocols available to treat malignant hyperthermia when triggering agents are used.3 Recovery facilities must be available and suitably equipped. Back up power sufficient to ensure patient safety should be available in case of an emergency.3 Documentation Prior to delivery of deep sedation/general anesthesia, patient safety requires that appropriate documentation shall address rationale for sedation/general anesthesia, informed consent, instructions to parent, dietary precautions, preoperative health evaluation, and any prescriptions along with the instructions given for their use.2 Because laws and codes vary from state to state, the Guideline on Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures2 should be followed as minimum requirements for a time-based anesthesia record. 1. Vital signs: Pulse and respiratory rates, blood pressure, and oxygen saturation must be monitored and recorded at least every 5 minutes2 throughout the procedure and at specific intervals until the patient has met documented discharge criteria. 2. Drugs: Name, dose, route, site, time of administration, and patient effect of all drugs, including local anesthesia, must be documented. When anesthetic gases are administered, inspired concentration and duration of inhalation agents and oxygen shall be documented. 3. 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. Requiring 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. 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 in-office anesthesia care providers must take all necessary measures to minimize risk to patients. The dentist must be familiar with the American Society of Anesthesiologists (ASA) physical status classification. Knowledge, preparation, and communication between professionals are essential.8 Prior to subjecting a patient to deep sedation/general

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anesthesia, the patient must undergo a preoperative health evaluation.2,9 High-risk patients should be treated in a facility properly equipped to provide for their care.2,9 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 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.

References 1. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2008;30(suppl):125-33. 2. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatr Dent 2008;30(suppl):143-59. 3. A merican Society of Anesthesiologists. Guidelines for office-based anesthesia. 2004. Available at: “http://www. asahq.org/publicationsAndServices/standards/12.pdf ”. Accessed April 20, 2009. 4. American Dental Association. Policy statement: The use of conscious sedation, deep sedation, and general anesthesia in dentistry. 2005. Available at: “http://www.ada.org/ prof/resources/positions/statements/useof.asp”. Accessed April 20, 2009. 5. Nick D, Thompson L, Anderson D, Trapp L. The use of general anesthesia to facilitate dental treatment. Gen Dent 2003;51:464-8. 6. Wilson S. Pharmacologic behavior management for pediatric dental treatment. Pediatr Clinic North Am 2000;47 (5):1159-73. 7. American Society of Anesthesiologists. Guidelines for ambulatory anesthesia and surgery. 2003. Available at: “http://www.asahq.org/publicationsAndServices/standards/ 04.pdf ”. Accessed April 20, 2009. 8. American Society of Anesthesiologists. ASA physical status classification system. Available at: “http://www.asahq. org/clinical/physicalstatus.htm”. Accessed June 24, 2009. 9. American Dental Association. Guidelines for the use of conscious sedation, deep sedation, and general anesthesia for dentists. 2005. Available at: “http://www.ada.org/ prof/resources/positions/statements/anesthesia_guidelines. pdf ”. Accessed April 20, 2009.


Guideline on Pediatric Restorative Dentistry Originating Committee

Clinical Affairs Committee – Restorative Dentistry Subcommittee Review Council Council on Clinical Affairs

Adopted 1991

Revised 1998, 2001, 2004, 2008

Purpose The American Academy of Pediatric Dentistry (AAPD) presents this guideline to assist the practitioner in the restorative care of infants, children, adolescents, and persons with special health care needs. The objectives of restorative treatment are to repair or limit the damage from caries, protect and preserve the tooth structure, reestablish adequate function, restore esthetics (where applicable), and provide ease in maintaining good oral hygiene. Pulp vitality should be maintained whenever possible.

Methods The AAPD convened a consensus conference on pediatric restorative dentistry in April, 2002. Consensus statements resulted from the expert literature review and science-based position papers presented.1 Results of the conference, updated literature review, MEDLINE searches using the terms “dental amalgam”, “dental composites”, “stainless steel crowns”, “glass ionomer cements”, and “dental sealants”, and expert opinion were used to revise these guidelines.

Background Restorative treatment is based upon the results of an appropriate clinical examination and is ideally part of a comprehensive treatment plan. The treatment plan shall take into consideration: 1. developmental status of the dentition; 2. caries-risk assessment2,3; 3. patient’s oral hygiene; 4. anticipated parental compliance and likelihood of timely recall; 5. patient’s ability to cooperate for treatment. The restorative treatment plan must be prepared in conjunction with an individually-tailored preventive program. Caries risk is greater for children who are poor, rural, or minority or who have limited access to care.4 Factors for high caries risk include decayed/missing/filled surfaces greater than the child’s age, numerous white spot lesions, high levels of mutans streptococci, low socioeconomic status, high caries rate in siblings/parents, diet high in sugar, and/or presence of dental appliances.5 Studies

have reported that maxillary primary anterior caries has a direct relationship with caries in primary molars6-8, and caries in the primary dentition is highly predictive of caries occurring in the permanent dentition.5 Restoration of primary teeth differs from restoration of permanent teeth, due in part to the differences in tooth morphology. The mesiodistal diameter of a primary molar crown is greater than the cervicoocclusal dimension. The buccal and lingual surfaces converge toward the occlusal. The enamel and dentin are thinner. The cervical enamel rods slope occlusally, ending abruptly at the cervix instead of being oriented gingivally, gradually becoming thinner as in permanent teeth. The pulp chambers of primary teeth are proportionately larger and closer to the surface. Primary teeth contact areas are broad and flattened rather than being a small distinct circular contact point, as in permanent teeth. Shorter clinical crown heights of primary teeth also affect the ability of these teeth to adequately support and retain intracoronal restorations. Young permanent teeth also exhibit characteristics that need to be considered in restorative procedures, such as large pulp chambers and broad contact areas that are proximal to primary teeth. Tooth preparation should include the removal of caries or improperly developed tooth structure to establish appropriate outline, resistance, retention, and convenience form compatible with the restorative material to be utilized. Rubber-dam isolation should be utilized when possible during the preparation and placement of restorative materials. As with all guidelines, it is expected that there will be exceptions to the recommendations based upon individual clinical findings. For example, stainless steel crowns (SSCs) are recommended for teeth having received pulp therapy. However, an amalgam or resin restoration could be utilized in a tooth having conversative pulpal access, sound lateral walls, and less than 2 years to exfoliation. 9 Likewise, a conservative Class II restoration for a primary tooth could be expanded to include more surface area when the tooth is expected to exfoliate within 1 to 2 years.

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Recommendations Dentin/enamel adhesives Dentin/enamel adhesives allow bonding of resin-based composites and compomers to primary and permanent teeth. Adhesives have been developed with reported dentin bond strengths exceeding that of enamel.10-12 In vitro studies have shown that enamel and dentin bond strength is similar for primary and permanent teeth.7-14 The clinical success of adhesives allows for more conservative preparation when using composite restorative materials. Adhesive systems currently follow either a “total-etch” or a “self-etch” technique. Total etch technique requires 3 steps. It involves use of an etchant to prepare the enamel while opening the dentinal tubules, removing the smear layer, and decalcifying the dentin. After rinsing the etchant, a primer is applied that penetrates the dentin, preparing it for the bonding agent. The enamel can be dried before placing the primer, but the dentin should remain moist. A bonding agent then is applied to the primed dentin. A simplified adhesive system that combines the primer and the adhesive is available. Because the adhesive systems require multiple steps, errors in any step can affect clinical success. Attention to proper technique for the specific adhesive system is critical to success.15 Recommendations: The dental literature supports the use of tooth bonding adhesives, when used according to the manufacturer’s instruction unique for each product, as being effective in primary and permanent teeth in enhancing retention of restorations, minimizing microleakage, and reducing sensitivity.16 Pit and fissure sealants Sealant has been described as a material placed into the pits and fissures of caries-susceptible teeth that micromechanically bonds to the tooth preventing access by cariogenic bacteria to their source of nutrients.17 Pit and fissure caries account for approximately 80-90% of all caries in permanent posterior teeth and 44% in primary teeth.18,19 Sealants reduce the risk of caries in those susceptible pits and fissures. Placement of resin-based sealants in children and adolescents have shown a reduction of caries incidence of 86% after 1 year and 58% after 4 years.20,21 Before sealants are placed, a tooth’s caries risk should be determined.22 Any primary or permanent tooth judged at risk would benefit from sealant application.22 The best evaluation of caries risk is done by an experienced clinician using indicators of tooth morphology, clinical diagnostics, caries history, fluoride history, and oral hygiene.22 Sealant placement on teeth with the highest risk will give the greatest benefit.22 High-risk pits and fissures should be sealed as soon as possible. Low-risk pits and fissures may not require sealants. Caries risk, however, may increase due to changes in patient habits, oral microflora, or physical condition, and unsealed teeth subsequently might benefit from sealant application.22 With appropriate diagnosis and monitoring, sealants can be placed on teeth exhibiting incipient pit and fissure caries.23 Studies have shown arrested caries and elimination of viable organisms under sealants or restorations with sealed margins.24-26 Surveys

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have shown that pediatric dentists often incorporate enameloplasty into the sealant technique.27 In vitro studies have shown enameloplasty may enhance retention of sealants.28-31 However, short-term clinical studies show enameloplasty as equal to but not better than sealant placement without enameloplasty.32,33 Isolation is a key factor in a sealant’s clinical success.34 Contamination with saliva results in decreased bond strength of the sealant to enamel.34 In vitro and in vivo studies report that use of a bonding agent will improve the bond strength and minimize microleakage.35,36 Fluoride application immediately prior to etching for sealant placement does not appear to affect bond strength adversely.37,38 Sealants must be retained on the tooth and should be monitored to be most effective. Studies have shown glass ionomer sealant to have a poor retention rate.39,40 Studies incorporating recall and maintenance have reported sealant success levels of 80% to 90% after 10 or more years.41,42 Recommendations: 1. Sealants should be placed into pits and fissures of teeth based upon the patient’s caries risk, not the patient’s age or time lapsed since tooth eruption. 2. Sealants should be placed on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions to inhibit lesion progression. Follow up care, as with all dental treatment, is recommended.22 3. Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal enameloplasty technique.22 4. A low-viscosity hydrophilic material bonding layer, as part of or under the actual sealant, is recommended for long-term retention and effectiveness.22 5. Glass ionomer materials could be used as transitional sealants.22 Glass ionomer cements Glass ionomers have been used as restorative cements, cavity liner/ base, and luting cement. The initial glass ionomer materials were difficult to handle, exhibited poor wear resistance, and were brittle. Advancements in 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.43,44 Glass ionomers have several properties that make them favorable to use in children: 1. chemical bonding to both enamel and dentin; 2. thermal expansion similar to that of tooth structure; 3. biocompatibility; 4. uptake and release of fluoride; 5. decreased moisture sensitivity when compared to resins. Glass ionomers are hydrophilic and tolerate a moist, not wet, environment, whereas resins and adhesives are affected adversely by water. Because of their ability to adhere, seal, and protect, glass ionomers often are used as dentin replacement materials.45-47


Glass ionomer has a coefficient of thermal expansion similar to dentin. Resin-modified glass ionomers have improved wear resistance compared to the original glass ionomers and are appropriate restorative materials for primary teeth.48-52 In permanent teeth, resin-based composites provide better esthetics and wear resistance than glass ionomers. Glass ionomer and resin “sandwich technique” was developed on the basis of the best physical properties of each.53 A glass ionomer is used as dentin replacement for its ability to seal and adhere while covered with a surface resin because of its better wear resistance and esthetics. Fluoride is released from glass ionomer and taken up by the surrounding enamel and dentin, resulting in a tooth that is less susceptible to acid challenge.54-56 Studies have shown that fluoride release can occur for at least 5 years.57,58 Glass ionomers can act as a reservoir of fluoride, as uptake can occur from dentifrices, mouthrinses, and topical fluoride applications.59,60 This fluoride protection, useful in patients at high risk for caries, has led to the use of glass ionomers as a luting cement for SSCs, space maintainers, and orthodontic bands.61,62 Other applications of glass ionomers where fluoride release has advantages are for interim therapeutic restorations (ITR) and the alternative (atraumatic) restorative technique (ART). These procedures have similar techniques but different therapeutic goals. ITR may be used in very young patients63, uncooperative patients, or patients with special health care needs64 for whom traditional cavity preparation and/or placement of traditional dental restorations are not feasible or need to be postponed. Additionally, ITR may be used for caries control in children with multiple open carious lesions, prior to definitive restoration of the teeth.65 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 necessarily functions as definitive treatment. These procedures involve the removal of soft tooth tissue using hand or slow-speed rotary instruments with caution to not expose the pulp when caries is deep. Leakage of the restoration can be minimized if unsound tooth structure is removed from the periphery of the preparation. Following preparation, the tooth is restored with an adhesive restorative material, such as selfsetting or resin-modified glass ionomer cement.64,65 This technique has been shown to reduce the levels of oral bacteria (eg, mutans streptococci, lactobacilli) in the oral cavity.62,64 Success is greatest when the technique is applied to single- or small 2-surface restorations.52,66 Inadequate cavity preparation with subsequent lack of retention and insufficient bulk can lead to failure.64 Recommendations: Glass ionomers can be recommended67 as: 1. luting cements; 2. cavity base and liner; 3. Class I, II, III, and V restorations in primary teeth; 4. Class III and V restorations in permanent teeth in high risk patients or teeth that cannot be isolated;

5.

caries control with: a. high-risk patients; b. restoration repair; c. ITR; d. ART.

Resin-based composites Resin-based composite is an esthetic restorative material used for posterior and anterior teeth. There are a variety of resin products on the market, with each having different physical properties and handling characteristics based upon their composition. “Resinbased composites are classified according to their filler size, because filler size affects polishability/esthetics, polymerization depth, polymerization shrinkage, and physical properties.”68 Microfilled resins have filler sizes less than 0.1 micron. Minifilled particle sizes range from 0.1 to 1 microns. Midsize resin particles range from 1 to 10 microns. Macrofilled particles range from 10 to 100 microns. The smaller filler particle size allows greater polishability and esthetics, while larger size provides strength. Hybrid resins combine a mixture of particle sizes for improved strength while retaining esthetics. Flowable resins have a lower volumetric filler percentage than hybrid resins. Highly-filled, small particle resins have been shown to have better wear characteristics.69-71 Resin-based composites allow the practitioner to be conservative in tooth preparation. With minimal pit and fissure caries, the carious tooth structure can be removed and restored while avoiding the traditional “extension for prevention” removal of healthy tooth structure. This technique of restoration with preventive sealing of the remaining tooth has been described as a preventive resin restoration.72 Resins require longer time for placement and are more technique sensitive than amalgams. In cases where isolation or patient cooperation is compromised, resin-based composite may not be the restorative material of choice. Recommendations73: Indications: Resin-based composites are indicated for: 1. Class I pit-and-fissure caries where conservative pre ventive resin restorations are appropriate; 2. Class I caries extending into dentin; 3. Class II restorations in primary teeth that do not ex tend beyond the proximal line angles; 4. Class II restorations in permanent teeth that extend approximately one third to one half the buccolingual intercuspal width of the tooth; 5. Class III, IV, V restorations in primary and permanent teeth; 6. strip crowns in the primary and permanent dentitions. Contraindications: Resin-based composites are not the restorations of choice in the following situations: 1. where a tooth cannot be isolated to obtain moisture control; 2. in individuals needing large multiple surface restora tions in the posterior primary dentition; clinical guidelines

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in high-risk patients who have multiple caries and/or tooth demineralization and who exhibit poor oral hygiene and compliance with daily oral hygiene, and when maintenance is considered unlikely.

Amalgam restorations Dental amalgam has been used for restoring teeth since the 1880s. Amalgam’s properties (eg, ease of manipulation, durability, relatively low cost, reduced technique sensitivity compared to other restorative materials) have contributed to its popularity. Esthetics and improved tooth-color restorative materials, however, have led to a decrease in its use. The durability of amalgam restorations has been shown in numerous studies.74-76 Studies of defective restorations have indicated that operator error plays a significant role the restoration’s durability.77,78 For example, in Class II restorations where the proximal box is large and the intercuspal isthmus is narrow, the restoration is stressed and can result in fracture. In primary teeth, studies have shown that 3-surface mesial-occlusal-distal (MOD) restorations can be placed but that SSCs are more durable.79-80 In primary molars, the patient’s age can affect the restoration’s longevity. 72-76 In children age 4 or younger, SSCs had a success rate twice that of amalgams. 74 The decision to use amalgam should be based upon the needs of each individual patient. Amalgam restorations often require removal of healthy tooth structure to achieve adequate resistance and retention. Glass ionomer or resin restorative materials might be a better choice for conservative restorations, thereby retain-ing healthier tooth structure. SSCs are recommended for primary teeth with pulpotomies. Yet, a Class I amalgam could be appropriate if enamel walls can withstand occlusal forces and the tooth is expected to exfoliate within 2 years.9 SSCs may be the better choice in patients with poor compliance and questionable long-term follow-up.81 Recommendations: Dental amalgam is recommended82 for: 1. Class I restorations in primary and permanent teeth; 2. Class II restorations in primary molars where the pre paration does not extend beyond the proximal line angles; 3. Class II restorations in permanent molars and pre molars; 4. Class V restorations in primary and permanent poste rior teeth. Stainless steel crown restorations Stainless steel crowns are prefabricated crown forms that are adapted to individual teeth and cemented with a biocompatible luting agent. “The SSC is extremely durable, relatively inexpensive, subject to minimal technique sensitivity during placement, and offers the advantage of full coronal coverage.”83 SSCs have been indicated for the restoration of primary and permanent teeth with caries, cervical decalcification, and/or developmental defects (eg, hypoplasia, hypocalcification), when failure of other available restorative materials is likely (eg, interproximal

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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, or for the intermediate restoration of fractured teeth. In high caries-risk children, definitive treatment of primary teeth with SSCs is better over time than multisurface intracoronal restorations. Review of the literature comparing SSCs and Class II amalgams concluded that, for multisurface restorations in primary teeth, SSCs are superior to amalgams.84 SSCs have a success rate greater than that of amalgams in children under age 4.76 The use of SSCs also should be considered in patients with increased caries risk whose cooperation is affected by age, behavior, or medical history. These patients often receive treatment under sedation or general anesthesia. For patients whose developmental or medical problems will not improve with age, SSCs are likely to last longer and possibly decrease the frequency for sedation or general anesthesia with its increased costs and its inherent risks. SSCs can be indicated to restore anterior teeth in cases where multiple surfaces are carious, where there is incisal edge involvement, following pulp therapy, when hypoplasia is present, and when there is poor moisture control.85 Where esthetics are a concern, the facing can be removed and replaced with a resinbased composite (open-faced technique). Several brands of primary SSCs are available with preformed tooth-colored veneers. These veneered SSCs can be more difficult to adapt and are subject to fracture or loss of the facing. Recommendations: 1. “Children at high risk exhibiting anterior tooth caries and/or molar caries may be treated with SSCs to pro tect the remaining at-risk tooth surfaces. 2. Children with extensive decay, large lesions, or multiple-surface lesions in primary molars should be treated with SSCs. 3. Strong consideration should be given to the use of SSCs in children who require general anesthesia.”83 Labial resin or porcelain veneer restorations A resin or porcelain veneer restoration is a thin layer of restorative material bonded over the facial or buccal surface of a tooth. Veneer restorations are considered conservative in that minimal, if any, tooth preparation is required. Porcelain veneers usually are placed on permanent teeth. Recommendations: Veneers may be indicated for the restoration of anterior teeth with fractures, developmental defects, intrinsic discoloration, and/or other esthetic conditions.86 Full-cast or porcelain-fused-to-metal crown restorations A cast or porcelain-fused-to-metal crown is a fixed restoration that employs metal formed to a desired anatomic shape or a metal substructure onto which a ceramic porcelain veneer is fused. The crown is cemented with a biocompatible luting cement.


Recommendations: Full-cast metal crowns or porcelain-fused-to-metal crown restorations may be utilized in permanent teeth that are fully erupted and the gingival margin is at the adult position for: 1. teeth having developmental defects, extensive carious or traumatic loss of structure, or endodontic treatment; 2. as an abutment for fixed prostheses; or 3. for restoration of single-tooth implants.87-89 Fixed prosthetic restorations for missing teeth A fixed prosthetic restoration replaces 1 or more missing teeth in the primary, transitional, or permanent dentition. This restoration attaches to natural teeth, tooth roots, or implants and is not removable by the patient. Growth must be considered when using fixed restorations in the developing dentition. Recommendations: Fixed prosthetic restorations to replace 1 or more missing teeth may be indicated to: 1. establish esthetics; 2. maintain arch space or integrity in the developing dentition; 3. prevent or correct harmful habits; or 4. improve function.90,91 Removable prosthetic appliances A removable prosthetic appliance is indicated for the replacement of 1 or more teeth in the dental arch to restore masticatory efficiency, prevent or correct harmful habits or speech abnormalities, maintain arch space in the developing dentition, or obturate congenital or acquired defects of the orofacial structures. Recommendations: Removable prosthetic appliances may be indicated in the primary, mixed, or permanent dentition when teeth are missing. Removable prosthetic appliances may be utilized to: 1. maintain space; 2. obturate congenital or acquired defects; 3. establish esthetics or occlusal function; or 4. facilitate infant speech development or feeding.92-94

References 1. Donly K. Pediatric Restorative Dentistry. Consensus Con 2. 3. 4. 5.

ference. April 15-16, 2002. San Antonio, Texas. Pediatr Dent 2002;24(5):374-6. Anderson M. Risk assessment and epidemiology of dental caries: Review of the literature. Pediatr Dent 2002;24(5): 377-85. American Academy of Pediatric Dentistry. Policy on use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent 2007;29(suppl):29-33. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 19881994. J Am Dent Assoc 1998;129(9):1229-38. Tinanoff N, Douglass J. Clinical decision-making for caries management in primary teeth. J Dent Educ 2001; 65(10):1133-42.

6. O’Sullivan DM, Tinanoff N. Maxillary anterior caries associated with increased caries in other teeth. J Dent Res 1993;72(12):1577-80. 7. Greenwell AL, Johnsen D, DiSantis TA, Gerstenmaier J, Limbert N. Longitudinal evaluation of caries patterns from the primary to the mixed dentition. Pediatr Dent 1990;12(5):278-82. 8. Al-Shal 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. Holan G, Fuks AB, Ketlz N. Success rate of formoscresol pulpotomy in primary molars restored with stainless steel crowns vs amalgam. Pediatr Dent 2002;24(3):212-6. 10. Chappell RP, Eick JD. Shear bond strength and scanning electron microscopic observation of six current dentinal adhesives. Quintessence Int 1994;25(5):359-68. 11. Tjan AHL, Castelnuovo J, Liu P. Bond strength of multistep and simplified-step systems. Am J Dent 1996;9(6): 269-72. 12. Mason PN, Ferrari M, Cagidiaco MC, Davidson CL. Shear bond strength of 4 dentinal adhesives applied in vivo and in vitro. J Dent 1996;24(3):217-22. 13. Bordin-Aykroyd S, Sefton J, Davies EH. In vivo bond strengths of 3 current dentin adhesives to primary and permanent teeth. Dent Mater 1992;8(2):74-8. 14. García de Araujo FB, García-Godoy F, Issao M. A comparison of 3 resin bonding agents to primary tooth dentin. Pediatr Dent 1997;19(4):253-7. 15. Finger WJ, Balkenhol M. Practitioner variability effects on dentin bonding with an acetone-based one-bottle adhesive. J Adhes Dent 1999;(4)1:311-4. 16. García-Godoy F, Donly KJ. Dentin/enamel adhesives in pediatric dentistry. Pediatr Dent 2002;24(5):462-4. 17. Simonsen RJ. Pit and fissure sealants. In: Clinical Applications of the Acid Etch Technique. Chicago, Ill: Quintessence Publishing Co, Inc; 1978:19-42. 18. Brown LJ, Kaste L, Selwitz R, Furman L. Dental caries and sealant usage in US children, 1988-1991: Selected findings from the third National Health and Nutrition Examination Survey. J Am Dent Assoc 1996;127(3):335-43. 19. National Center for Health Statistics, CDC. National Health and Nutrition Examination Surveys 1999-2004. Available at: “http://www.cdc.gov/nchs/about/major/ nhanes/nhanes99-02.htm”. Accessed June 9, 2008. 20. Llodra JC, Bravo M, Delgado-Rodriguez M, Baca P, Galvez R. Factors influencing the effectiveness of sealants: A meta-analysis. Community Dent Oral Epidemiol 1993;21(5):261-8. 21. Ahovuo-Saloranta A, Hijri A, Nordblad A, Worthington H, Makela M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2004(3): CD001830. 18E. 22. Feigal, RJ. The use of pit and fissure sealants. Pediatr Dent 2002;24(5):415-22. clinical guidelines

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23. Handelman SL, Buonocore MG, Heseck DJ. A preliminary report on the effect of fissure sealant on bacteria in dental caries. J Prosthet Dent 1972;27(4):390-2. 24. Handelman SL, Washburn F, Wopperer P. Two-year report of sealant effect on bacteria in dental caries. J Am Dent Assoc 1976;93(5):967-70. 25. Going RE, Loesche WJ, Grainger DA, Syed SA. The viability of microorganisms in caries lesions five years after covering with a fissure sealant. J Am Dent Assoc 1978;97(3):455-62. 26. Mertz-Fairhurst EJ, Adair SM, Sams DR, et al. Cariostatic and ultraconservative sealed restorations: Nine-year results among children and adults. ASDC J Dent Child 1995;62 (2):97-107. 27. Primosch RE, Barr ES. Sealant use and placement techniques among pediatric dentists. J Am Dent Assoc 2001; 132(10):1442-51. 28. Wright GZ, Hatibovic-Kofman S, Millenaar DW, Braverman I. The safety and efficacy of treatment with airabrasion technology. Int J Paediatr Dent 1999;9(2):133-40. 29. Chan DC, Summitt JB, García-Godoy F, Hilton TJ, Chung KH. Evaluation of different methods for cleaning and preparing occlusal fissures. Oper Dent 1999;24(6):331-6. 30. Geiger SB, Gulayev S, Weiss EI. Improving fissure sealant quality: Mechanical preparation and filling level. J Dent 2000;28(6);407-12. 31. Zervou C, Kugel G. Leone C, Zavras A, Doherty EH, White GE. Enameloplasty effects on microleakage of pit-andfissure sealants under load: An in vitro study. J Clin Pediatr Dent 2000;24(4):279-85. 32. Le Bell Y, Forsten L. Sealing of preventively enlarged fissures. Acta Odontol Scand 1980;38(2);101-4. 33. Shapira J, Eidelman E. Six-year clinical evaluation of fissure sealants placed after mechanical preparation: A matched pair study. Pediatr Dent 1986;8(3):204-5. 34. Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B. Evidence-based clinical recommendations for the use of pit-and-fissure sealants. J Am Dent Assoc 2008; 139(3):257-67. 35. Hebling J, Feigal RJ. Use of one-bottle adhesive as an intermediate bonding layer to reduce sealant microleakage on saliva-contaminated enamel. Am J Dent 2000;13(4):187-91. 36. Feigal RJ, Hitt JC, Splieth C. Sealant retention on salivary contaminated enamel: A two-year clinical study. J Am Dent Assoc 1993;124(3):88-97. 37. Koh SH, Chan JT, You C. Effects of topical fluoride treatment on tensile bond strength of pit and fissure sealants. Gen Dent 1998;46(3):278-80. 38. Warren DP, Infante NB, Rice HC, Turner SD, Chan JT. Effect of topical fluoride on retention of pit-and-fissure sealants. J Dent Hyg 2001;75(1):21-4. 39. Boksman L, Gratton DR, McCutcheon E, Plotzke OB. Clinical evaluation of a glass ionomer cement as a fissure sealant. Quintessence Int 1987;18(10):707-9. 40. Forss H, Saarni UM, Seppä L. Comparison of glass ionomer and resin-based fissures sealants: A 2-year clinical trial. Community Dent Oral Epidemiol 1994;22(1):21-4. 192

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41. Simonsen RJ. Retention and effectiveness of dental sealant after 15 years. J Am Dent Assoc 1991;122(10):34-42. 42. Romcke RG, Lewis, DW Maze BD, Vickerson RA. Retention and maintenance of fissure sealants over 10 years. J Can Dent Assoc 1990;56(3):235-7. 43. Mitra SB, Kedrowski BL. Long-term mechanical properties of glass ionomers. Dent Mater 1994:10(2):78-82. 44. Douglas WH, Lin CP. Strength of the new systems. In: Hunt PR, ed. Glass Ionomers: The Next Generation. Philadelphia, Pa: International Symposia in Dentistry, PC; 1994:209-16. 45. Quackenbush BM, Donly KJ, Croll TP. Solubility of a resin-modified glass ionomer cement. ASDC J Dent Child 1998;65(5):310-2, 354. 46. Kerby RE, Knobloch L, Thakur A. Strength properties of visible light-cured, resin-modified glass ionomer cements. Oper Dent 1997;22(2):79-83. 47. Croll TP. Visible light-hardened glass-ionomer cement base/liner as an interim restorative material. Quintessence Int 1991;22(2):137-41. 48. Welbury RR, Shaw AJ, Murray JJ, Gordon PH, McCabe JF. Clinical evaluation of paired compomer and glass ionomer restorations in primary molars: Final results after 42 months. Br Dent J 2000;189(2):93-7. 49. Vilkinis V, Hörsted-Bindslev P, Baelum V. Two-year evaluation of Class II resin-modified glass ionomer cement/ composite open sandwich and composite restorations. Clin Oral Investig 2000;4(3):133-9. 50. Rutar J, McAllan L, Tyas MJ. Three-year clinical performance of glass ionomer cement in primary molars. Int J Paediatr Dent 2002;12(2):146-7. 51. Donly KJ, Segura A, Kanellis M, Erickson RL. Clinical performance and caries inhibition of resin-modified glass ionomer cement and amalgam restorations. J Am Dent Assoc 1999;130(10):1459-66. 52. Croll TP, Bar-Xion Y, Segura A, Donly KJ. Clinical performance of resin-modified glass ionomer cement restorations in primary teeth. A retrospective evaluation. J Am Dent Assoc 2001;132(8):1110-6. 53. Wilson AD, McLean JW. Laminate restorations. In: Glass Ionomer Cement. Chicago, Ill: Quintessence Publishing Co; 1988:159-78. 54. 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. 55. Scherer W, Lippman N, Kalm J, LoPresti J. Antimicrobial properties of VLC liners. J Esthet Dent 1990;2(2):31-2. 56. Tyas MJ. Cariostatic effect of glass ionomer cements: A 5year clinical study. Aust Dent J 1991;36(3):236-9. 57. Forsten L. Fluoride release from a glass ionomer cement. Scand J Dent Res 1977;85(6):503-4. 58. Swartz ML, Phillips RW, Clark HE. Long-term fluoride release from glass ionomer cements. J Dent Res 1984;63 (2):158-60. 59. Forsten L. Fluoride release and uptake by glass ionomers and related materials and its clinical effect. Biomaterials 1998;19(6):503-8.


60. Donly KJ, Nelson JJ. Fluoride release of restorative materials exposed to a fluoridated dentifrice. ASDC J Dent Child 1997;64(4):249-50. 61. Donly KJ, Istre S, Istre T. In vitro enamel remineralization at orthodontic band margins cemented with glass ionomer cement. Am J Orthod Dentofacial Orthop 1995;107(5): 461-4. 62. Vorhies AB, Donly KJ, Staley RN, Wefel JS. Enamel demineralization adjacent to orthodontic brackets bonded with hybrid glass ionomer cements: An in vitro study. Am J Orthod Dentofacial Orthop 1998;114(6):668-74. 63. Wambier DS, dos Santos FA, Guedes-Pinto AC, Jaeger RG, Simionato MR. 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. 64. 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. 65. Dulgergil DT, Soyman M, Civelek A. Atraumatic restorative treatment with resin-modified glass ionomer material: Short-term results of a pilot study. Med Princ Pract 2005;14(3):277-80. 66. Ersin NK, Candan U, Aykut A, Oncag O, Eronat E, Kose T. A clinical evaluation of resin-based composite and glass ionomer cement restorations placed in primary teeth using the ART approach: Results at 24 months. J Am Dent Assoc 2006;137(11):1529-36. 67. Berg JH. Glass ionomer cements. Pediatr Dent 2002;24 (5):430-8. 68. Burgess JO, Walker R, Davidson JM. Posterior resin-based composite: Review of the literature. Pediatr Dent 2002; 24(5):465-79. 69. Pallav P, de Gee AJ, Davidson CL. The influence of admixing microfiller to small-particle composite resins on wear, tensil strength, hardness and surface roughness. J Dent Res 1989;68(3):489-90. 70. Robertson TM, Bayne SC, Taylor DF, Sturdevant JR. Five-year clinical wear analysis of 19 posterior composites [abstract No. 63]. J Dent Res 1988;67:120. 71. Bayne SC, Taylor DF, Wilder AD, Heymann HO, Tangen CM. Clinical longevity of 10 posterior composite materials based on wear [abstract No. 630]. J Dent Res 1991; 70:344. 72. Simonsen RJ. Preventive resin restorations: Three-year results. J Am Dent Assoc 1980;100(4):535-9. 73. Donly KJ, García-Godoy F. The use of resin-based composite in children. Pediatr Dent 2002;24(5):480-8. 74. Levering NJ, Messer LB. The durability of primary molar restorations: I. Observations and predictions of success of amalgams. Pediatr Dent 1988;10(2):74-80. 75. Hunter B. Survival of dental restorations in young patients. Community Dent Oral Epidemiol 1985;18(5): 285-7.

76. Holland IS, Walls AW, Wallwork MA, Murray JJ. The longevity of amalgam restorations in deciduous molars. Br Dent J 1986;161(7):255-8. 77. Dahl DE, Ericksen HM. Reasons for replacement amalgam dental restorations. Scand J Dent Res 1978;86(5):404-7. 78. Roberts JF, Sheriff M. The fate on survival of amalgam and preformed crown molar restorations placed in a specialist paediatric dental practice. Br Dent J 1990;169(8):237-44. Erratum in Br Dent J 1990;169(9):285. 79. Waggoner WF. Restorative dentistry for the primary dentition. In: Pinkham J, Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak AJ, eds. Pediatric Dentistry: Infancy Through Adolescence. 4th ed. St. Louis:  Elsevier/Saunders; 2005:341-74. 80. Randall RC, Vrijhoef MA, Wilson NH. Efficacy of preformed metal crowns vs amalgam restorations in primary molars: A systematic review. J Am Dent Assoc 2000;131 (3):337-43. 81. Seale NS. Stainless steel crowns in pediatric dentistry. In: Pinkham J, Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak AJ, eds. Pediatric Dentistry: Infancy Through Adolescence. 4th ed. St. Louis: Elsevier/Saunders; 2005:361-2. 82. Fuks AB. The use of amalgam in pediatric dentistry. Pediatr Dent 2002;24(5):448-55. 83. Seale NS. The use of stainless steel crowns. Pediatr Dent 2002;24(5):501-5. 84. Randall RC. Preformed metal crowns for primary and permanent molar teeth: Review of the literature. Pediatr Dent 2002;24(5):489-500. 85. Waggoner WF. Restoring primary anterior teeth. Pediatr Dent 2002;24(5):511-6. 86. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am 1983;27(4):671-84. 87. Simonsen R, Thompson V, Barrack G. Etched Cast Restorations: Clinical and Laboratory Techniques. Quintessence Publishing: Chicago Ill; 1983. 88. Creugers NHJ, van’t Hof MA, Vrijhoef MMA. A clinical comparison of 3 types of resin-retained cast metal prostheses. J Prosthet Dent 1986;56(3):297-300. 89. McLaughlin G. Porcelain fused to tooth: A new esthetic and reconstructive modality. Compend Contin Educ Dent 1984;5(5):430-5. 90. Thompson VP, Livaditis GJ. Etched casting acid etch composite bonded posterior bridges. Pediatr Dent 1982;4 (1):38-43. 91. Wood M, Thompson VP. Anterior etched cast resin-bonded retainer: An overview of design, fabrication, and clinical use. Compend Contin Educ Dent 1983;4(3):247-56, 258. 92. Winstanley RB. Prosthodontic treatment of patients with hypodontia. J Prosthet Dent 1984;52(5):687-91. 93. Abadi BJ, Kimmel NA, Falace DA. Modified overdentures for the management of oligodontia and developmental defects. ASDC J Dent Child 1982;49(2):123-6. 94. Nayar AK, Latta JB, Soni NN. Treatment of dentinogenesis imperfecta in a child: Report of a case. ASDC J Dent Child 1981;48(6):453-5. clinical guidelines

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Guideline on Pulp Therapy for Primary and Immature Permanent Teeth Originating Committee

Clinical Affairs Committee – Pulp Therapy Subcommittee Review Council Council on Clinical Affairs

Adopted 1991

Revised 1998, 2001, 2004, 2009

Purpose The American Academy of Pediatric Dentistry (AAPD) intends this guideline 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 This revision included a new systematic literature search of the MEDLINE/Pubmed electronic data base using the following parameters: Terms: “pulpotomy”, “pulpectomy”, “indirect pulp treatment”, “stepwise excavation”, “pulp therapy”, “pulp capping”, “pulp exposure”, “bases”, “liners”, “calcium hydroxide”, “formocresol”, “ferric sulfate”, “gluteraldehyde pulpotomies”, “glass ionomer”, “mineral trioxide aggregate” (MTA), “bacterial microleakage under restorations”, “dentin bonding agents”, “resin modifies glass ionomers” (RMGI’s), and “endodontic irrigants”; Fields: all fields, Limits: within the last 10 years, humans, English, and clinical trials. 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 objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues. It is a treatment objective to maintain 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

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treatment of the young permanent dentition. A tooth without a vital pulp, however, can remain clinically functional.1 The indications, objectives, and type of pulpal therapy depend on whether the pulp is vital or nonvital, based on the clinical diagnosis of normal pulp (symptom free and normally responsive to vitality testing), reversible pulpitis (pulp is capable of healing), symptomatic or asymptomatic irreversible pulpitis (vital inflamed pulp is incapable of healing), or necrotic pulp.2 The clinical diagnosis3 is derived from a: 1. comprehensive medical history; 2. review of past and present dental history and treatment, including current symptoms and chief complaint; 3. subjective evaluation of the area associated with the current symptoms/chief complaint by questioning the child and parent on the location, intensity, duration, stimulus, relief, and spontaneity; 4. objective extraoral examination as well as examination of the intraoral soft and hard tissues; 5. if obtainable, radiograph(s) to diagnose pulpitis or ne crosis showing the involved tooth, furcation, periapical area, and the surrounding bone; and 6. clinical tests such as palpation, percussion, and mobility.1,4 In permanent teeth, electric pulp tests and thermal tests may be helpful.3 Teeth exhibiting signs and/or symptoms such as a history of spontaneous unprovoked toothache, a sinus tract, soft tissue inflammation 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. These teeth are candidates for nonvital pulp treatment.5,6 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 pulpitis and are candidates for vital pulp therapy. Teeth diag-


nosed with a normal pulp requiring pulp therapy or with reversible pulpitis should be treated with vital pulp procedures.7-10

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.1,5,6 It is recommended that all pulp therapy be performed with rubber-dam or other equally effective isolation to minimize bacterial contamination of the treatment site. This guideline is intended to recommend the best currently-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 nonvital primary and immature permanent teeth. Pulp therapy requires periodic clinical and radiographic assessment of the treated tooth and the supporting structures. Post-operative clinical assessment generally should be performed every 6 months and could occur as part of a patient’s periodic comprehensive oral examinations. Patients treated for an acute dental infection initially may require more frequent clinical reevaluation. A radiograph of a primary tooth pulpectomy should be obtained immediately following the procedure to document the quality of the fill and to 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.11 Since failure of a primary molar pulpotomy may be evidenced in the furcation, posterior tooth pulpotomies should be monitored by radiographs that clearly demonstrate the interradicular area. Bitewing radiographs obtained as part of the patient’s periodic comprehensive examinations may suffice. If a bitewing radiograph does not display the interradicular area, a periapical image is indicated. Pulp therapy for immature permanent teeth should be reevaluate radiographically 6 and 12 months after treatment and then periodically at the discretion of the clinician. For any tooth that has undergone pulpal therapy, clinical signs and/or symptoms may prompt a clinician to select a more frequent periodicity of reassessment. Apexification, reimplantation of avulsions, and placement of prefabricated post and cores are not indicated for primary teeth. For endodontic procedures not included in this section, the AAPD supports the AAE’s Guide to Clinical Endodontics.12

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 liquid 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. Placement of a thin protective liner such as calcium hydroxide, dentin bonding agent, or glass ionomer cement is at the discretion of the clinician.13,14 • 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.15,16 • 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 tertiary dentin formation, and minimize bacterial microleakage.17,18 Adverse post-treatment clinical signs or symptoms such as sensitivity, pain, or swelling should not occur. Indirect pulp treatment Indirect pulp treatment is a procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration.1 The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material.19 A radiopaque liner such as a dentin bonding agent,20 resin modified glass ionomer,21,22 calcium hydroxide,23,24 zinc oxide/eugenol,24 or glass ionomer cement7,9,25-27 is placed over the remaining carious dentin to stimulate healing and repair. If calcium hydroxide is use, a glass ionomer or reinforced zinc oxide/eugenol material should be placed over it to provide a seal against microleakage since calcium hydroxide has a high solubility, poor seal, and low compressive strength.28-31 The use of glass ionomer cements or reinforced zinc oxide/eugenol restorative materials has the additional advantage of inhibitory activity against cariogenic bacteria.32,33 The tooth then is restored with a material that seals the tooth from microleakage. Interim therapeutic restorations (ITR) with glass ionomers can used for caries control in teeth with carious 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.34,35 Current literature indicates that there is inconclusive evidence that it is necessary to reenter the tooth to remove the residual caries.36,37 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.32,33,36-40 Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies.7,9,20,22-27,35 It also allows for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.

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• Indications: Indirect pulp treatment is indicated in a primary tooth with no pulpitis18 or with reversible pulpitis when the deepest carious dentin is not removed to avoid a pulp exposure.8 The pulp is judged by clinical and radiographic criteria to be vital and able to heal from the carious insult.8,9 • Objectives: The restorative material should seal completely the involved dentin from the oral environment. The tooth’s vitality should be preserved. No post-treatment 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 pathologic changes. There should be no harm to the succedaneous tooth. Direct pulp cap When a pinpoint mechanical exposure of the pulp is encountered during cavity preparation or following a traumatic injury, a biocompatible radiopaque base such as mineral trioxide aggregate (MTA)41-44 or calcium hydroxide45 may be placed in contact with the exposed pulp tissue. The tooth is restored with a material that seals the tooth from microleakage.7 • Indications: This procedure is indicated in a primary tooth with a normal pulp following a small mechanical or traumatic exposure when conditions for a favorable response are optimal.41-45 Direct pulp capping of a carious pulp exposure in a primary tooth is not recommended.1 • Objectives: The tooth’s vitality should be maintained. No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. Pulp healing and reparative 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 with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. The coronal pulp is amputated, and the remaining vital radicular pulp tissue surface is treated with a long-term clinicallysuccessful medicament such as Buckley’s Solution of formocresol or ferric sulfate.46-52 Electrosurgery also has demonstrated success.53 Gluteraldehyde54,55 and calcium hydroxide50,52,56 have been used but with less long-term success. MTA is a more recent material used for pulpotomies with a high rate of success. Clinical trials show that MTA performs equal to or better than formocresol or ferric sulfate8,11,57-61 and may be the preferred pulpotomy agent in the future.61,62 After the coronal pulp chamber is filled with zinc/oxide eugenol or other suitable base, the tooth is restored with a restoration that seals the tooth from microleakage. The most effective long-term restoration has been shown to be a stainless steel crown. However, 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 2 years or less.63-65

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• 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.6 The coronal tissue is amputated, and the remaining radicular tissue is judged to be vital without suppuration, purulence, necrosis, or excessive hemorrhage that cannot be controlled by a damp cotton pellet after several minutes, and there are no radiographic signs of infection or pathologic resorption. • Objectives: The radicular pulp should remain asymptomatic without adverse clinical signs or symptoms such as sensitivity, pain, or swelling. There should be no postoperative radiographic evidence of pathologic external root resorption. Internal root resorption can 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.52,55,66-68 There should be no harm to the succedaneous tooth. Nonvital pulp treatment for primary teeth diagnosed with irreversible pulpitis or necrotic pulp Pulpectomy Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or necrotic due to caries or trauma. The root canals are debrided and shaped with hand or rotary files. 21 Since instrumentation and irrigation with an inert solution alone cannot adequately reduce the microbial population in a root canal system, disinfection with irrigants such as 1% sodium hypochlorite and/or chlorhexidine is an important step in assuring optimal bacterial decontamination of the canals.68-70 Because it is a potent tissue irritant, sodium hypochlorite must not be extruded beyond the apex.71 After the canals are dried, a resorbable material such as nonreinforced zinc/oxideeugenol,5,72 iodoform-based paste (KRI),73 or a combination paste of iodoform and calcium hydroxide (Vitapex®, Endoflax®)74-76 is used to fill the canals. The tooth then is restored with a restoration that seals the tooth from microleakage. • 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 (eg, excessive hemorrhage that is not controlled with a damp cotton pellet applied for several minutes) or pulp necrosis (eg, suppration, purulence). The roots should exhibit minimal or no resorption. • Objectives: Following treatment, the radiographic infectious process should resolve in 6 months, as evidenced by bone deposition in the pretreatment radiolucent areas, and pretreatment clinical signs and symptoms should resolve within a few weeks. There should be radiographic evidence of successful filling without gross overextension or underfilling.72,74,76 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.


Young permanent teeth Vital pulp therapy for teeth diagnosed with a normal pulp or reversible pulpitis Protective liner A protective liner is a thinly-applied liquid 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. Placement of a thin protective liner such as calcium hydroxide, dentin bonding agent, or glass ionomer cement is at the discretion of the clinician.13,14 The liner must be followed by a well-sealed restoration to minimize bacterial leakage from the restoration-dentin interface.17,18 • 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.17,18 Adverse post-treatment signs or symptoms such as sensitivity, pain, or swelling should not occur. Indirect pulp treatment Indirect pulp treatment 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.6 In recent years, rather than complete the caries removal in 2 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.77-79 The risk of this approach is either an unintentional pulp exposure or irreversible pulpitis.78 More recently, the stepwise excavation of deep caries has been revisited70-82 and shown to be successful in managing reversible pulpitis without pulpal perforation and/or endodontic therapy.83 This approach involves a 2-step process. The first step is the removal of carious dentin along the dentin-enamel junction (DEJ) 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.83-85 The second step is the removal of the remaining caries and placement of a final restoration. The most common recommendation for the interval between steps is 3-6 months, allowing sufficient time for the formation of tertiary dentin and a definitive pulpal diagnosis. Critical to both steps of excavation is the placement of a well-sealed restoration.17,18 The decision to use a one-appointment caries excavation or a step-wise technique should be based on the individual patient circumstances since the research available is inconclusive on which approach is the most successful over time.36,37 • Indications: Indirect pulp treatment is indicated in a permanent tooth diagnosed with a normal pulp with no symptoms of pulpitis or with a diagnosis of reversible pulpitis. The pulp is

judged by clinical and radiographic criteria to be vital and able to heal from the carious insult.6 • Objectives: The intermediate and/or final restoration should seal completely the involved dentin from the oral environment. The vitality of the tooth should be preserved. No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. There should be no radiographic evidence of internal or external root resorption 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 1 to 3 mm or deeper to reach healthy pulp tissue. Pulpal bleeding must be controlled by irrigation with a bacteriocidal agent such as sodium hypochlorite or chlorhexidine68-70 before the site is covered with calcium hydroxide6,91,92 or MTA.9395 While calcium hydroxide has been demonstrated to have longterm success, MTA results in more predictable dentin bridging and pulp health.96 MTA (at least 1.5 mm thick) should cover the exposure and surrounding dentin followed by a layer of light cured resin-modified glass ionomer.90 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 pulpal bleeding is controlled within several minutes. The tooth must be vital, with a diagnosis of normal pulp or reversible pulpitis.6 • Objectives: The remaining pulp should continue to be vital after partial pulpotomy. There should be no adverse clinical 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 radiolucency 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 is removed to a depth of 1 to 3 mm or more to reach the deeper healthy tissue. Pulpal bleeding is controlled using bacteriodical irrigants such as sodium hypochlorite or chlorhexidine69,70, and the site then is covered with calcium hydroxide97-100 or MTA.6,101 White, rather than gray, MTA is recommended in anterior teeth to decrease the chance of discoloration. The 2 versions have been shown to have similar properties.102,103 While calcium hydroxide has been demonstrated to have longterm success, MTA results in more predictable dentin bridging and pulp health.96 MTA (at least 1.5 mm thick) should cover the exposure and surrounding dentin, followed by a layer of light-cured resin-modified glass ionomer.101 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. Pulpal bleeding after removal of inflamed pulpal tissue must be controlled. Neither CLINICAL GUIDELINES

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time between the accident and treatment nor size of exposure is critical if the inflamed superficial pulp tissue is amputated to healthy pulp.104 • 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 resorption, abnormal canal calcification, or periapical radiolucency postoperatively. Teeth with immature roots should show continued normal root development and apexogenesis. 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 implementing the appropriate vital pulp therapy previously described in this section (ie, indirect pulp treatment, direct pulp capping, partial pulpotomy for carious exposures and traumatic exposures). 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 pulpal 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 debridement, disinfection, and shaping of the root canal system, obturation of the entire root canal is accomplished with a biologically-acceptable, nonresorbable filling material. Obturation as close as possible to the cementodentinal junction should be accomplished with gutta percha or other filling material acceptable as described in the Guide to Clinical Endodontics.14 • Indications: Pulpectomy or conventional root canal treatment is indicated for a restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified. For root canal-treated teeth with unresolved periradicular 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 post-treatment 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 periradicular supporting tissues clinically or radiographically. Apexification (root end closure) Apexification is a method of inducing root end closure of an incompletely formed nonvital permanent tooth by removing the coronal and nonvital radicular tissue just short of the root end and placing a biocompatible agent such as calcium hydroxide in the canals for 2-4 weeks to disinfect the canal space. Root end closure is accomplished with an apical barrier such as MTA.105 In instances when complete closure cannot be accomplish 198

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by MTA, an absorbable collagen wound dressing (eg, CollaCote®)106 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 canal space can be filled with MTA or composite resin instead of gutta percha to strengthen the tooth against fracture.107 • Indications: This procedure is indicated for nonvital 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 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 1. Fuks AB. Pulp therapy for the primary dentition. In: Pinkham JR, Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak A, eds. Pediatric Dentistry: Infancy Through Adolescence. 4th ed. St. Louis, Mo: Elsevier Saunders Co; 2005:375-93. 2. American Association of Endodontists. Glossary of Endodontic Terms. 7th ed. Chicago, Ill: American Association of Endodontists; 2003. 3. American Association of Endodontists. Systematic endodontic diagnosis. Insert to the Fall/Winter edition of Endodontics: Colleagues for Excellence; 1996. 4. McDonald RE, Avery DR, Dean JA. Management of trauma to the teeth and supporting tissues. In: Dentistry for the Child and Adolescent. 8 th ed. St Louis, Mo: Mosby Inc; 2004:455-502. 5. Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent 1996;18(1):57-63. 6. Camp JH, Fuks AB. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Cohen S, Hargreaves KM, eds. Pathways of the Pulp. 9th ed. St. Louis, Mo: Mosby Elsevier; 2006:834-59. 7. Farooq NS, Coll JA, Kuwabara A, Shelton P. Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent 2000;22(4):278-86. 8. Fuks AB. Current concepts in vital pulp therapy. Eur J Pediatr Dent 2002;3(3):115-20. 9. 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. 10. Murray PE, About I, Franquin JC, Remusat M, Smith AJ. Restorative pulpal and repair responses. J Am Dent Assoc 2001;132(4):482-91. 11. Holan G, Eidelman E, Fuks AB. Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatr Dent 2005;27(2):129-36.


12. American Association of Endodontists. Guide to Clinical Endodontics. 4th ed. Chicago, Ill: American Association of Endodontists; 2004. 13. Itota T, Nakabo S, Torii Y, Narukami T, Doi J, Yoshiyama M. Effect of fluoride-releasing liner on demineralized dentin. Quintessence Int 2006;37(4):297-303. 14. Weiner RS, Weiner LK, Kugel G. Teaching the use of bases and liners: A survey of North American dental schools. J Am Dent Assoc 1996;127(11):1640-5. 15. Wisithphrom K, Murray PE, About I, Windsor LJ. Interactions between cavity preparation and restoration events and their effects on pulp vitality. Int J Periodontics Restorative Dent 2006;26(6):596-605. 16. de Souza Costa CA, Teixeira HM, Lopes do Nascimento AB, Hebling J. Biocompatibility of resin-based dental materials applied as liners in deep cavities prepared in human teeth. J Biomed Mater Res B Appl Biomater 2007; 81(1):175-84. 17. Murray PE, Hafez AA, Smith AJ, Cox CF. Bacterial microleakage and pulp inflammation associated with various restorative materials. Dent Mater 2002;18(6):470-8. 18. Rabchinsky J, Donly KJ. A comparison of glass-ionomer cement and calcium hydroxide liners in amalgam restorations. Int J Periodontics Restorative Dent 1993;13(4): 378-83. 19. Büyükgüral B, Cehreli ZC. Effect of different adhesive protocols vs calcium hydroxide on primary tooth pulp with different remaining dentin thicknesses: 24 month results. Clin Oral Investig 2008;12(1):91-6. 20. Falster CA, Araújo FB, Straffon LH, Nör JE. Indirect pulp treatment: in vivo outcomes of an adhesive resin system vs calcium hydroxide for protection of the dentin-pulp complex. Pediatr Dent 2002;24(3):241-8. 21. Lo EC, Holmgren CJ, Hu D, Van Palenstein Helderman W. Six-year follow up of atraumatic restorative treatment restorations placed in Chinese school children. Community Dent Oral Epidemiol 2007;35(5):387-92. 22. de Souza EM, Cefaly DF, Terada RS, Rodrigues CC, de Lima Navarro MF. Clinical evaluation of the ART technique using high density and resin-modified glass ionomer cements. Oral Health Prev Dent 2003;1(3):201-7. 23. Pinto AS, de Araújo FB, Franzon R, et al. Clinical and microbiological effect of calcium hydroxide protection in indirect pulp capping in primary teeth. Am J Dent 2006;19(6):382-6. 24. Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB. Indirect pulp treatment of primary posterior teeth: A retrospective study. Pediatr Dent 2003:25(1):29-36. 25. Davidovich E, Weiss E, Fuks AB, Beyth N. Surface antibacterial properties of glass ionomer cements used in a traumatic restorative treatment. J Am Dent Assoc 2007; 138(10):1347-52. 26. M archi JJ, de Araújo FB, Froner AM, Straffon LH, Nör JE. Indirect pulp capping in the primary dentition: A 4 year follow-up study. J Clin Pediatr Dent 2006;31 (2):68-71.

27. Menezes JP, Rosenblatt A, Medeiros E. Clinical evaluation of atraumatic restorations in primary molars: A comparison between 2 glass ionomer cements. J Dent Child 2006;73(2):91-7. 28. Brännström M. Communication between the oral cavity and the dental pulp associated with restorative treatment. Oper Dent 1984;9(2):57-68. 29. Pereira JC, Manfio AP, Franco EB, Lopes ES. Clinical evaluation of Dycal under amalgam restorations. Am J Dent 1990;3:67-70. 30. Tam LE, Pulver E, McComb D, Smith DC. Physical properties of calcium hydroxide and glass-ionomer base and lining materials. Dent Mater 1989;5:145-9. 31. Lewis BA, Burgess JO, Gray SE. Mechanical properties of dental base materials. Am J Dent 1992;5:69-72. 32. Duque C, Negrini Tde C, Hebling J, Spolidorio DM. Inhibitory activity of glass-ionomer cements on cariogenic bacteria. Oper Dent 2005;30(5):636-40. 33. Loyola-Rodriguez JP, García-Godoy F, Linquist R. Growth inhibition of glass ionomer cements on mutans streptococci. Pediatr Dent 1994;16(5):346-9. 34. Wambier DS, dos Santos FA, Guedes-Pinto AC, Jaeger RG, Simionato MR. Ultrastructural and microbiological analysis of the dentin layers affected by carious lesions in primary molars treated by minimal intervention. Pediatr Dent 2007;29(3):228-35. 35. Coll JA. Indirect pulp capping and primary teeth: Is the primary tooth pulpotomy out of date? Pediatr Dent 2008;30(3):230-6. 36. Ricketts DNJ, Kidd EAM, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003808. DOI:10.1002/14651858. CD003808.pub2. 37. Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: A critical review. J Am Dent Assoc 2008;139(6):705-12. 38. Ribeiro CC, Baratieri LN, Perdigao J, Baratieri NM, Ritter AV. A clinical, radiographic, and scanning electron microscopic evaluation of adhesive restorations on carious dentin in primary teeth. Quintessence Int 1999;30 (9):591-9. 39. Foley J, Evans D, Blackwell A. Partial caries removal and cariostatic materials in carious primary molar teeth: A randomized controlled clinical trail. Br Dent J 2004;197(11):697-701. 40. Oliveira EF, Carminatti G, Fontanella V, Maltz M. The monitoring of deep caries lesions after incomplete dentin caries removal: Results after 14-18 months. Clin Oral Investig 2006;10(2):134-9. 41. Agamy HA, Bakry NS, Mounir MM, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulp-capping agents in pulpotomized primary teeth. Pediatr Dent 2004;26(4):302-9.

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42. Maroto M, Barbería E, Planells P, García-Godoy F. Dentin bridge formation after mineral trioxide aggregate (MTA) pulpotomies in primary teeth. Am J Dent 2005;18(3): 151-4. 43. Caicedo R, Abbott PV, Alongi DJ, Alarcon MY. Clinical, radiographic and histological analysis of the effects of mineral trioxide aggregate used in direct pulp capping and pulpotomies of primary teeth. Aust Dent J 2006;51 (4):297-305. 44. Tuna D, Olmez A. Clinical long-term evaluation of MTA as a direct pulp capping material in primary teeth. Int Endod J 2008;41(4):273-8. 45. Kopel HM. The pulp capping procedure in primary teeth “revisited”. ASDC J Dent Child 1997;64(5):327-33. 46. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: A retrospective study. Pediatr Dent 2000;22(3):192-9. 47. Burnett S, Walker J. Comparison of ferric sulfate, formocresol, and a combination of ferric sulfate/formocresol in primary tooth vital pulpotomies: A retrospective radiographic survey. ASDC J Dent Child 2002;69(1):44-8. 48. Ibricevic H, Al-Jame Q. Ferric sulphate and formocresol in pulpotomy of primary molars: Long term follow-up study. Eur J Paediatr Dent 2003;4(1):28-32. 49. Loh A, O’Hoy P, Tran X, et al. Evidence-based assessment: Evaluation of the formocresol versus ferric sulfate primary molar pulpotomy. Pediatr Dent 2004;26(5):401-9. 50. Markovic D, Zivojinovic V, Vucetic M. Evaluation of three pulpotomy medicaments in primary teeth. Eur J Paediatr Dent 2005;6(3):133-8. 51. Vargas KG, Packham B. Radiographic success of ferric sulfate and formocresol pulpotomies in relation to early exfoliation. Pediatr Dent 2005;27(3):233-7. 52. Huth KC, Paschos E, Hajek-Al-Khatar N, et al. Effectiveness of 4 pulpotomy techniques – Randomized controlled trial. J Dent Res 2005;84(12):1144-8. 53. Dean JA, Mack RB, Fulkerson BT, Sanders BJ. Comparison of electrical and formocresol pulpotomy procedures in children. Int J Pediatr Dent 2002;12(3):177-82. 54. Waterhouse PJ. Formocresol and alternative primary molar pulpotomy medicaments: A review. Endod Dent Traumatol 1995;11(4):157-62. 55. Shumayrikh NM, Adenubi JO. Clinical evaluation of gluteraldehyde with calcium hydroxide and gluteraldehyde with zinc oxide eugenol in pulpotomy of primary molars. Endod Dent Traumatol 1999;15(6):259-64. 56. Zurn D, Seale NS. Light-cured calcium hydroxide vs formocresol in human primary molar pulpotomies: A randomized controlled trial. Pediatr Dent 2008;30(1):34-41. 57. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Success of mineral trioxide aggregate in pulpotomized primary molars. J Clin Pediatr Dent 2005;29(4):307-11. 58. Maroto M, Barbería E, Vera V, García-Godoy F. Mineral trioxide aggregate as pulp dressing agent in pulptomy treatment of primary molars: 42-month clinical study. Am J Dent 2007;20(5):283-6. 200

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59. Peng L, Ye L, Tan H, Zhou X. Better outcomes in pulpotomies on primary molars with MTA. Evidence-Based Dentistry 2007;8:11-12. 60. Fuks AB, Papagiannoulis L. Pulpotomy in primary teeth: Review of the literature according to standardized criteria. Eur Arch Paediatr Dent 2006;7(2):64-71. 61. Ng FK, Messer LB. Mineral trioxide aggregate as a pulpotomy medicament: A narrative review. Eur Arch Paediatr Dent 2008;9(1):4-11. 62. Seale NS, Glickman GN. Contemporary perspectives on vital pulp therapy: Views from the endodontists and pediatric dentists. Pediatr Dent 2008;30(3):261-7. 63. Guelmann M, Fair J, Bimstein E. Permanent versus temporary restorations after emergency pulpotomies in primary molars. Pediatr Dent 2005;27(6):478-81. 64. 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. 65. Guelmann M, McIlwain MF, Primosch RE. Radiographic assessment of primary molar pulpotomies restored with resin-based materials. Pediatr Dent 2005;27(1):24-7. 66. Thompson KS, Seale NS, Nunn ME, Huff G. Alternative method of hemorrhage control in full strength formocresol pulpotomy. Pediatr Dent 2001;23(3):217-222. 67. 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. 68. Siqueira JF Jr, Rôças IN, Paiva SS, Guimarães-Pinto T, Magalhaes KM, Lima KC. Bacteriologic investigation of the effects 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. 69. 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. 70. Zehnder M. Root canal irrigants. J Endod 2006;32(5): 389-98. 71. Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents. Compend Contin Educ Dent 2007;28(10):548-50. 72. 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. 73. 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. 74. 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. 75. Kubota K, Golden BE, Penugonda B. Root canal filling materials for primary teeth: A review of the literature. ASDC J Dent Child 1992;59(3):225-7.


76. Primosch RE, Ahmadi A, Setzer B, Guelmann M. A retrospective assessment of zinc oxide-eugenol pulpectomies in vital maxillary primary incisors successfully restored with composite resin crowns. Pediatr Dent 2005;27(6): 470-7. 77. Oen KT, Thompson VP, Vena D, et al. Attitudes and expectations of treating deep caries: A PEARL Network survey. Gen Dent 2007;55(3):197-203. 78. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002;33(2):151-9. 79. Fairbourn DR, Charbeneau GT, Loesche WJ. Effect of improved Dycal and IRM on bacteria in deep carious lesions. J Am Dent Assoc 1980;100(4):547-52. 80. Leksell E, Ridell K, Cvek M, Mejàre I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1996;12(4):192-6. 81. Massler M. Treatment of profound caries to prevent pulpal damage. J Pedod 1978;2(2):99-105. 82. B jørndal L, Thylstrup A. A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: A 1-year follow-up study. Community Dent Oral Epidemiol 1998;26(2):122-8. 83. Bjørndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res 1997;31(6):411-7. 84. 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. 85. 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. 86. Horsted P, Sondergaard B, Thylstrup A, El Attar K, Fejerskov O. A retrospective study of direct pulp capping with calcium hydroxide compounds. Endod Dent Traumatol 1985;1(1):29-34. 87. Baume LJ, Holz J. Long term clinical assessment of direct pulp capping. Int Dent J 1981;31(4):251-60. 88. 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(9): 525-8. 89. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical study of direct pulp capping applied to carious-exposed pulps. J Endod 1996;22(10):551-6. 90. 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. 91. Mejàre I, Cvek M. Partial pulpotomy in young permanent teeth with deep carious lesions. Endod Dent Traumatol 1993;9(6):238-42.

92. Nosrat IV, Nosrat CA. Reparative hard tissue formation following calcium hydroxide application after partial pulpotomy in cariously exposed pulps of permanent teeth. Int Endod J 1998;31(3):221-6. 93. El-Meligy OAS, Avery DR. Comparison of mineral trioxide aggregate and calcium hydroxide as pulpotomy agents in young permanent teeth (apexogenesis). Pediatr Dent 2006;28(5):399-404. 94. 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. 95. Witherspoon DE, Small JC, Harris GZ. Mineral trioxide aggregate pulpotomies: A series outcomes assessment. J Am Dent Assoc 2006;137(9):610-8. 96. Chacko V, Kurikose S. Human pulpal response to mineral trioxide aggregate (MTA): A histological study. J Clin Pediatr Dent 2006;30(3):203-10. 97. Fuks AB, Gavra S, Chosack A. Long-term followup of traumatized incisors treated by partial pulpotomy. Pediatr Dent 1993;15(5):334-6. 98. de Blanco LP. Treatment of crown fractures with pulp exposure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82(5):564-8. 99. Blanco L, Cohen S. Treatment of crown fractures with exposed pulps. J Calif Dent Assoc 2002;30(6):419-25. 100. 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. 101. 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. 102. Ferris DM, Baumgartner JC. Perforation repair comparing two types of mineral trioxide aggregate. J Endod 2004;30(6):422-4. 103. 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. 104. Pereira JC, Stanley HR. Pulp capping: Influence of the exposure site on pulp healing: Histologic and radiographic study in dog’s pulp. J Endod 1981;7(5):213-23. 105. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25(3):197-205. 106. 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. 107. Katebzadeh N, Dalton BC, Trope M. Strengthening immature teeth during and after apexification. J Endod 1998;24(4):256-9.

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Guideline on Management of Acute Dental Trauma Originating Council


Adopted 2001

Revised 2004, 2007, 2010

Purpose The American Academy of Pediatric Dentistry (AAPD) intends these guidelines to define, describe appearances, and set forth objectives for general management of acute traumatic dental injuries rather than recommend specific treatment procedures that have been presented in considerably more detail in text-books and the dental/medical literature. Methods This guideline is an update of the previous document revised in 2007. It is based on a review of the current dental and medical literature related to dental trauma. An electronic search was conducted using the following parameters: Terms: “teeth”, “trauma”, “permanent teeth”, and “primary teeth”; Field: all fields; Limits: within the last 10 years; humans; English. There were 5269 articles that matched these criteria. Papers for review were chosen from this list and from references within select articles. In addition, a review of the journal Dental Traumatology was conducted for the years 2000-2009. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion including those from the 2008 AAPD “Symposium on Trauma: A Comprehensive Update on Permanent Tooth Trauma in Children” (Chicago, Ill). The recommendations are congruent with the 2007 guidelines developed by the International Association of Dental Traumatology.1-3 Background Facial trauma that results in fractured, displaced, or lost teeth can have significant negative functional, esthetic, and psychological effects on children.4,5 Dentists and physicians should collaborate to educate the public about prevention and treatment of traumatic injuries to the oral and maxillofacial region. The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when motor coordination is developing.6 The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents,

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violence, and sports.7-10 All sporting activities have an associated risk of orofacial injuries due to falls, collisions, and contact with hard surfaces.11 The AAPD encourages the use of protective gear, including mouthguards, which help distribute forces of impact, thereby reducing the risk of severe injury.13,14 Dental injuries could have improved outcomes if the public were aware of first-aid measures and the need to seek immediate treatment.14-17 Because optimal treatment results follow immediate assessment and care,18 dentists have an ethical obligation to ensure that reasonable arrangements for emergency dental care are available.19 The history, circumstances of the injury, pattern of trauma, and behavior of the child and/or caregiver are important in distinguishing nonabusive injuries from abuse.20 Practitioners have the responsibility to recognize, differentiate, and either appropriately manage or refer children with acute oral traumatic injuries, as dictated by the complexity of the injury and the individual clinician’s training, knowledge, and experience. Compromised airway, neurological manifestations such as altered orientation, hemorrhage, nausea/vomiting, or suspected loss of consciousness requires further evaluation by a physician. To efficiently determine the extent of injury and correctly diagnose injuries to the teeth, periodontium, and associated structures, a systematic approach to the traumatized child is essential.21,22 Assessment includes a thorough medical and dental history, clinical and radiographic examination, and additional tests such as palpation, percussion, sensitivity, and mobility evaluation. Intraoral radiography is useful for the evaluation of dentoalveolar trauma. If the area of concern extends beyond the dentoalveolar complex, extraoral imaging may be indicated. Treatment planning takes into consideration the patient’s health status and developmental status, as well as extent of injuries. Advanced behavior guidance techniques or an appropriate referral may be necessary to ensure that proper diagnosis and care are given.


All relevant diagnostic information, treatment, and recommended follow-up care are documented in the patient’s record. Appendix I is a sample document for recording assessment of acute traumatic injuries. This sample form, developed by the AAPD, is provided as a practice tool for pediatric dentists and other dentists treating children. It was developed by pediatric dentistry experts and offered to facilitate excellence in practice. This form, however, does not establish or evidence a standard of care. In issuing this form, 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. Welldesigned follow-up procedures are essential to diagnose complications. After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition.6,21,23 If determined that the displaced primary tooth has encroached upon the developing permanent tooth germ, removal is indicated.3,6,24-28 In the primary dentition, the maxillary anterior region is at low risk for space loss unless the avulsion occurs prior to canine eruption or the dentition is crowded.23 Fixed or removable appliances, while not always necessary, can be fabricated to satisfy parental concerns for esthetics or to return a loss of oral or phonetic function.6 When an injury to a primary tooth occurs, informing parents about possible pulpal complications, appearance of a vestibular sinus tract, or color change of the crown associated with a sinus tract can help assure timely intervention, minimizing complications for the developing succedaneous teeth.3,6,29,30 Also, it is important to caution parents that the primary tooth’s displacement may result in any of several permanent tooth complications, including enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption patterns or sequence.29 The risk of trauma-induced developmental disturbances in the permanent successors is greater in children whose enamel calcification is incomplete.23,31 The treatment strategy after injury to a permanent tooth is dictated by the concern for vitality of the periodontal ligament and pulp. Subsequent to the initial management of the dental injury, continued periodic monitoring is indicated to determine clinical and radiographic evidence of successful intervention (ie, asymptomatic, positive sensitivity to pulp testing, root continues to develop in immature teeth, no mobility, no periapical pathology).1,2,21,24,32 Initiation of endodontic treatment is indicated in cases of spontaneous pain, abnormal response to pulp sensitivity tests, lack of continued root formation or apexogenesis, or breakdown of periradicular supportive tissue.1,2,21,24,32 To restore a fractured tooth’s normal esthetics and function, reattachment of the crown fragment is an alternative that should be considered.21,24,33 To stabilize a tooth following traumatic injury, a splint may be necessary.24,34-38 Flexible splinting assists in heal-

ing.21,39 Characteristics of the ideal splint include: 1. easily fabricated in the mouth without additional trauma; 2. passive unless orthodontic forces are intended; 3. allows physiologic mobility; 4. nonirritating to soft tissues; 5. does not interfere with occlusion; 6. allows endodontic access and vitality testing; 7. easily cleansed; 8. easily removed. Instructions to patients having a splint placed include to: 1. consume a soft diet; 2. avoid biting on splinted teeth; 3. maintain meticulous oral hygiene; 4. use chlorhexidine/antibiotics if prescribed; 5. call immediately if splint breaks/loosens.

Recommendations Infraction Definition: incomplete fracture (crack) of the enamel without loss of tooth structure. Diagnosis: normal gross anatomic and radiographic appearance; craze lines apparent, especially with transillumination. Treatment objectives: to maintain structural integrity and pulp vitality.24,40,41 General prognosis: Complications are unusual.42 Crown fracture–uncomplicated Definition: an enamel fracture or an enamel-dentin fracture that does not involve the pulp. Diagnosis: clinical and/or radiographic findings reveal a loss of tooth structure confined to the enamel or to both the enamel and dentin.1,3,6,18-21,23,26,30,32,39,41,43,44 Treatment objectives: to maintain pulp vitality and restore normal esthetics and function. Injured lips, tongue, and gingiva should be examined for tooth fragments. When looking for fragments in soft tissue lacerations, radiographs are recommended.1 For small fractures, rough margins and edges can be smoothed. For larger fractures, the lost tooth structure can be restored.1,3,6,21,23,26,29,30,32,41-44 General prognosis: The prognosis of uncomplicated crown fractures depends primarily upon the concomitant injury to the periodontal ligament and secondarily upon the extent of dentin exposed.22 Optimal treatment results follow timely assessment and care. Crown fracture–complicated Definition: an enamel-dentin fracture with pulp exposure. Diagnosis: clinical and radiographic findings reveal a loss of tooth structure with pulp exposure.1,3,6,21 Treatment objectives: to maintain pulp vitality and restore normal esthetics and function.29 Injured lips, tongue, and gingiva should be examined for tooth fragments. When looking for fragments in soft tissue lacerations, radiographs are recommended.1

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• Primary teeth: Decisions often are based on life expectancy of the traumatized primary tooth and vitality of the pulpal tissue. Pulpal treatment alter natives are pulpotomy, pulpectomy, and extrac tion.3,6,23,26,30 • Permanent teeth: Pulpal treatment alternatives are direct pulp capping, partial pulpotomy, full pulpotomy, and pulpectomy (start of root canal therapy).1,21,42,43 There is increasing evidence to suggest that utilizing conservative vital pulp therapies for mature teeth with closed apices is as appropriate a management technique as when used for immature teeth with open apices.45 General prognosis: The prognosis of crown fractures appears to depend primarily upon a concomitant injury to the periodontal ligament.21 The age of the pulp exposure, extent of dentin exposed, and stage of root development at the time of injury secondarily affect the tooth’s prognosis.21 Optimal treatment results follow timely assessment and care. Crown/root fracture Definition: an enamel, dentin, and cementum fracture with or without pulp exposure. Diagnosis: Clinical findings usually reveal a mobile coronal fragment attached to the gingiva with or without a pulp exposure. Radiographic findings may reveal a radiolucent oblique line that comprises crown and root in a vertical direction in primary teeth and in a direction usually perpendicular to the central radiographic beam in permanent teeth. While radiographic demonstration often is difficult, root fractures can only be diagnosed radiographically.1,3,6,21,30 Treatment objectives: to maintain pulp vitality and restore normal esthetics and function.11 • Primary teeth: When the primary tooth cannot or should not be restored, the entire tooth should be removed unless retrieval of apical fragments may result in damage to the succedaneous tooth.3,6 • Permanent teeth: The emergency treatment objec tive is to stabilize the coronal fragment. Definitive treatment alternatives are: to remove the coronal fragment followed by a supragingival restoration or necessary gingivectomy; osteotomy; or surgical or orthodontic extrusion to prepare for restoration. If the pulp is exposed, pulpal treatment alternatives are pulp capping, pulpotomy, and root canal treatment.1,21,42 General prognosis: Although the treatment of crown-root fractures can be complex and laborious, most fractured permanent teeth can be saved.21 Fractures extending significantly below the gingival margin may not be restorable. Root fracture Definition: a dentin and cementum fracture involving the pulp.

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Diagnosis: Clinical findings reveal a mobile coronal fragment attached to the gingiva that may be displaced. Radiographic findings may reveal 1 or more radiolucent lines that separate the tooth fragments in horizontal fractures. Multiple radiographic exposures at different angulations may be required for diagnosis. A root fracture in a primary tooth may be obscured by a succedaneous tooth.1,3,6,21 Treatment objectives: • Primary teeth: Treatment alternatives include ex traction of coronal fragment without insisting on removing apical fragment or observation.3,6,23 It is not recommended to reposition and stabilize the coronal fragment.3 • Permanent teeth: Reposition and stabilize the co ronal fragment.1,21 in its anatomically correct posi tion as soon as possible to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity.24 General prognosis: Pulp necrosis in root-fractured teeth is attributed to displacement of the coronal fragment and mature root development.21,47 In permanent teeth, the location of the root fracture has not been shown to affect pulp survival after injury.21,47 Therefore, preservation of teeth with root fractures occurring in the tooth’s cervical third should be attempted.21,47 Young age, immature root formation, positive pulp sensitivity at time of injury, and approximating the dislocation within 1 mm have been found to be advantageous to both pulpal healing and hard tissue repair of the fracture.39,47,48 Concussion Definition: injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth. Diagnosis: Because the periodontal ligament absorbs the injury and is inflamed, clinical findings reveal a tooth tender to pressure and percussion without mobility, displacement, or sulcular bleeding. Radiographic abnormalities are not expected.1,3,6,21,23,32 Treatment objectives: to optimize healing of the periodontal ligament and maintain pulp vitality.1,3,6,21,23,24,32,49 General prognosis: For primary teeth, unless associated infection exists, no pulpal therapy is indicated.6 Although there is a minimal risk for pulp necrosis, mature permanent teeth with closed apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be followed carefully.21 Subluxation Definition: injury to tooth-supporting structures with abnormal loosening but without tooth displacement. Diagnosis: Because the periodontal ligament attempts to absorb the injury, clinical findings reveal a mobile tooth without displacement that may or may not have sulcular bleeding. Radiographic abnormalities are not expected.1,3,6,21


Treatment objectives: to optimize healing of the periodontal ligament and neurovascular supply.1,3,6,21,23,24,26-28,30,32,49 • Primary teeth: The tooth should be followed for pathology. • Permanent teeth: Stabilize the tooth and relieve any occlusal interferences. For comfort, a flexible splint can be used. Splint for no more than 2 weeks. General prognosis: Prognosis is usually favorable.23,32 The primary tooth should return to normal within 2 weeks.6 Mature permanent teeth with closed apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be followed carefully.21 Lateral luxation Definition: displacement of the tooth in a direction other than axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs.23,32,50 Diagnosis: Clinical findings reveal that a tooth is displaced laterally with the crown usually in a palatal or lingual direction and may be locked firmly into this new position. The tooth usually is not mobile or tender to touch. Radiographic findings reveal an increase in periodontal ligament space and displacement of apex toward or though the labial bone plate.1,3,6,21,50 Treatment objectives: • Primary teeth: to allow passive or spontaneous re positiong if there is no occlusal interference.3 When there is occlusal interference, the tooth can be gently repositioned or slightly reduced if the interference is minor.3 When the injury is severe or the tooth is nearing exfoliation, extraction is the treatment of choice.3,6,24,26-28,30 • Permanent teeth: to reposition as soon as possible and then to stabilize the tooth in its anatomically correct position to optimize healing of the peri odontal ligament and neurovascular supply while maintaining esthetic and functional integrity. Re positioning of the tooth is done with digital pressure and little force. A displaced tooth may need to be extruded to free itself from the apical lock in the cortical bone plate. Splinting an addi tional 2 to 4 weeks may be needed with breakdown of marginal bone.1,21,24,49,50 General prognosis: Primary teeth requiring repositioning have an increased risk of developing pulp necrosis compared to teeth that are left to spontaneously reposition.6 In mature permanent teeth with closed apices, pulp necrosis and pulp canal obliteration are common healing complications while progressive root resorption is less likely to occur.50 Intrusion Definition: apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket.23,32,51

Diagnosis: Clinical findings reveal that the tooth appears to be shortened or, in severe cases, it may appear missing. The tooth’s apex usually is displaced labially toward or through the labial bone plate in primary teeth and driven into the alveolar process in permanent teeth. The tooth is not mobile or tender to touch. Radiographic findings reveal that the tooth appears displaced apically and the periodontal ligament space is not continuous. Determination of the relationship of an intruded primary tooth with the follicle of the succedaneous tooth is mandatory. If the apex is displaced labially, the apical tip can be seen radiographically with the tooth appearing shorter than its contra-lateral. If the apex is displaced palatally towards the permanent tooth germ, the apical tip cannot be seen radiographically and the tooth appears elongated. An extraoral lateral radiograph also can be used to detect displacement of the apex toward or though the labial bone plate. An intruded young permanent tooth may mimic an erupting tooth.1,3,6,21,51 Treatment objectives: • Primary teeth: to allow spontaneous reeruption ex cept when displaced into the developing successor. Extraction is indicated when the apex is displaced toward the permanent tooth germ.3,6,24,26-28,30 • Permanent teeth: to reposition passively (allowing re-eruption to its preinjury position), actively (repositioning with traction), or surgically and then to stabilize the tooth with a splint for up to 4 weeks in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. For immature teeth with more eruptive potential (root ½ to ²/³ formed), the objective is to allow for spontaneous eruption. In mature teeth, the goal is to reposition the tooth with orthodontic or surgical extrusion and initiate endodontic treatment within the first 3 weeks of the traumatic incidence.1,21,24,49,51 General prognosis: In primary teeth, 90% of intruded teeth will reerupt spontaneously (either partially or completely) in 2 to 6 months.23,52 Even in cases of complete intrusion and displacement of primary teeth through the labial bone plate, a retrospective study showed the reeruption and survival of most teeth for more than 36 months.53 Ankylosis may occur, however, if the periodontal ligament of the affected tooth was severely damaged, thereby delaying or altering the eruption of the permanent successor.6 In mature permanent teeth with closed apices, there is considerable risk for pulp necrosis, pulp canal obliteration, and progressive root resorption.51 Immature permanent teeth that are allowed to reposition spontaneously demonstrate the lowest risk for healing complications.54,55 Extent of intrusion (7 mm or greater) and adjacent intruded teeth have a negative influence on healing.54

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Extrusion Definition: partial displacement of the tooth axially from the socket; partial avulsion. The periodontal ligament usually is torn.23,32,56 Diagnosis: Clinical findings reveal that the tooth appears elongated and is mobile. Radiographic findings reveal an increased periodontal ligament space apically.1,3,6,21,56 Treatment objectives: • Primary teeth: to allow tooth to reposition sponta neously or reposition and allow for healing for minor extrusion (

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