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ESTABLISHMENT OF A DENTAL HOME FOR PEDIATRIC DENTAL PATIENTS Dr. Lisa Jacob Chief of Pediatric Dental Medicine Dell Children’s Medical Center Austin, TX
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Early Early Detection __ Infants be evaluated by a dentist within 6 months of eruption of their first tooth and no later than 12 months __ Allows a dentist to assess a child’s risk of developing caries __ Counsel parents and caregivers about what they can do to reduce risk © Lisa S Jacob, DDS, MS 2009
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Goal Establish an ongoing relationship between dentist and the patient, inclusive of all aspects of oral health care, delivered in a comprehensive continuously accessible, coordinated and family centered way © Lisa S Jacob, DDS, MS 2009
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Dental Home D0145- Oral evaluation for a patient under three years of age and counseling with primary caregiver D0145- Oral evaluation for a patient under three years of age and counseling with primary caregiver Goal: To prevent dental problems Goal: To prevent dental problems © Lisa S Jacob, DDS, MS 2009
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First Dental Home Visit 1. 1. Review of Dental and Medical history 2. 2. Comprehensive oral examination 3. 3. Caries risk assessment 4. 4. Application of topical fluoride varnish 5. 5. Dental prophylaxis 6. 6. Oral hygiene instructions with primary caregiver 7. 7. Dental anticipatory guidance 8. 8. Establishment of recall schedule © Lisa S Jacob, DDS, MS 2009
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Why complete a caries risk assessment? Determine potential for development of Severe Early Childhood Caries by identifying: √ Oral Health Status √ Potential transmission sources Direct dental anticipatory guidance content Determine an appropriate recall periodicity schedule for the child © Lisa S Jacob, DDS, MS 2009
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Caries Risk Assessment Tool (CAT) 2002- American Academy of Pediatric Dentistry (AAPD) adopted CAT for infants, children, and adolescents 2006 AAPD revised the CAT AAPD encouraged both dental and non-dental health care providers to use the CAT Clinicians had to perform an adequate visual examination of the child’s teeth and mouth © Lisa S Jacob, DDS, MS 2009
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Risk factors to consider History Determined by interviewing the parent/primary caregiver Clinical evaluation Determined by examining the child’s mouth Supplemental Professional Assessment Optional © Lisa S Jacob, DDS, MS 2009
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High caries risk patient Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator Single risk in any area of the “high risk” category classifies a child as being “high risk” © Lisa S Jacob, DDS, MS 2009
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Child’s use of dental home Frequency of dental visits Never :High risk Irregular: Moderate risk Regular: Low risk http:// www.ardentoys.co.uk/images/uploads/bay-tree-house2.jpg © Lisa S Jacob, DDS, MS 2009
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Child has decay Yes: High risk No: Low risk www1.istockphoto.com/file_thumbview_approve/1609464/2/istockphoto_1609464_uh_oh_a_cavity_vector.jpg © Lisa S Jacob, DDS, MS 2009
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Patients with special needs Especially those that impact motor coordination or cooperation Ectodermal dysplasia Dental enamel is not well mineralized Newbrun E. Current treatment modalities of oral problems of patients with Sjogren’s syndrome: caries prevention. Adv Dent Res. 1996: 10; 20-34. Newbrun E. Current treatment modalities of oral problems of patients with Sjogren’s syndrome: caries prevention. Adv Dent Res. 1996: 10; 20-34. © Lisa S Jacob, DDS, MS 2009
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Parent’s socioeconomic status Low SES: High risk Midlevel SES: Moderate risk High SES: Low risk http://library.thinkquest.org/J003358F/money_tree5.jpg © Lisa S Jacob, DDS, MS 2009
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Impaired saliva composition/flow Long-term doses of medications can increase caries risk Long-term doses of medications can increase caries risk Impaired salivation High mineral loss Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake and complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol. 2001: 46; 412-23. Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake and complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol. 2001: 46; 412-23. © Lisa S Jacob, DDS, MS 2009
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Time lapsed since child’s last cavity <12 months: High risk 12-24 months: Moderate risk >24 months: Low risk http://www.ntlf.com/images/calendar.jpg © Lisa S Jacob, DDS, MS 2009
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Child wears braces or orthodontic/oral appliances Yes: High risk No: Low risk © Lisa S Jacob, DDS, MS 2009
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Child’s immediate family has decay Yes: High risk No: Low risk Yes: High risk No: Low risk The earlier the child is infected… the higher the risk of caries the higher the risk of caries Vertical transmission Mother to child Vertical transmission ↓ Mother to child Horizontal transmission Sibling to sibling Horizontal transmission ↔ Sibling to sibling © Lisa S Jacob, DDS, MS 2009
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Daily intakes Between-Meals and cavity producing foods Mealtimes: Low risk 1-2 snacks: Moderate risk >3 snacks: High risk Consumption of juice, carbonated beverages or sports drinks Use of bottle/sippy cup containing liquid other than water Use of sweetened medications © Lisa S Jacob, DDS, MS 2009
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Child’s exposure to fluoride High Risk Does not use fluoridated toothpaste Does not use fluoridated toothpaste Drinking water is not fluoridated Drinking water is not fluoridated Does not take fluoride supplements Does not take fluoride supplements Moderate Risk Uses fluoridated toothpaste Uses fluoridated toothpaste Usually does not drink fluoridated water Usually does not drink fluoridated water Does not take fluoride supplements Does not take fluoride supplements Low Risk Uses fluoridated toothpaste Uses fluoridated toothpaste Drinks fluoridated water Drinks fluoridated water Takes fluoride supplements Takes fluoride supplements © Lisa S Jacob, DDS, MS 2009
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Times per day that the child’s teeth/gums are brushed <1: High risk <1: High risk 1: Moderate risk 1: Moderate risk 2-3: Low risk 2-3: Low risk http://www.eslkidstuff.com/images/toothbrush. gif © Lisa S Jacob, DDS, MS 2009
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Clinical Evaluation Clinical Evaluation © Lisa S Jacob, DDS, MS 2009
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Visible Plaque Present: High risk Absent: Low risk http://www.scharfphoto.com/fine_art_prints/archives/199901-024-Dental-Plaque.jpg http://www.scharfphoto.com/fine_art_prints/archives/199901-024-Dental-Plaque.jpg © Lisa S Jacob, DDS, MS 2009
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Gingivitis Present: High risk Absent: Low risk © Lisa S Jacob, DDS, MS 2009
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Areas of enamel demineralization >1: High risk 1: Moderate risk None: Low risk http://www.uiowa.edu/~c090247/images/varnish/demineralized.jpg http://www.uiowa.edu/~c090247/images/varnish/demineralized.jpg © Lisa S Jacob, DDS, MS 2009
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Enamel Defects Deep pits/fissures Present: High risk Absent: Low risk http://www.ojrd.com/content/figures/1750-1172-2- 17-1.jpg http://www.ojrd.com/content/figures/1750-1172-2- 17-1.jpg © Lisa S Jacob, DDS, MS 2009
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Tooth anatomy and hypoplastic defects Developmental pits and deep pits have been shown to predispose a child to develop dental caries © Lisa S Jacob, DDS, MS 2009
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Radiographic Enamel Caries Present: High risk Absent: Low risk http://www.ndeb.ca/en/accredited/images/SNAG-0202.jpg http://www.ndeb.ca/en/accredited/images/SNAG-0202.jpg © Lisa S Jacob, DDS, MS 2009
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Levels of mutans streptococci or Lactobacilli High: High risk Moderate: Moderate risk Low: Low risk © Lisa S Jacob, DDS, MS 2009
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Dental Record Document Caries Risk ▲ High ► Moderate ► Moderate ▼ Low © Lisa S Jacob, DDS, MS 2009
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Topical Fluoride Varnish D1206 Topical Fluoride Varnish D1206 * Therapeutic application for moderate to high caries risk patients * Goal is to eliminate or control a disease * Prevent and re-mineralize early caries © Lisa S Jacob, DDS, MS 2009
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Fluoride Varnish Advantages High dose with minimal volume Minimal swallowing Contact on teeth for hours Reduced caries Low plasma fluoride levels Tolerated by children Unit dose Fast © Lisa S Jacob, DDS, MS 2009
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Fluoride Varnish 5% NAF Disadvantages Fuzzy, sticky and uneven Appearance on tooth 4-6 hours you can’t brush Soft food for one day © Lisa S Jacob, DDS, MS 2009
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Topical Fluoride Inhibits demineralization Enhances re-mineralization Inhibits plaque bacteria © Lisa S Jacob, DDS, MS 2009
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Topical application of fluoride D1203 (Child) FoamsGels Most effective if placed in mouth for four minutes Most effective if placed in mouth for four minutes © Lisa S Jacob, DDS, MS 2009
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Fluoride testing Fluori-check (Omnii Oral) © Lisa S Jacob, DDS, MS 2009
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Fluoride Products © Lisa S Jacob, DDS, MS 2009
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Oral Hygiene Instructions D1330 ToothbrushingFlossing © Lisa S Jacob, DDS, MS 2009
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Toothbrushes Electric toothbrush Spin Brush © Lisa S Jacob, DDS, MS 2009
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Surround Toothbrush _ 3 rows of bristles _ Compact head _ Helps protect the oral environment if the person moves unexpectedly during brushing © Lisa S Jacob, DDS, MS 2009
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Flossers
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Nutritional counseling for control of dental disease D1310 * Frequency of intake is more important than overall quantity * “Grazing” between meals should be discouraged * Avoid frequent consumption of sodas * Sweet intake should be limited-mealtime © Lisa S Jacob, DDS, MS 2009
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Bacterial Cultures Identify the presence of cariogenic bacterial infections
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Caries Susceptibility Test D0425 If mother has had active dental decay in the past 12 months, dentist may perform a bacterial culture on the mother If primary caregiver’s bacteria count is significant, the dentist will develop prevention strategy Minimizes the risk of mom transmitting the infection to the child © Lisa S Jacob, DDS, MS 2009
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Recommendations for caregiver √ Antibacterial rinse √ Chew xylitol gum or mints each day Studies show that chewing xylitol gum 4 times a day helps reduce the transmission of cariogenic bacteria from caregivers to infants © Lisa S Jacob, DDS, MS 2009
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Dental anticipatory Guidance * Age appropriate information/education for parents * Multi-topic overview of oral health environmental influences * Directed at increasing the parents understanding of the importance of good health © Lisa S Jacob, DDS, MS 2009
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Dental anticipatory Guidance * Discuss oral health and home care * Development of Mouth and Teeth * Oral Habits * Diet, Nutrition and Food Choices * Fluoride Needs * Injury Prevention * Antimicrobials © Lisa S Jacob, DDS, MS 2009
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Birth -1 year old √ Clean baby’s mouth/brush teeth √ Parents need to maintain their own oral health √ Do not share utensils and cups √ Discuss primary tooth eruption patterns √ Discuss teething and ways to sooth sore gums © Lisa S Jacob, DDS, MS 2009
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Birth-1 year old √ Review pacifier use √ Do not put baby to bed with bottle √ Encourage use of cup by year one √ Fluoride needs √ Child proof the home √ Car seat usage √ Discuss use of medications with sweeteners © Lisa S Jacob, DDS, MS 2009
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1-3 years old ☺ Offer healthy food, snacks, drinks ☺ Clean baby’s teeth ☺ Use fluoridated toothpaste (smear) ☺ Continue regular dental visits ☺ Discuss importance of baby teeth with parents ☺ Begin weaning of non-nutritive sucking habits by age 2 © Lisa S Jacob, DDS, MS 2009
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1-3 years old Continue ☺ Healthy nutritional choices ☺ Frequency of exposures Do not use sippy cup like a bottle No running with objects in mouth Helmet use with toddlers riding bikes © Lisa S Jacob, DDS, MS 2009
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3-5 years old * Pea-sized amount of fluoridated toothpaste * Discuss permanent tooth eruption patterns * Importance of teeth * Discuss consequences of digit sucking or prolonged non nutritive sucking * Should be using a regular cup © Lisa S Jacob, DDS, MS 2009
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Behavior Guidance * “a clinical art form and skill built on a foundation of science” * Continuum of interaction involving the dentist, dental team, the parent, and the patient © Lisa S Jacob, DDS, MS 2009
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Goals √ Establish communication √ Alleviate fear and anxiety √ Deliver quality dental care √ Build a trusting relationship between dentist and child √ Promote child’s positive attitude toward dental health © Lisa S Jacob, DDS, MS 2009
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Dental Office Website __ Introduce parents to the practice Location __ FQHC dental within medical clinic Design Design __ Kid friendly © Lisa S Jacob, DDS, MS 2009
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DENTAL TEAM BEHAVIOR Receptionist __ First contact with parent via phone __ Sets expectations __ First staff member the child meets Dental Assistant __ Language Dental Hygienist __ Establish rapport Dentist __ “White Coat Syndrome” © Lisa S Jacob, DDS, MS 2009
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Recommend behavior guidance based on: * Health history * Special health needs * Dental Needs * Type of treatment required required * Consequences of no treatment * Emotional and intellectual development of patient * Parental preferences © Lisa S Jacob, DDS, MS 2009
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BASIC BEHAVIOR GUIDANCE © Lisa S Jacob, DDS, MS 2009
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VOICE CONTROL Gain the patient’ attention Establish adult-child roles Controlled alteration of : Voice Volume Pace Tone © Lisa S Jacob, DDS, MS 2009
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Non-verbal Communication Reinforcement and guidance of behavior through: Appropriate contact Posture Body Language Facial Expression Gain or maintain the patient’s attention © Lisa S Jacob, DDS, MS 2009
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TELL-SHOW-DO Tailored verbal explanation of procedures Educate – importance of dental visit Familiarize patient with dental setting Demonstrate: It’s OK to Visual, Auditory,Touch,Taste, Smell Visual, Auditory,Touch,Taste, Smell © Lisa S Jacob, DDS, MS 2009
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POSITIVE REINFORCEMENT Rewarding desired behavior ☺ Verbal praise ☺ Prizes ☺ Facial expression Gives appropriate feedback Strengthens recurrence of those behaviors © Lisa S Jacob, DDS, MS 2009
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DISTRACTION Diverting the patient’s attention from what may be perceived as an unpleasant procedure ≈ Find out interests ≈ Give patient a short break © Lisa S Jacob, DDS, MS 2009
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PARENTAL PRESENCE/ABSENCE __ Gain patient’s attention __ Improve compliance __ Depends on if the parent can help reduce the patient’s anxiety __ Parental attitudes have changed __ Legal reasons __ Do not use with parents who are unwilling or unable to extend effective support © Lisa S Jacob, DDS, MS 2009
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MODELING Have a patient observe the positive behavior of another patient © Lisa S Jacob, DDS, MS 2009
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HYPNOSIS Guided self-imagery that focuses in relaxation and analgesia * Helps decrease gagging * Helps overcome dental phobia © Lisa S Jacob, DDS, MS 2009
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ADVANCE BEHAVIOR GUIDANCE → Protective Stabilization → Nitrous oxide → Conscious Sedation → General anesthesia © Lisa S Jacob, DDS, MS 2009
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PROTECTIVE STABILIZATION * Any form of restriction of movement by a patient in the dental environment * Reduce or eliminate untoward patient movement * Protect patient, staff, dentist or parent from injury * Facilitate delivery of quality dental care © Lisa S Jacob, DDS, MS 2009
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INDICATIONS Patient requires immediate diagnosis or limited treatment Patient requires immediate diagnosis or limited treatment Use with sedated patient that need to help reduce untoward movement Use with sedated patient that need to help reduce untoward movement © Lisa S Jacob, DDS, MS 2009
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PHYSICAL RESTRAINS Head holds Hand guarding Used by dental assistant Therapeutic holds Third person © Lisa S Jacob, DDS, MS 2009
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Dental Record for any use of Stabilization Informed consent IndicationType Duration of application Frequency of stabilization evaluation and safety adjustments Behavior evaluation/rating during stabilization © Lisa S Jacob, DDS, MS 2009
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Precautions with protective stabilization √ Tightness and duration must be monitored √ Do not restrict breathing and circulation √ Must not use if patient experiences severe stress or hysteria © Lisa S Jacob, DDS, MS 2009
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MOUTH PROPS McKesson Bite Block Molt © Lisa S Jacob, DDS, MS 2009
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Mouth Rest Open Wide Mouth Rest- Disposable Reusable Can hold a saliva ejector in place © Lisa S Jacob, DDS, MS 2009
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Positioning Devices ☺ Wheelchair head supports ☺ Bean Bags ☺ Rainbow Airway Positioner © Lisa S Jacob, DDS, MS 2009
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Stay N Place Booster Chair © Lisa S Jacob, DDS, MS 2009
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Rainbow Elbow and Knee Stabilizers Easy to apply and remove “Incremental Relaxation” teaching tool for patients to learn safe behavior © Lisa S Jacob, DDS, MS 2009
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Pedi-Wrap
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NITROUS OXIDE Safe and effective technique to Reduce anxiety Enhance effective communication Rapid onset of action Easily titrated and reversible Rapid recovery Helps with: analgesia, amnesia and gag reflex reduction © Lisa S Jacob, DDS, MS 2009
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CONSCIOUS SEDATION √ Control anxiety √ Minimize psychological trauma √ Maximize potential of amnesia √ Control behavior movement © Lisa S Jacob, DDS, MS 2009
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DENTAL RECORD * Informed consent * Instructions and information * Medical evaluation * Time based record monitoring patient HR, BP, RR, Oxygen saturation * Adverse events * Time and condition of patient at discharge © Lisa S Jacob, DDS, MS 2009
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General Anesthesia * Controlled state of unconsciousness accompanied with a loss of protective reflexes * Provide safe, efficient and effective dental care * Eliminate anxiety * Reduce untoward movement * Aid in treatment of mentally, physically or medically compromised patient © Lisa S Jacob, DDS, MS 2009
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Minimal Intervention * Modern medical approach to the management of oral disease * Early Diagnosis * Change environment * Repair © Lisa S Jacob, DDS, MS 2009
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Early Detection Identify Assess any potential caries risk factors Recognition White spot lesions Gingivitis © Lisa S Jacob, DDS, MS 2009
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Change Environment Prevent Minimize risk factors to prevent caries Rebalance oral environment Remineralize © Lisa S Jacob, DDS, MS 2009
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RESTORE Restore tooth with bioactive materials Preserve tooth structure Repair http:// www.wpclipart.com/tools/hammer/hammer_1.png © Lisa S Jacob, DDS, MS 2009
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Dental Restorative Material Glass Ionomer Glass Ionomer Composite Composite Amalgam Amalgam Resin Crown Resin Crown Stainless steel crown Stainless steel crown © Lisa S Jacob, DDS, MS 2009
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Glass Ionomer Restorations Fluoride release Fluoride release Primary and permanent teeth Primary and permanent teeth Cement stainless steel crowns Cement stainless steel crowns Orthodontic appliances Orthodontic appliances Transitional restorations for caries control Transitional restorations for caries control Tooth isolation Tooth isolation High caries risk High caries risk Base Base © Lisa S Jacob, DDS, MS 2009
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Resin-based composite Excellent restoration in primary and permanent dentition in low caries risk patient May not be ideal for patient at high risk for dental decay May not be ideal for patient at high risk for dental decay Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatric Dentistry. 2002: 24; 480-8. Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatric Dentistry. 2002: 24; 480-8. © Lisa S Jacob, DDS, MS 2009
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Frequency of Radiographs Depends on caries risk of patient ADA/FDA Guidelines © Lisa S Jacob, DDS, MS 2009
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Low Caries Risk Primary and Mixed Dentition Bitewings every 12-24 months Adolescent with permanent dentition Bitewings every 18-36 months Adult Dentate or partially edentulous Bitewings every 24-36 months © Lisa S Jacob, DDS, MS 2009
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High Caries Risk Child and adolescent with permanent dentitions Bitewings should be taken every 6-12 months Adult dentate or Partially Edentulous Bitewings every 6-18 months © Lisa S Jacob, DDS, MS 2009
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Frequency of Recall Exam and Prophys Low Risk: Every year Moderate Risk: Every 6 months High risk: Every 3 months © Lisa S Jacob, DDS, MS 2009
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Frequency of Prophylaxis Depends on caries risk of patient at discretion of practitioner. © Lisa S Jacob, DDS, MS 2009
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Low Caries Risk Goal is to MAINTAIN Recall exam every year Radiographs Every 12-18 months in primary teeth Every 2 years in permanent teeth Continue good diet and oral hygiene Daily use of fluoridated toothpaste © Lisa S Jacob, DDS, MS 2009
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Moderate Caries Risk _ Goal is to REPAIR _ Recall every six months _ Radiographs every 18-24 months _ Fluoride varnish every 6 months _ Daily use of xylitol or fluoride rinse _ Change Behavior by decreasing snacking © Lisa S Jacob, DDS, MS 2009
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High Caries risk Goal is to REPAIR and RESTORE Recall every three months Radiographs every 6-12 months Glass ionomer as an interim material Fluoride varnish every 3 months Chew 5 pieces of xylitol gum every day © Lisa S Jacob, DDS, MS 2009
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High Caries Risk * Counsel on diet * Review oral hygiene instructions © Lisa S Jacob, DDS, MS 2009
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Take Home Messages for Parents Cavities are preventable Caries is an infectious disease Transmitted from parents/caregivers © Lisa S Jacob, DDS, MS 2009
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Suggestions for Practitioners √ Be flexible √ Be flexible √ Be consistent √ Be Compassionate √ PRAISE, PRAISE, PRAISE © Lisa S Jacob, DDS, MS 2009
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Q&A Session © Lisa S Jacob, DDS, MS 2009
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