Pediatric  Dental  Health

• Pain is defined as “an unpleasant sensory and emotional experience.” Pain is also a subjective experience.
• The two types of pain are acute and chronic.
• Acute pain is associated with a brief period of tissue injury (a cut) or inflammation (toothache or dental surgery). The most common type of pain experienced by children is acute pain resulting from illness, injury, or medical/dental procedures.
• Chronic persistent pain describes near-constant pain which continues over three months or longer.
• Suffering occurs when the pain is overwhelming, when the pain leads a child to feel out of control, when the pain is chronic, or when the source of pain is unknown.
  
  CAUSES OF ORAL AND DENTAL PAIN
• Dental procedures and toothaches cause the release of prostaglandins and therefore cause pain. Prostaglandins are potent vasodilators and pro-inflammatory compounds that cause the erythema (redness), pain, and hyperemia (increased blood flow) associated with trauma or oral tissue damage.
• The enzyme cyclooxygenase converts arachidonic acid to prostaglandins and thromboxanes.
• Prostaglandin-synthesis inhibitors (PSI) include acetaminophen (Tylenol), ibuprofen (Motrin), and aspirin. PSI’s reduce pain because they interfere with the function of the enzyme cyclooxygenase.
  
  PHYSIOLOGY OF PAIN PERCEPTION
• The physiologic events that lead to the perception of pain is called “nociception.” Nociceptive pain is what a child detects when there is tissue injury or inflammation.
• Nociception can be divided into four processes:
  (1) transduction, (2) transmission, (3) modulation, and (4) perception.
• Transduction refers to a process in which noxious stimuli are translated into electrical signals at the sensory nerve endings. The nerves endings are called primary afferent nociceptors.
• A-delta nerve fibers are responsible for the sharp, stabbing pain of a toothache. This is also known as first pain.
• C-polymodal nerve fibers give rise to pain described as dull, aching, and poorly localized. This is also known as second pain.
  
  FACTORS WHICH INFLUENCE PAIN PERCEPTION IN CHILDREN
• Pain has emotional, sensory, behavioral, and cognitive components.
• Some of the factors which influence the pain experience in children include:
  Biological factors, psychological factors, cultural factors, temperament, context, previous experience, pain sensitivity, coping skills, cognitive development, and parental anxiety.
  
  PAIN ASSESSMENT AND MEASUREMENT IN CHILDREN
• Pain assessment is the “fifth vital sign,” and is essential for the management of pain in children. The assessment of pain begins with taking a medical history and performing a physical exam to determine the cause of the pain. Treatment should be directed at both the pain as well as the cause of the pain.
• The assessment of pain includes measurement. Pain measurement tools include physiological (heart rate), behavioral, and self-report (pain face scale) measures.
• For neonates, infants, children under 4 years of age, and children with developmental disabilities:
  The primary methods of pain assessment are behavioral observational scales. These scales score limb and body movement, facial expressions, and verbal responses. Facial expression is the most reliable behavioral pain assessment measure for this age group.
• For children three to eight years old:
  Self-reported measures include face scales, which are a series of photographs or drawings of faces showing increased degrees of distress. Remember that toddlers and preschoolers may use words like “hurt” or “owie” to report pain.
• For children eight or more years of age:
  They can generally use the same visual-analog pain scales used by adults. They involve rating the intensity of pain on a horizontal ruler.
  
  OVERVIEW OF MANAGING ORAL AND DENTAL PAIN
• The key to managing pain from medical or dental procedures is anticipation. Effective pain management involves a combination of pharmacologic, psychologic, cognitive-behavioral, and physical treatments.
• Simple measure for dealing with a child in pain include:
  Reassurance, explanation, a calm environment, and gentle handling.
  Cold or hot packs.
  Cognitive-behavioral techniques, such a breathing exercises.
• Oral analgesics and pain medication:
  Oral forms of pain medication are the most common pharmacologic therapy for children in pain. They are suitable for mild to moderate pain. Analgesic treatment should include proper dosing according to: body weight, physiologic situation, and the medical situation.
• Local anesthetics and nerve blocks:
  Local anesthetics are used to stop the conduction of pain impulses through the nerves.
• Conscious sedation:
  The use of sedatives alone during painful procedures does not provide analgesia, but makes a child less able to communicate distress.
• Behavioral and cognitive intervention:
  These techniques are either behavioral (teaching new behaviors), or cognitive ( teaching new thoughts for coping with pain), or a combination or the two.
• Hypnosis:
  This technique involves helping children to focus away from the feared aspects of a medical or dental procedure.
  
  ORAL ANALGESICS AND PAIN MEDICATIONS
• The non-steroidal anti-inflammatory agents (NSAIDs), acetaminophen, salicylates (aspirin), and weak opioids (codeine) are the most commonly used analgesic agents for relieving pain in children.
  According to the World Health Organization (WHO), mild pain can usually be controlled with a non-opioid agent. Moderate pain can usually be controlled with a combination of a non-opioid agent combined with a weak opioid (acetaminophen-codeine combination).
• Acetaminophen (Tylenol):
  This is the most widely used antipyretic (fever reducer) and mild analgesic (pain reliever) for children. Acetaminophen blocks the central production of prostaglandins, thus producing analgesia (pain relief) with no peripheral anti-inflammatory action. Therefore, no adverse affects on platelet function or GI tract occur. Acetaminophen overdose occurs after ingesting as little as 120 mg/kg, and should be treated with NAC (N-acetylcysteine) at a dose of 70 mg/kg every 4 hours, as early as possible.
• Ibuprofen (Motrin):
  This and other NSAIDs (Non-Steroidal Anti-inflammatory Drugs) block the central as well as the peripheral production of prostaglandins – resulting in analgesia as well as anti-inflammatory effects. NSAIDs block the cyclooxygenase enzymes: COX-1 and COX-2.
  COX-1 helps synthesize the prostaglandins that protect the gastric mucosa, and help synthesize the thromboxanes that initiate platelet aggregation ( part of blood clotting).
  COX-2 leads to the synthesis of the prostaglandins that promote inflammation, which is undesirable.
  The NSAIDS and salicylates should be avoided in patients who have: asthma, bleeding disorders, gastric ulcers, or surgical bleeding.
• Aspirin use in children has declined since the 1970’s after reports of its association with Reye’s hepatic encephalopathy (Reye’s syndrome).
• When acetaminophen or ibuprofen provide insufficient analgesia, a weak opioid (codeine) may be added to the analgesic. Weak opioids provide analgesia through interaction with the mu opioid receptor in the CNS.
• Most of the commonly used opioids, including codeine, activate the mu1 receptor, which is responsible for analgesia. Activation of the mu2 receptor leads to the undesired effects of: respiratory depression, sedation, constipation, nausea, and vomiting. Opioids depress the ventilation rate by depressing the response of the brain to carbon dioxide.
• One of the causes of opioid-induced pruritis (itching) is histamine release. In severe cases an antihistamine can be administered. Diphenhydramine (Benadryl) is given at a dose of 0.5 mg/kg for pruritis.
• Opioids, such as codeine and meperidine, are contraindicated in children who:
  have acute or chronic respiratory disease, asthma, seizures, or who have been taking MAO inhibitors within the last 14 days.
• Codeine:
  Approximately 10% of the codeine is metabolized into morphine, and this 10% is responsible for all of the analgesic effects of codeine. The analgesic effect of codeine results from its direct agonistic properties at the mu opioid receptor.
• If codeine provides insufficient analgesia, the next opioid to consider using is oxycodone. Oxycodone causes less nauseau and vomiting than codeine. Percocet contains both oxycodone and acetaminophen.
  
  HOW TO PRESCRIBE ORAL ANALGESICS FOR CHILDREN
• Acetaminophen (Tylenol):
  10-15 mg/kg every 4-6 hours.
  The children’s elixer has an acetaminophen concentration of 160mg/5ml(teaspoon).
• Ibuprofen (Motrin):
  10 mg/kg every 6 hours.
  The children’s suspension has an ibuprofen concentration of 100mg/5ml.
• Codeine:
  0.5 – 1.0 mg/kg every 4 hours.
  Acetaminophen with codeine elixer is available with 120 mg acetaminophen and 12 mg codeine per 5 ml(teaspoon).
  A tablet preparation is available which contains 325 mg acetaminophen with 30 mg of codeine (Tylenol #3).
• "Magic mouthwash":
  50-50 mixture of Maalox with diphenhydramine. This mixture is swished in the mouth every 4 hours, as needed, to control the discomfort of stomatitis or ulcerative lesions. For younger children, it may be applied with a cotton-tipped swab.
  
  LOCAL ANESTHETICS AND NERVE BLOCKS IN CHILDREN
• Children should have a comfortable experience when going to the dentist. Local anesthetics are an important tool for the control of pain and discomfort during dental treatment. Anesthetics prevent the production and propagation of nerve signals.
• Techniques used to decrease pain during an intraoral injection include: using a topical anesthetic (benzocaine) before giving an injection, using a higher-gauge (thinner) needle, distracting the child by encouraging deep breathing, and by shaking the lip during the injection.
• An imperfect injection technique is the most common cause of problems in getting a child numb. Another common cause of problems is that local anesthetics do not work well in an acidic environment - such as an inflamed or abscessed area. It is therefore sometimes useful to control a dental infection with antibiotics before a local anesthetic can be successfully used.
• An important requirement for administering a local anesthetic is for the dentist to be familiar with the manner in which the teeth are innervated. The dentist should use the smallest possible dose which achieves adequate anesthesia. The maximum dose for lidocaine injection in children is 4.5 mg/kg per appointment when children are sedated.
• Local anesthetics have a low margin of safety between the effective dose and the toxic dose. The lethal dose for many local anesthetics is only 3 times that of the effective dose. Deaths following local anesthetic administration are almost always a result of overdose. Since the 1960’s, dentists have begun using an aspirating syringe, which has a small internal harpoon that engages the rubber stopper of the local anesthetic carpule. This technique enables dentists to aspirate for blood, and see if the needle has inadvertently entered a blood vessel – before injecting the anesthetic solution.
• Bupivicaine (Marcaine) is an amide local anesthetic with a high toxic potential, and should not be used in children. The duration of anesthesia with bupivicaine can be as long as 24 hours.
• Deaths following local anesthetic administration are almost always the result of an overdose. For example: a 35 lb child should never receive more than 2 carpules of 2% lidocaine during a dental appointment.
• The most common cause of a true allergic reaction to a local anesthetic is sensitivity to the preservative in the anesthetic solution. Bisulfites are widely-used preservatives, and may be the offending agents in a true allergy to local anesthetic.
  
  CONSCIOUS SEDATION FOR CHILDREN
• Some of the drugs used in pediatric conscious sedation include meperidine, chloral hydrate, midazolam, and ketamine.
• The oral route is the oldest of all routes of drug administration, and still the most commonly used. It is a useful method for managing uncooperative or fearful children who need dental treatment. The oral route offers some advantages over other routes, including decreased incidence of adverse reactions, lower cost, and ease of administration. The disadvantages of the oral route include prolonged onset time, prolonged duration of action, and erratic absorption from the GI tract. Most orally administered drugs demonstrate the highest blood levels at approximately 60 minutes after ingestion. The absorption of a drug from the GI tract is affected by its lipid solubility, the pH of the gastric juice, slow gastric emptying time, inactivation of the drug by the liver, and drug bioavailability.
• Oral Demerol and Vistaril:
  Demerol (meperidine) is an opioid with a useful sedative side-effect. The child needs to be NPO for 6 hours to prevent emesis or aspiration. Contraindications to Demerol use include: asthma, seizures, chronic or acute respiratory disease, or MAO inhibitor use within the last 14 days.
  Mild respiratory depression can be managed by repeatedly waking the patient and encouraging deep breathing. In urgent situations, assisted ventilation or an injection of naloxone (Narcan) at 0.01 mg/kg may be needed.
  Oral Demerol is administered at a dose of 5.0 mg/kg. Sedative effects are obvious after 45 to 75 minutes
  Vistaril is an effective anti-emetic and is always given when Demerol is used. The usual dose is 25 mg per appointment.
• Nasal Versed:
  This is a relatively safe drug to use for sedation, as long as the dose is appropriate for the child’s weight. The child needs to be NPO for 6 hours to prevent emesis or aspiration. It is administered nasally at a dose of 0.2 mg/kg. Sedative effects are obvious after 20 minutes. This dose may be repeated once per sedation visit.
  
  BEHAVIORAL AND COGNITIVE INTERVENTION
• Behavioral techniques include: desensitization, positive reinforcement, and relaxation.
  Desensitization involves gradually increasing exposure to the feared stimulus (the treatment room, the needle), while maintaining anxiety at low levels. This technique requires a great deal of time before it can be successful, however.
  Positive reinforcement involves rewarding a child for any positive behavior, or even for just coping with the procedure. Rewards include praise, small toys, or stickers.
  Relaxation training teaches children to engage in progressive relaxation of muscle groups, or teaches controlled breathing.
• Cognitive interventions include:
  Preparation (tell-show-do), memory change, and hypnosis.
  Preparation involves providing children with procedural and sensory information about the next procedure. Procedural information describes each step of the procedure. Sensory information includes descriptions of sensations that a child will experience.
• Combined behavioral and cognitive interventions include:
  Distraction and modeling/rehearsal.
  Distractions include: singing, visual distractions, or shaking the lip during administration of a dental local anesthetic. Distraction is more effective in infants and young children than older children.
  Modeling and rehearsal involves having an adult or other child demonstrate positive coping behaviors. In small children, for example, a doll can model holding still during a procedure.
  
  HYPNOSIS FOR PAIN MANAGEMENT
• Hypnosis is useful in calming frightened children and helping them to tolerate painful procedures. Hypnosis uses suggestion to potentiate therapeutic action. Suggestion can be delivered verbally, but can also be embedded in voice tone, facial expression, and what is not said. A good hypnotist demonstrates deftness in the use of language, voice tone, pacing, and knowledge of human motivations and anxieties
• The primary goals of hypnotherapy are to:
  Capture the child’s trust and attention, reduce distress, reframe pain and distress into something positive, and help the child dissociate from the pain by using positive suggestion.
• Most hypnotic interventions use the natural hypnoidal state of a child in the emergency room (heightened focus, dependency, constricted perception), and redirect it.
• The hypnotic process involves three stages:
  1) Induction. Helping the child dissociate from the environment and helping him/her become increasingly involved in an imagined fantasy.
  2) Deepening. Increasing the dissociation from the pain.
  3) Suggestion. Verbally suggesting that the child imagine and find a favorite place that is safe.
• Characteristics of hypnosis intervention include:
  1) Place an anchoring hand on the shoulder, arm, or forehead of the patient.
  2) Use a calm but direct voice.
  3) Pace the rate of speech to the patient’s breathing while gradually slowing down.
  4) Use positive suggestions.
• Hypnotic analgesia appears to be regulated by active inhibitory control of incoming stimuli at the cortical level of the brain.
  
  An article in the Journal of the Canadian Dental Association provides a brief review of the role of acetaminophen, non-steroidal anti-inflammatory drugs, and opioids in the management of acute postoperative pain. It also explains the interplay between analgesics and cyclooxygenase enzymes in the controlling pain.
  
  Haas DA: An update on analgesics for the management of acute postoperative dental pain. Journal of the Canadian Dental Association. September 2002; 68(8): 476-482
  
  
  

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