Friday, May 26, 2006

Hospital Pediatric Dentistry

It is sometimes necessary to complete dental treatment on children using general anesthesia. This is especially true when the child is very young and has a large amount of treatment. We also use general anesthesia for older patients who have a hard time cooperating in the normal dental setting. We do not do this on a whim. Often, treatment is first attempted in an office setting with or without sedative medications. However, if there is a lot of work to be done, the hospital is often the best way to safely accomplish treatment.



Every day, I see young children with what is called "baby bottle syndrome". Basically, this is rampant decay on the teeth of a preschooler. According to the American Academy of Pediatric Dentistry and the American Academy of Pediatrics, parents should wean their children off of nighttime baby bottle or ad-lib breast-feeding after one year of age. The key here is no bottle during the night or right before they go to sleep. Yes, I know it's harder to say than to do. Children do not need to be fed during the night once they are over one year of age. Now, water is just fine at night, just not milk, formula, or juices. Having said that, caries is caused by bacteria. There are many risk factors, some of which we can control and some we cannot. We can't control salivary flow, immune response, etc. That's one reason some kids have such severe problems at such a young age.

Here is a short video of a hospital case. There is a lot on this video I did not show. I tried to be the cameraman and the actor. I set up things so you could see better what was going on. This is an actual patient (whose parents did give written consent. See here for Disclaimer and consent issues. His/her identity is not shown). I know there are dentists who do things a little differently and I was a little hesitant to post this. Just take it for what it is and I hope you learn something. I have to say I sounded a little different on this video as I am wearing a mask most of the time.

Another perspective from a Pediatric Dentistry Resident on: The Operating Room

42 comments:

Sue G said...

My 5 year old daughter has been scheduled for 8 stainless steel crowns under general anesthesia. My Pediatric dentist has referred me to the Pediatric School of Dentistry at UNC Chapel Hill in NC. I am worried about getting the work done in a training environment??? Is this a good idea? We are doing it for financial reasons since there is so much work to do and my daughter will not do it voluntarily! Is there anywhere I can see some photos of what her mouth will look like after this procedure?? I am
scared to death about her being being sedated..........they said it may be about 3 hours long??
Many thanks for any info you can offer.

Dr. Dean Brandon said...

see my other posts on these subjects. As far as UNC they have a great pediatric dentistry program. School environments do good work it's just sometimes more inconveinent--longer appointments etc. Good luck.

Anonymous said...

Thanks for the video. I would love to see the after shot. My daugther is almost 3 and just had 6 crowns (4 top front + 2 back), 4 fillings, and 1 pulpotomy done at Scottish Rite hospital in Atlanta yesterday. She is doing well. I'm a bit emotional about her front four NuSmile crowns. They're not placed as perfectly as I would expect. Her left lateral seems to be longer than the other 3. I don't want to put her through anything else, but shouldn't they have been placed the crowns perfectly and evenly across the front? What are my options?

Dr. Dean Brandon said...

Nusmile are usually used if there is not much tooth left to hang on to. Any front tooth crown is difficult to place. You might address your concern with the dentist, but I suspect they will suggest waiting till she is old enough to cooperate in the dental office setting --they might be able to make some adjustments then, but with those crowns it is not easy.

Rajeswari said...

Hi Doc,

My 3 year old son was having 4 stainless steel crowns and 4 upper front teeth caps under General Anesthesia!!!His upper right front tooth got chipped out when he played with older kid in a BirthDay Party!!So one tooth got chipped out and some portions were left.The nerve came out and it was pink in colour.So the pediatric dentist has suggested the procedure under GA.But as a parent it was a very stressful time!!!But everything went smooth and work hasd done.But is there anyway other than GA,for the non cooperating kids.In my sons case he was having 8 cavities.So they have suggested GA.We are not stressed about the dental procedure.Only GA gaves us stressful time and is there any side effects of GA,when they become big kid??

Thanks

Dr. Dean Brandon said...

I just did two general anesthesia cases yesterday. There are always risks, including the risk of doing nothing. For a preschooler with extensive treatment needs, GA is often the best option. Consult your dentist. Also read my posts on sedation.

Rajeswari said...

Doc,

Thanks for the reply.Your blog is very interesting and what is the procedure for giving sedation for toddlers in Wisconsin state(Is it a deep sedation or consious sedation??)I read in your blog somewhere each state the procedure is diferent!!!

Dr. Dean Brandon said...

Every state is different, but most Drs. I speak with either do conscious sedation in the office, or general anesthesia in the hospital. Deep sedation is so close to general anesthesia that it usually requires different protocols and procedures and regulations that it is often better to go to the OR--I do not know about Wisconsin.

Rajeswari said...

My son had dental surgery on May 1 2009 under Oral liquid,Mask and sedation through IV.After the procedure he was so cranky and we cant control him and crying for 45 minutes and yesterday nothing happened.But today(May 4th 2009) after afternoon nap he gotup and very cranky and cried and rolled in floor and cried!!We are really worried!!Is it a normal thing after procedure!!!How long usually takes for him to recover??He is eating and drinking good!!!We called the dentist office.May he willreturn call tomorrow!!

Thanks

Dr. Dean Brandon said...

I always have a followup visit after a few days after an OR case.. Most medications wear off the first day.

Rajeswari said...

Doc,

This is about my 3 year old son who had dental surgery under GA.This is 3rd time he was having nightmare and cranky,disoriented,cried for one and half an hour.We went to the dentist for post-op checkup.Regarding teeth no problem at all.No pain.Everything looks fine.Even we spoke to anasthesiologist.He said that my son was not under conscious sedation,he was under full sleep.So it was not a problem with anesthesia.So it is not the problem with the dentist or anesthesia,where is the problem arise.We are really stressed out!!!And also the Dr who gave anesthesia told that it will fadeaway within 2 weeks after the procedure!!!But we know that he is not having pain with his teeth!!For pain relief they gave tylenol with morphine in hospital.So is it because of that??
We are not into medical field so we dont know anything.It is really stressful!!

Dr. Dean Brandon said...

Sorry to hear of your difficulties. All I can say is that almost all the kids I see int he OR (general anesthesia) are doing quite well after a few days.

Anonymous said...

Dr. Brandon -

My 2 year old daughter is scheduled for 4 crowns (under general anesthesia) in 2 weeks. I am of course apprehensive about her going to sleep. Is there a rule of thumb where the child is too young for this?

Also, the anesthesia group the hospital utilizes are not 'pediatric' anesthesiologists. Do you forsee a problem in this?

Dr. Dean Brandon said...

I have 2 year olds under general anesthesia at the hospital frequently. I have had a few one year olds, but I do not like to treat one year olds in the hospital unless certain parameters are met, plus there are just not many that young that need work.

Of course address your concerns to your dentist and also. if you can the anesthesiologist if you have specific anesthesia concerns.

Anonymous said...

My 3 years old son has 4 cavity. 2 with the front molar and looks small. And 2 cavity with the lower bottom molar. The pediatric dentist I went to told me the cavity is not too big, so filling should be fine. so the filling was done,but 2 months later, all filling came off and my son had a dental access with fever of 105 and he was admitted to children's hospital for 4 days for dental abscess due to the filling that was done to the bottom molar. The hospital dentist had to extract the bottom molar tooth #L for this emergency case. After release from the hospital, I took him to another pediatric dentist to get the other molar fill to prevent further complication. The dentist put a temporary filling to it. After 1 month, my son is having a lot of pain with that tooth that was filled. I went back to the dentist worry my son may had another dental abscess, the dentist told me it is a pattern of my son have dental abscess after filling, he recommends to have the tooth extracted to avoid future complication. The dentist had never took any X-ray from the beginning when the cavity is filled. He said my son is not cooperative, so he can not take any X-ray. He didn't even try. He said it is not an option to save the tooth when he is not cooperative. The only option is to extract it. I do not want to have the tooth extract again because he is only 3 years old. I feel like both incidents of dental abscess are the careless of both dentists. Is there any other option beside to extract the tooth before any X-ray is taken. By the way, there is no sign of abscess can be seen at this point except my son complaints pain when chewing on that side. Please give me some advise. Should I have him seen in hospital for treatment? Thank you.

Dr. Dean Brandon said...

Most 3 year olds cannot do the kind of x-rays that might show decay between the back teeth--some can, but most cannot. I have seen cases where a reletively small restoration (due to a small cavity) will later on abscess. Usually, however, if the decay is deep, we do a pulpotomy and a crown-reduces the chance of an abscess. Still, if the cavity is small, I do a filling. Age and cooperation seem to be a factor for you here in addition to the possibility that he may be prone to abscesses. You might ask about options other than the hospital like sedation. I however, cannot speak to the appropriatness of any treatment. Oh, if a baby molar is really abscessed, I remove it. Doesn't have to be in the hospital just for that most of the time. Sounds like it needs some followup.

MarjieGann said...

My 6 year old has an autism spectrum disorder and some pretty extreme anxiety about procedures done in and around his head, like having his hair cut, temperature taken, teeth brushed, etc. I recently took him to a dentist because I can see he has a cavity in one of his molars. The hole is in the side, between his teeth, rather than in the top. The dentist is going to use G.A. (which I expected, given my son's temperment) to do a root canal, which I didn't expect. Why would a root canal be more appropriate than a filling? My son has Medicaid; might this have affected the dentist's choice?

Thanks in advance. Marjie

Dr. Dean Brandon said...

The rerm "root canal" in this case is probably slang and probably means something like a pulpotomy which is quite common and not unexpected in kids teeth.
What is a Pulpotomy?

Anonymous said...

My son is 3.5 and just underwent work under GA. He was supposed to get 8 crowns and his 4 front teeth pulled, but the dentist pulled 11 teeth including all his molars! We can't go back and change what happened, but is there a way to give my son some of his chewing surfaces back by getting a denture or something? I was shocked and appalled that this was done without my concent, but just want my little boy to be okay.

Dr. Dean Brandon said...

Sometimes the decay is so severe in baby teeth that removal is the best course of action. Most kids I have seen do quite well eating even with several missing teeth. In fact ,without all that decay/infection present , they actually eat better and gain weight mor rapidly--at least that is my experience.

I have only done a variation on a complete "kiddie denture" one time--on a child in my residency 20 years ago. This was when his six year molars were erupting and it was used as a short term guide for proper eruption of the new teeth.

Janette said...

Hi doctor - great blog, thank you. My 4-1/2 yr old is scheduled this month for OR treatment of 12 teeth with cavities. She is a spirited child and, no surprise, was uncooperative in the office chair/gas, hence the GA. Work is being done by a pediatric dentist at hospital surgery center. 4 pulpotomies/crowns on molars, crowns on 2 top front, and a variety of other fillings. Combined price of $7500 (no insurance). We want to do this only once. What questions should I be asking the anesthesiologist and dentist regarding 1) the anesthesia, and 2) how the work will look/hold up. What materials take best for the 2 front top crowns? Cavities in those 2 teeth are small and on the back side at gumline, so there is likely a good amount of tooth available to work with. Obviously I want the teeth to look nice as well as be healthy. Reading your blog has enlightened me on topics I hadn't considered, such as the possibility of many more teeth pulled than planned, unattractive results, etc. What are common pitfalls of which parents should be aware before the work begins? Thanks again.

Dr. Dean Brandon said...

Well, looks like you have thought of a lot of things already. The key is to communicate with your doctor. Also, make sure your expectations are reasonable.

As far as doing this only once--yes, most of my cases I only have to do once, but these kids with early decay are at risk. They often have further decay but it tends to be more manageable as the kids are older and the OR case is not needed by that time. Increased preventive strategies, and regular visits to catch things early are a must.

If you had a house that a hurricane damaged, there would be an extensive amount of work to do. Once finished, you can't leave the doors open letting in the rain. Routine maintenance and the occasional repair is usually needed...don't know if that's a good analogy, but.....Good Luck.

Anonymous said...

We just took my 3 year old to the dentist for the first time. They took x-rays and said that he has surface cavities on all 4 of his top front teeth. They want to put caps on while they use gas to sedate him. This hit me like a ton of bricks and at the time I was speechless. Well, now I have questions and there office is closed. Is this totally necessary? Why can't they just do fillings. He did amazing in the chair but I really don't want to put him trough this if we don't have to. Are there any other options besides capping them or pulling them? Thanks

Dr. Dean Brandon said...

Sounds like you need to discuss this issue further with your dentist. Decay is a disease process. The "fix" varies depending on the severity, location, depth of decay, the age of the patient, and many other things. Please feel free to read here on the blog as there is a whole lot addressing your concerns. There are posts (and comments) on crowns, fillings, sedation, general anesthesia, why fix teeth, behavior management, etc. Good luck. I think the more information you have the better you well feel about any decision you make.

Cara Ng said...

Thank you for your informative blogs/videos. It is greatly appreciated.

I have a 5yr son who made his first trip to the dentist last week. The dentist, here in Hong Kong, has suggested we do the work that needs to be done under GA. She was not able to get a proper xray as he was gagging on the films put between his teeth. Without the xray, we have found that he has 9 cavities. He will need 7 fillings and one pulpotomy with crown. She has suggested not filling the top two cavities as his teeth will fall out soon enough and the decay isn't too bad yet. He was excellent in the chair and was a model patient, but he does have some anxiety going into the office and that coupled with a terrible gag reflex has contributed to her GA suggestion.
Doing this in Hong Kong would cost around $5000USD and is just not feasible for us. However, I have been researching getting it done in the Philippines, where the cost could be reduced to 1/4 of the HK cost. I would ONLY go to an "international hospital" to have it done.

My question is: how should I be deciding if sedation or GA is the way to go? That is my biggest problem. I don't necessarily have a problem with GA if I know it will be the fastest, safest, and easiest way to get all of the work done. I'm not really sure if it's a good idea for him to be awake and under sedation during the 2.5-3 hours they say it will take to do the work or if GA is the best choice.

Any insights on how to choose whether to use GA or sedation?
Thank you!

Dr. Dean Brandon said...

As written here and other places in this blog, I do general anesthesia cases every month and sedation cases every day. If there is enough work that would require multiple sedation appointments (you can only do so much at a time), then GA often seems the better option. It's hard to say. I will say, it's usually easier to sedate a slightly older child than a very young child (2-3) because the meds seem to work more predictably. By the way there are good Pediatric Dentists in the Philippines (I am sure Hong Kong too), but I actually went to school in my residency with a super great lady from Manila. I think she practices there now, maybe in Manila or Makati. Her name is Dr. Marirose Ramirez. If you see her say hi for me. Good luck.

Dr. Dean Brandon said...

To answer, often GA is an excellent way to go for treatment needs if indicated. You have to decide in conjunction with your pediatric dentist what is best.

Our Family said...

My son is scheduled to go in to have his two bottom teeth removed next week. He was born with them and as a result of them not having enough enamel they have discentagrated and all that is left are the root it looks like. He is only 14 months old and the reason he is going to have them removed is because the dentist doesn't want an infection to occur. I agree with this but do you think he is too young at 14 months to go under GA for this and maybe we should wait until he is 2 or could an infection occur if we wait?

Dr. Dean Brandon said...

The medical safety of general anesthesia should be discussed with your pediatrician and pediatric dentist (or oral surgeon) or even the anesthesiologist. Most of the time, if it's elective, I wait till they are 18 months old or older. I do not have a hard and fast rule, however. Depends on the risk of problems with the teeth-that is a judgement call. Many children undergo general anesthesia at young ages.

Joel said...

My 2 1/2 year old daughter saw the Ped Dentist for the first time today - didn't go well emotionally or physically. Her back molars are yellow and brown with decay, particularly the bottoms. They suggest GA and capping them at Children's Hospital, Bham. When she turned 2 she suffered from Osteomylitis in her spine and was on STRONG antibiotics. Do you think those might have caused decay? Also, she has MAJOR egg, milk, nut & shellfish allergies. We dealt with these allergy issues and GA with her prior illness but wasn't sure about the dental side of things. I am terrified; This is bringing back some scary moments we encountered before.

Dr. Dean Brandon said...

As you may read here on the blog, cavities, are caused by a bacteria. Sometimes teeth do not form properly called hypoplasia which could be caused by developmental disturbances (for baby molars that is before birth or just after), however, I see hypoplasia and cavities all the time with no heath history problems. So, trying to pinpoint a cause is quite difficult if not impossible. Just because they have hypoplasia (kind of a yellow color or malformed), does not mean they will get cavities. If they begin to break down or do get cavities, restorations are usually indicated, and thus where you seem to be today. I see 2 year olds with decay every day. Please feel free to read more here on the blog about all these topics. If a pediatric dentist thought treatment in a hospital setting was the best way, he is probably right. I know a few of the pediatric dentists down there in B'ham, and you will do well at Children's.

Anonymous said...

Hi. My 15 month old is going to be scheduled to have his 4 front teeth capped under general anesthesia. He had enamel deformities and there has been decay. Can you tell me how the risks compare between a 1 year old and an older child? He is bigger, 25 lbs. I am still concerned about the risks.

Thank you.

Dr. Dean Brandon said...

The medical considerations for general anesthesia is ultimately up to physicians, specifically the anesthesiologist. In general, health children face less anesthesia risks than children with multiple health problems such as heart disease, thyroid problems or other such conditions. There is no cut and dry answer as far as age or weight. There is also the consideration of alternatives. What are the consequences of no treatment?--infection, worsening decay and pain? If general anesthesia is not chosen, is "conscious sedation" in the dentla office an option, or would that pose more risks under less controlled circumstances? These questions would be discussed with the dentist and the child's physician and the anesthesiologist.

Anonymous said...

my child is 2 and has to have all 4 upper front teeth crowned, my options are versed in the office or done in the hospital while put to sleep...which is safer, he is a very strongwilled child and fought the dentist.

He had iv sedation for a mri with a drug called profonol? he seemed to have done great is this what they use when doing the work at vthe hospital?
I am very nervous i have heard bad things about the versed for children that already are strongwilled.

Dr. Dean Brandon said...

They use a number of drugs/gases in the hospital setting. Some like Forane or Halothane are gases. These are general anesthetics. The anesthesiologist decides which to use int he hospital. Medications used for in office sedation are not used as general anesthetics. Versed is one of those drugs which can help in some cases. You can read my thought s on these medications in my posts and here on my post on Sedative Drugs used in pediatric dentistry

Generally, most two year old's need to be in the hospital if it's more than just a simple procedure. Not always though. Versed is usually used for short procedures.

Brittany Powell said...

Dr. Dean,
My four year old son is getting four NuSmile crowns on his front teeth in two days. The dentist doing the procedure has not fully explained to me how the procedure works. Thanks so much for the video and showing step by step what will happen. Also what should I expect after? Will there be a certain diet change? How long would he be uncomfortable? I am sorry for asking so much, but I cannot find any good information other than on your blogs.
Thank you.

Brittany Powell said...

Dr. Dean Brandon,
My four year old son is having four Nusmile crowns put on Wednesday. First, I would like to thank you for posting a step by step video of what will be happening during the operation. I was wanting to know though, what should I expect after? Will there be a certain diet? How long should I expect him to be in discomfort?
Thank you in advance.

Dr. Dean Brandon said...

Most kids do very well after most dental treatment--now in this post the child is under general anesthesia--and they usually have more minor concerns like a sore throat with that rather than the dentistry. Also nusmile crowns are stainless steel with white on the front. see my post on white crowns for baby teeth.

Maria said...

Dr.Brandon, I'm so thankful for finding your blog. My son is 3yrs and 5mos tomorrow. When he was 20mos old he had his 2front teeth capped the 2 on.each side of the front ones pulled. He also had 2 fillings. 8mos after one of his caps had to be rebonded on the back of the front tooth. Here we are again with the same issue on that same cap. Except now it is worst. I took him back to the dentist on Monday and she said yeap it has to be replaced. :( From day one we saw that there was an indention on the back of that crown and looked black quite the opposite of the tooth/cap right beside it.

My son also has 3 new cavities which I'm very sad and surprised to hear. Since he is not a juice drinker and we brush regularly. Clearly something is going on though and it saddens us deeply. :( The problem is the dentist can not do the GA procedure till September 18th. I found another dentist who can do the procedure sooner but it would be at their office with a anesthesiologist present. My son is not cooperative at all. It took 3nurses and me just to do the.check up. He gets so scared as soon as we drive up to the office.

1. Should his cap be deteriorating like that so quickly?

2. CWhy can't they just temporary apply some bonding on it like they did 10mos ago? Until they can get to it on Sept 18th.

3. Should I get a second opinion and would it be safe for my scared 3yr old to have an in office procedure?

PS his first procedure was done at an outpatient surgical facility and that is where it would be done on September 18th.

Patiently awaiting your reply.... Thank you kindly

Dr. Dean Brandon said...

Maria, thanks for asking, but I cannot really tell you what is going on if they are not my patient, I have not done exam, etc. Plus there is a lot of detailed complex questions there.

I will say in general fillings and crowns in baby teeth take a beating. The best "crowns' for baby teeth are stainless steel silver crowns, they hold up better--of course if they are in the front - not too many people want that--so, we do white crowns which arebetter looking but weaker, more fragile--read my posts on white crowns for baby teeth, etc. There is also the fact of why did he get so many cavities so young? Obviously, he is quite prone as many that age are. Fillings can break down easily if there is new decay.

As far as anesthesia, we do cases in the hospital, but some pediatric dentists do them in the office with an anesthesiologist or CRNA. Again, a very complex situation. Many pediatric dentists are very very busy and their services are in great demand. A long wait for specialized treatment is not uncommon. Good Luck! and don't feel sad--I know it's a lot to have to deal with but he will be fine.

Jillian Ortner said...

Doc,
My son is 2, he needs two cavities fixed on his front top two teeth. His dentist plans on sealing his molars while he's under. His appointment is in two weeks. His H&P is in a week. I've talked to his pediatrician, briefly. She thinks GA is a bit extreme in his case. Also, he's a tiny guy, 5% body fat. He gets blue lips and limbs if we are at the pool longer than about an hour. I don't know what effects anesthesia could have on him. Can't we just get his teeth filled regularly, and seal his molars later? (only two of his 2yr molars are in anyway, so he'd have to do it in his office at a later date anyway). I'm beyond scared I'm petrified. (I'm a combat vet, and I've never need more frightened...). Would I be a horrible mother if I made them go about this a different way?

Dr. Dean Brandon said...

Jillian,
I pray everything goes well no matter the situation. I rely on a child's physician and the anesthesiologist whether a child is ready for general anesthesia. Of course there are common sense things like if they have a bad chest cold, no we cancel and reschedule when they are better. I might suggest asking to have an assessment by the anesthesiologist who will be doing the case (sometimes it is a group of docs and they don't even know specifically who would be doing the case till that day, but you can ask if one of them would do the pre op physical and answer more questions about your child's specific health conditions.) They look anyways right before surgery.

One option is to do work in the office, but that relies on a child being cooperative. I mean he does not fight or resist lying down for an examination, and would not likely cry getting a cleaning. Most 2 year olds do neither, that is they put up some resistance for the most basic of things, so doing surgical operative dentistry (fillings etc,) that is often asking too much of a small child, and asking too much of the dentist and staff. Basically, sometimes you just can't do the treatment safely or comfortably. In office sedative drugs on young children often do not work well as you would like and cary medical risks as well.
That leaves few other choices, basically waiting till he is older and more cooperative. Of course decay gets worse with time too. Most kids who are 4 years old are usually cooperative enough to do routine treatment int he office setting with or without sedation. Read more on the blog here about behavior and sedation if you are interested.
I cannot tell you what is best--Ultimately things like this are a combination decision between the parent, pediatric dentist and the physicians.