DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
Penicillin VK remains the empiric antibiotic of choice for the treatment of odontogenic infections [37]. It is effective against the gram-positive anaerobes commonly associated with these infections. Amoxicillin-clavulanate, a derivative of penicillin VK, is absorbed more rapidly and is more effective against gram-negative bacteria [38; 75]. Both medications are available in suspension formulations, with amoxicillin also available as a chewable tablet. Clindamycin is the alternative antibiotic of choice when a patient is allergic to penicillin VK or amoxicil- lin, but the development of pseudomembranous colitis is a potential risk when this agent is used. Consultation with the patient’s pediatrician is recommended prior to prescribing this medication. Cephalosporins should be considered, par- ticularly if the patient has had a previous course of penicillin or amoxicillin [37]. LOCAL ANESTHETICS Adequate pain control during restorative or surgical procedures is essential for patient comfort and for the ability to complete the procedure. Many adults have fears or phobias about dental treatment that originate from the pain they experienced dur- ing a childhood dental procedure during which pain control was inadequate. Therefore, prevention of pain should be an utmost concern. Supraperiosteal infiltration with a local anesthetic provides successful anesthesia for maxillary deciduous and permanent teeth. This technique is also successful for all mandibular deciduous teeth but decreases for mandibular molars, as bone density increases with age. An inferior alveolar nerve block (IANB) may be required to provide successful anesthesia for the deciduous mandibular molars in older children and will be required to successfully anesthetize permanent molars. The mandibular bicuspids may be anesthetized by an IANB or by infiltration of the mental nerve. A topical anesthetic such as benzocaine (available in concen- trations up to 20%) can be applied to the mucosa prior to the injection. The minimum required amount is placed on a cotton tip applicator, which is then spread on the isolated and dry mucosa. A staff member should remain with the patient to maintain isolation of the area and minimize swallowing of the topical anesthetic, which can cause nausea in some patients. As with all medications, the choice of local anesthetic for a pediatric patient must consider the age, weight, medical his- tory, and type and duration of the planned procedure. The margin of safety will be less in smaller, younger children. One can ascertain the safe limit for a pediatric patient by determin- ing the dose (in mg) of a given local anesthetic per kilogram of body weight (mg/kg), which will establish the maximum cumulative dose per appointment. If the maximum dose of lidocaine is 4.5 mg/kg for an entire appointment, a child who weighs approximately 16 kg should not receive more than two carpules of 2% lidocaine per appointment [39]. This is only a guide, as other factors (e.g., hepatic or renal impairment) can decrease a patient’s ability to metabolize or excrete a local anesthetic.
Other local anesthetics, such as mepivacaine, prilocaine, and articaine, have established guidelines for the maximum allowable dose per appointment, also expressed as mg/kg. In general, the younger the age and the lower the weight of the pediatric patient, the lower the maximum allowable dose of local anesthetic. Clinicians should begin with these guidelines and use less if the medical history dictates or if a minimal amount of treatment is required. The vasoconstrictor epinephrine is added to local anesthetics to prolong the duration of anesthesia and to aid in hemosta- sis in surgical cases. Preservatives such as sodium bisulfite or sodium metabisulfite are also added to local anesthetics that contain epinephrine in order to prolong their shelf life. Patients with allergies to sulfite compounds could develop an allergic reaction if a local anesthetic with epinephrine is used. For these patients, alternative anesthetics, such as mepivacaine plain, are reasonable alternatives. The use of local anesthetics carries with it the responsibility of heightened safety. Before any local anesthetic is used, the dentist and staff should be fully trained in cardiopulmonary resuscitation for pediatric patients. Equipment and medica- tions necessary in the event of a medical emergency should be easily accessible and all staff members should be trained in their appropriate use. Periodic emergency drills will define the role each staff member should assume during a medical emergency. Clinicians who infrequently use local anesthetics for pediatric patients should be cognizant of the differences in the safe maximum allowable dose of a given anesthetic among different patient populations.
ORAL AND MAXILLOFACIAL LESIONS
HERPES SIMPLEX Several systemic diseases that affect children and adolescents can present with oral and facial lesions. But the most common cause of oral ulcerations in children is an initial infection with herpes simplex virus-1 (HSV-1). Primary herpetic gingivosto- matitis (PHG) usually occurs after 6 months of age and has the highest incidence between 12 and 18 months of age [16]. In children with PHG, the gingival tissues appear red and edematous, with small vesicular lesions and ulcerations on the oral mucosa. Patients will have pain, malaise, and headache and may be febrile. Liquid nutritional supplements and a soft, bland diet may be necessary during this period. Healing occurs spontaneously within 7 to 14 days with no residual scarring from the herpetic lesions. Although this initial attack will resolve, it is not cured. The virus will migrate to a regional nerve ganglion and can become reactivated in the future as recurrent herpes labialis. These recurrent lesions usually occur at the mucocutaneous junction of skin and lips, and unlike PHG, the oral mucosa and gingival tissues are typically uninvolved. Lesions of recurrent attacks heal in 10 to 14 days without scarring. Pediatric patients who are immunocompro- mised can have a more aggressive course of HSV-1 infection
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