Jeffrey Smith

October 24 2017

Intern-Mentor GT

Period 5 and 6

Annotated Sources

American Academy of Pediatric Dentistry. www.aapd.org. Accessed 25 October 2017.

The American Academy of Pediatric Dentistry website provides information about local
pediatric dentists and guidelines for practices. On the homepage there is a tool that parents can
use to search for local pediatric dentists. The resource center includes links to parent information,
membership management, and other options pertaining to AAPD membership. The AAPD
publications page has advertising opportunities, AAPD journal publications, and brochures. Oral
health and policy guidelines include the AAPD guidelines that are used in most pediatric offices.
The news tab shows recent publications of importance and upcoming changes to policies. The
public policy tab reviews the role of the political action committees and the importance of
spreading AAPD policy. There is a tab for residency programs. It covers the availability of
residence programs in all 50 US states. The website also has a link that leads to continuing
learning opportunities.
This website provides a link to the AAPD guidelines, a critical component of behavioral
management standards. The methods used in most dental practices have their roots in the AAPD
guidelines. The website allows for easy access to the pdf. Many of the publications found on the
website are open access, so a membership is not required. The layout of the website is simple
and allows for easy use. The website offers outside links for local pediatric dentists and dental
supply companies. It offers sufficient information for parents seeking dental care for their child.
Providers can quickly access their account and be notified on any policy changes. All policy
changes are published online.

Bajric, E., and S. Kobaslija. "Factors That Determine Child Behavior during Dental Treatment."
Balkan Journal of Dental Medicine, vol. 20, no. 2, 2016, pp. 69-77.

For most patients, dental appointments are not enjoyable. Some experiences at a dentist
office may leave the patient with long or short term consequences. The consequences can be
divided into long term and short term. Long term consequences pose a challenge to pediatric
dentists that work to provide quality care while ensuring the child is comfortable. In order to
deliver quality dental care, practitioners must focus on the root cause of anxiety and alter the
treatment plan accordingly. Children develop fears of different stimuli at varying ages. A child
under six months old may be afraid of loud noises, while a 4 year old could be afraid of losing
contact with a family member. The cognitive ability of a child limits the treatment because the
child is not able to accurately describe his or her fears. Parents can help their children grow and
develop a response to stimuli, but others shield their children. As a result, the child may not be
able to receive dental care without the presence or contact with a parent. The three coping
mechanisms are internal, external, and destructive. Destructive includes becoming angry or
violent. External is the use of a person or distraction during a period of pain to relieve the child.
Internal coping mechanisms include the patient helping when exposed to a stressful stimuli.
Facial expressions can be used to gauge the comfort level of a child. They can be useful, but a
angered or resistant child may make fake facial expressions. The fake expressions can include
pain when no stimuli is added or discomfort when no stressor is added. Patients are divided into
four groups depending on their willingness to receive treatment: apprehensive patients, patients
who are visiting the dentist, but do not like to do that, patients who partially avoid the dentist,
and patients that totally avoid the dentist. A parent can shape the quality of the child’s oral health
care by acting as a role model. Children are more likely to develop dental fear if their parents
suffered from dental fear. Parents influence their child’s behavior. Dental care is even influenced
by the personality of a child. Shy or quiet children require more personal attention. Extroverts
and loud children may be more difficult to corale.
The source is helpful to my research. The article provides a detailed overview of nearly
all of the factors in a dental office that may cause stress or concern for a patient. The article also
discusses the factors outside of a dental office like parental influence and the child’s personality.
Dental fear was not the only focus of the article. It discussed the implications of treating a patient
with severe dental fear. The office and dental team play a part in shaping the experience of a
scared child. The points addressed in the article are similar to those found in the American
Academy of Pediatric Dentistry guidelines.

Beaudette, Jennifer R., et al. "Oral Health, Nutritional Choices, and Dental Fear and Anxiety."
Dentistry Open Access Journal, vol. 5, no. 1, Jan. 2017.

The article discusses the relationship between nutritional choices, dental procedures, and
the anxiety or fear that can develop as a result of the procedure. Lack of nutrient intake as a
result of oral health can lead to the development of chronic diseases. Dental procedures can limit
food intake and reduce the variety of foods consumed, but patients can prolong the period of
malnutrition because of dental fear or anxiety. The cycle of dental fear highlights the immediate
impact of avoiding dental care. If the diet of the patient is considered, the quality of life and oral
health will drastically decrease. Tooth loss makes food consumption painful or uncomfortable.
The study found that the majority of the patients with missing teeth fell below the poverty line.
Individuals with missing teeth ate less fruits and vegetables. They ate more cholesterol and less
fiber. If the dentition is compromised, patients may be unable to consume healthier alternatives
like raw vegetables. The connection between compromised dentition and poor health is not well
established. Blood and urine samples were collected to analyze the concentrations of vitamin C,
vitamin E and beta-carotene. There was a correlation between the number of teeth and vitamin C
serum level. The researchers cited the cooking method as the cause for the drop in vitamin C
serum levels. The study found that women reported dental fear or anxiety more than male
patients. The other reasons listed for missing appointments besides for dental fear include: lack
of time, cost of treatment, dislike of dentists, concern over pain, or they felt it was not necessary.
Dentists can typically gauge the level of dental fear a patient is suffering from. A clear indicator
of severe fear or anxiety is the request for anaesthesia. Techniques used to reduce dental fear
include aromatherapy, distraction, relaxation, hypnosis, and communication.
The article is helpful to me, but there are several claims that lack evidence. When the
vitamin C serum levels are reviewed, cooking methods are cited as the reason behind the vitamin
C deficiency in vegetables. The claim was pinned onto the end of the argument and lacked any
sort of evidence to support such a claim. The article mentions that women report dental fear at a
higher rate than men because men feel social pressure to remain tough. The claim was
unsupported and added nothing to the argument. Tooth loss is an important factor in diet, so the
specificity about the financial situation provided an example of a demographic that is vulnerable
to the development of dental fear or anxiety. The article offered an in depth look at an important
part of behavioral management, but more research needs to be done on the social perception of
men, and the decrease in vitamin C serum levels in varying cooking methods.

Bullappa, Deepa et al. “Association of Feeding Methods and Streptococcus Mutans Count with
Early Childhood Caries: A Cross-Sectional Study.” International Journal of Clinical
Pediatric Dentistry 10.2 (2017): 119–125. PMC. Web. 24 Oct. 2017.

Early childhood caries is a multifactorial disease that leads to decay in the primary
dentition. The caries risk varies from patient to patient, but the main cause is the bacteria in the
saliva. Streptococcus mutans are the primary microorganism associated with early childhood
caries. The study was conducted to observe the connection between feeding methods,
streptococcus mutans, and early childhood caries in subjects ranging from three to five. Mothers
were given questionnaires that outlined feeding habits. Questions covered the oral health habits
and diet. Saliva was collected from each subject in order to measure pH and culture agar plates.
Neonatal factors were considered because they can also cause the transmission of S. mutans by
vertical transmission. The factors include delivery method. Children delivered by a cesarean
section developed S. mutans earlier than vaginally birthed children. Different types of milk
contribute differently to early childhood caries. Most of the subjects in the study were breast and
bottle fed. Most of the mothers questioned brushed or assisted in the brushing of their child’s
teeth. The saliva samples collected from the infants and mothers had similar pHs. Mothers and
children also shared a similar salivary rate. A strong correlation was found between the level of
S. mutans counts and early childhood caries. The study concluded that motherly habits should be
identified in order to create a risk level for infants. Mothers should use gauze or a clean cloth to
clean gum pads. Mothers need to be informed of the danger of nighttime bottle feeding and
harmful snacking patterns. Parents need to hold themselves responsible and serve as role models
for their children’s oral health.
The source is helpful to my research. The study focuses on the connection between
motherly influence, streptococcus mutans, and early childhood caries risk. Parents are the most
important individuals in a child's life, so their role in oral hygiene needs to be understood. If a
parent has suffered from dental caries, then their child is at a higher risk as a result. Early
childhood caries and behavioral management may seem distant, but the quality of oral care a
child receives at home directly impacts the ease of care in the office setting. Cariogenic bacteria
can be spread by salivary exchange, so parents saliva will end up shaping the future of the child’s
oral health care. Knowing parent history helps a dentist create a treatment plan tailored to the
child’s predicted path. The treatment plan may account for behavioral difficulties that need to be
considered.

Castro, Alessandra Maia, and Roberta Cristina Gomes Espinosa. "Behavior Guidance
Techniques Used in Dental Care for Patients with Special Needs: Acceptance of Parents."
Pesquisa Brasileira em Odontopediatria e Clínica Integrada, vol. 16, no. 1, July 2016,
pp. 113-21.

Patients that suffer from Autism Spectrum Disorder (ASD) may have cognitive
impairment and physical disability. Families consult doctors in varying fields of medicine to
improve the quality of life for their child. Dentists are presented with the challenge of adapting
treatment to consider cognitive deficiencies and physical limitations. The lack of physical
movement limits treatment options. Basic behavior management techniques can be used with
success, but success is not guaranteed with all special needs patients. SN patients may have an
impaired memory, so incentives or prizes do not work as well as they do with other patients. If
basic behavior management techniques do not work, advanced techniques can be employed.
They include protective stabilization, sedation, and general anesthesia. Dentists must consider
family context as well as limitations when creating and following a treatment plan. The study
was conducted to evaluate the acceptance of different behavior management techniques in
parents. Parents of special needs patients were informed of the diagnosis specific to the
disability. They were then asked if they would accept, accept with restrictions, or do not accept
the method being described. The methods include tell-show-do, distraction, positive
reinforcement, non-verbal communication, nitrous oxide inhalation, sedation, and general
anesthesia. Tell-show-do, distraction, and positive reinforcement were all accepted without
reservation. The technique with the lowest acceptance rate was nitrous oxide inhalation.
Sedation was preferred by parents of a child with physical disability. Age was an important
factor in acceptance rate. Younger patients had a significantly lower acceptance rates. Parents
accepted some methods over others because of familiarity. As the level of education increased,
the acceptance rate increased.There were few rejected methods.
The study is a great example of parental influence on behavioral management techniques.
Informed consent is the process where a dentist informs the parent or guardian about the
treatment and results of the treatment. The results could include bloody gums as a result of
gingivitis or screaming and crying because of fear. Parents can reject the proposed treatment if it
conflicts with personal beliefs. The study shows the power of a parent’s choice. Nitrous oxide
inhalation was the least accepted even though a patient is more vulnerable when sedated or under
the influence of general anesthesia. Parents of special needs children have control over nearly
every aspect of their life. This pattern is carried into oral health.

Cephas, Kimberly D., and Juhee Kim. "Comparative Analysis of Salivary Bacterial Microbiome
Diversity in Edentulous Infants and Their Mothers or Primary Caregivers Using
Pyrosequencing." Public Library of Science, 10 Aug. 2011,
journals.plos.org/plosone/article?id=10.1371/journal.pone.0023503. Accessed 25 Oct.
2017.
 The high rate of caries development has caused a need for updated detection and
prevention protocol. The main cariogenic bacteria is Streptococcus mutans. Porphyromonas
gingivalis, Tannerella forsythia, and Treponema denticola are known causes of gum diseases.
Those are not the only bacteria that contribute to caries and compromised periodontal health.
Newfound culprits include Actinomyces, Granulicatella, Veillonella, Bifidobacteriaceae, and
Scardovia. The study was conducted to identify bacterial change in saliva depending on the
region in the mouth and how it compared to a mother’s sample. The regions include the saliva,
tongue dorsum, soft tissues, supragingival, and subgingival plaque. The saliva, tongue, and soft
tissues are hotspots of S. mutans growth. The same characteristics have been found in parental
saliva. The researchers predicted that the bacterial composition of the child’s saliva would be
less diverse than the mothers and that it would be more similar to its own mother’s saliva than
other mothers. The findings of the study support the claim that the infant saliva is less diverse
than the mothers. Infants had 620 species of bacteria while parents had 734 unique species of
bacteria. The saliva of the child was not more similar to its own mother than other mothers. The
comparison between mothers and non-mothers was too close to declare a definitive answer. The
most common bacteria found in both ages was Firmicutes.
The study was not helpful to my research. The purpose of the study matched the claim
that mothers can transmit cariogenic bacteria by vertical transmission. The claim was proven to
be false. Although the article provides evidence against the claim, it supports the complexity of
caries formation. Caries vulnerability is connected to the parent’s role in behavior management.
The study detracts from the role of the parent. Even though the bacterial composition may not be
identical, parents can still impact their child’s oral health by acting as role model. Caries risk
assessment is impacted by the level of oral health a parent has. The habits will likely be passed
along and define the path the child will follow.

Ginsberg, Dr. Edward L. Personal interview. 6 Oct. 2017.

Dr. Edward L. Ginsberg, my mentor, has practiced pediatric dentistry for thirty three
years. After receiving his undergraduate degree in biology, Dr. Ginsberg attended the University
of Maryland School of Dentistry and earned his D.D.S. In 1984, he founded the smiles4children
dental practice. In 1985, he joined the University of Maryland Dental School as a part time
clinical professor in the department of pediatric dentistry. Dr. Ginsberg is a member of the
Maryland State Board of Dental Examiners sedation committee and the examination committee
of the American Board of Pediatric Dentistry. He is also a diplomate of the American Board of
Pediatric Dentistry, a fellow of the American Academy of Pediatric Dentistry, American College
of Dentists, and International College of Dentists. Dr. Ginsberg is the only pediatric dentist on
the Johns Hopkins Hospital Cleft and Craniofacial team.

"Guideline on Behavioral Guidance for the Pediatric Dental Patient." American Academy of
Pediatric Dentistry 2016-17 Definitions, Oral Health Policies, and Clinical Practice
Guidelines, pp. 185-98.
 The article outlines the behavioral interactions that commonly occur in pediatric dental
practices. Communication is the most important aspect in treatment because it establishes a
connection between the provider, patient, and parent or guardian. The first factor that influences
the quality of care is the parent. Parents can shift a child’s perspective of the dentist through
home behavior. The quality of domestic life and style of parenting can foster behavioral
problems in children. Behavioral problems can lead to a lack of coping mechanisms and
sensitivity to treatment. The first aspect of behavioral management in the office setting is the
introduction to the facility and faculty. Front office staff shape a parent’s initial perception of the
practice. The first staff member that greets patients should maintain a relaxed and upbeat
attitude. Games or books can be used to distract patients. Before a patient can receive care, an
initial assessment must be performed. The assessment provides the doctor with previous medical
history and oral health habits. Communication between the dental staff can include facial
expressions, posture, or body movements. In order to maintain an efficient connection the
method of communication must be consistent. A hygienist's voice should not fluctuate or
increase in volume when the patient is cooperating. Informed consent is the review of care and
proposed treatments. Patients should always be informed of procedures before they begin. A
provider has the responsibility to inform the patient of all the treatment options they have at their
disposal. The provider may emphasis one over another and provide concrete reasoning, but they
may not offer a single procedure if others would also be applicable. A dentist may defer if the
patient is too active or violent while care is being administered. The patient would have to make
the provider concerned for the wellbeing of themselves, the staff or other individuals nearby in
order to a decision to be made. A parent can also defer treatment if the provided options do not
meet the expectations of the parent. During treatment there are different styles of
communication. The differing types should be utilized in the appropriate situation. They include
Tell-show-do and Ask-tell-ask. They maintain a flow of information between the patient and
provider. A provider should never engage in Tell-tell-tell where the child is overwhelmed and
uncomfortable. In the case that a patient is nervous or uncomfortable with treatment, a provider
can offer a game or movie to act as a distraction. Positive reinforcement and specific praise
should be used often. The praise can help contribute to a positive view of oral health care.
Parental presence or absence can also relax a child. In severe cases where other coping
mechanisms failed, memory restructuring can be used. Memory restructuring involves the four
components: visual reminders, positive reinforcement through verbalization, concrete examples
to encode sensory details, and a sense of accomplishment. Nitrous oxide is another approach to
relaxing particularly resistant patients. The usage of Nitrous Oxide allows the patient to sit for
longer treatments, raise the pain threshold, and aid in the treatment of patients with autism
spectrum disorder or other physically compromised patients. Protective stabilization is the usage
of restraints to protect the patient, provider, and hygienist during treatment. It is used as the last
resort because it can create scarring experiences. Documentation of behavioral patterns aids
future treatment. The Frankl Behavioral Scale is a concise way to report the patient's behavior.
This source is extremely helpful to me. The American Academy of Pediatric Dentistry is
a nonprofit organization that publishes oral health and clinical practice guidelines. The
guidelines cover an extensive range of topics including advanced behavioral management, dental
neglect, and vending machines in schools. The article provides an in depth approach to different
situations. After the overview of each concept, there are examples of when the method would
and would not be used. The guidelines are reviewed every year by the Council of Clinical
Affairs. I have seen the communication techniques in the offices, but the article provides an
explanation for the usage of each method. The article references recent research and highlights
the changes from previous guidelines. The lack of specific examples in the article allows
practitioners to interpret the techniques in their own way. The guidelines are the basis for
treatment, so they are continually changing with technological improvements. The behavioral
management chapter has not been revised since 2015.

Hernandez, Purnima, and Zachary Ikkanda. "Behavior Management of Children with Autism
Spectrum Disorders in Dental Environments." The Journal of the American Dental
Association, vol. 142, no. 3, Mar. 2011, pp. 281-87.

Autism spectrum disorders are neurobehavioral disorders. Qualitative impairments in

communication, social interaction, and restrictive repetitive and stereotyped patterns of behavior,
interests and activities can make dental treatment challenging. Hernandez and Ikanda compiled
different treatment approaches to identify which technique addresses the problems that ASD
patients pose. Typical communication methods like Tell-Show-Do and Ask-Tell-Ask are
ineffective, but distractions like a game or movie capture the patient’s attention. Stern voice
control and specific praise are effective communication methods for most patients, but they do
not consistently work with ASD patients. The usage of a stern voice or tone may initially register
as negative and cause the patient to follow the given instructions, but there is little evidence that
shows the patient will recall the connotations of a stern voice. The approach of offering rewards
is more effective than stern voice because the provider must maintain a stern tone throughout the
procedure. Rewards only create momentary positive images, but small rewards, like stickers,
would need to be used based on the frequency of the praise. Physical restraints are typically the
last resort for making a patient compliant, but they can be used with ASD patients if the dentist
deems the patient hazardous or a threat to their own wellbeing. It is common for dentists to used
sedation or general anaesthesia for longer procedures. Dentists can reduce the need for sedation
or restraints by performing simpler and routine procedures. The effectiveness of the proposed
technique is limited by the atmosphere of the typical pediatric dental office.
The article is helpful in that it provides a viewpoint regarding difficult patients and the
changes that need to be made to treat them. Patients with ASDs or other physical limitations pose
a challenge to typical dental treatment. Hernandez and Ikkanda found contradicting research and
clearly stated the differences. None of the proposed techniques will work for all patients because
there is a wide range of behavioral complications that ASD patients can suffer from. Behavioral
studies tend to focus on patients that suffer from minor issues. The field of research on the
changes required for ASD patients will never reach a definitive conclusion because of the
complexity of the disorder, but dentists can continue to change procedures to accommodate
patient needs.

Kawia, Hassan Mohamed, and Hawa Shariff Mbawalla. "Application of Behavior Management
Techniques for Paediatric Dental Patients by Tanzanian Dental Practitioners." The Open
Dentistry Journal, vol. 9, 2015, pp. 455-61.
A study conducted by Tanzanian dental practitioners focused on the application and
effectiveness of behavior management techniques. Behavior management techniques, BMTs, are
used to establish a line of communication between the dentist and patient. The communication
can relieve stress and improve the quality of dental care. BMTs have changed since the 1950s.
They placed an increased focus on establishing communication and empathy. Some of the most
common techniques include tell-show-do, distraction, and voice control. BMTs can be
considered pharmacological or nonpharmacological. BMTs are used across the world. Each
technique is adapted to fit cultural standards or habits. A preference includes the presence of a
parent. Tell-show-do techniques are popular in Israel while Australian dentists allow the child to
influence an aspect of treatment. Older practitioners used BMTs less than younger practitioners.
Female dentists spent more time with patients before treatment on average. Indian and Nigerian
dentists primarily use tell-show-do. Dentists need to be flexible in the usage of BMTs and
consider the cognitive level of the patient when choosing a technique. Dentists were interviewed
about their BMT usage. All of the dentists used the tell-show-do technique. 98.6 percent said
they used protective stabilization. Most were aware of the universally accepted techniques. The
more experienced dentists had a higher usage of the universal standards.
The study reveals that the behavioral management guidelines used in Tanzania are
consistent with those used across the globe. The introduction outlines the preferred techniques in
different countries. The researchers cite a specific dentist and the technique used, then they
project that idea over the entire region. The study lacked significant evidence to support the
claim. The grouping helps differentiate the impact of experience on BMT usage. A difference
between US and Tanzanian techniques is the usage of protective stabilization. Protective
stabilization is a controversial technique in the United States. A patient is more likely to develop
scarring memories from the experience. The restraints can hurt a child if intense resistance
occurs and the airway can be restricted depending on the restraint used. The study offers a
glimpse into the behavior management practices of a country other than the United States. It
supports methods used in the US.

Nishimura, Michiko, and Omar M. Rodis. "Influence of Diet on Caries Activities and Caries
Risk Grouping in Children, and Changes in Parenting Behavior. "International Journal of
the Japanese Society of Pediatric Dentistry, vol. 22, no. 2, 12 Nov. 2012, pp. 117-24.

The goal of the study was to identify how diet influenced the activity of caries and how
diet changed after parents were provided with oral health instructions based on the caries-risk
level. Subjects were divided into six caries risk groups depending on their level of oral health
compared to a typical individual of that age. The groups included low risk, moderate risk,
progressive border, improved border, moderately high, and high. Parents completed a
questionnaire with questions pertaining to the child’s oral health habits at home. Questions
included: Do you check and brush your child’s teeth?, How many times a day does your child
ingest sucrose-containing foods?, and Do you determine the total time of your child’s sucrose
containing food intake? The questions were used to gauge the parents rigidness and enforcement
of oral health habits. Depending on the patient's risk of developing caries, parents were provided
with oral hygiene instructions tailored to each specific risk level. Most of the subjects were
placed into the low to moderate caries risk categories. Only 78 subjects were considered high
caries risk. Breast feeding and liquid intake of liquids other than water raised the risk of caries
development in 18 month olds. This pattern remained consistent with subjects at 24 months old.
The questionnaire showed that parents of high risk subjects had worse habits than those with low
to moderate risk caries. Because caries in a multi factorial disease, a single cause can not be
isolated. The experiment showed the connection between high caries risk, high sucrose diet, and
minimal parental intervention. Diet was consistent across the low to improved border caries risk
groups. The determining factor was oral hygiene habits.
The article is very helpful to me. The study focuses on the prevalence of high caries risk
in patients with varying diets and parental influence. Parents are a key component of behavioral
management. They impact oral health at home and contribute to the atmosphere in a dental
office. Even if a child has a healthy diet, they are still susceptible to a high caries risk. The
quality of oral care at home determines the level of treatment required at each appointment. A
child with worse oral health will receive more intensive care. While some patients may remain
compliant, many become defiant and prolong the treatment. A parent that is less likely to follow
up on routine oral care is less likely to utilize preventative measures to ensure their child’s oral
health improves.

Patil, Vidyavathi H., and Karan Vaid. "Evaluation of Effectiveness Dental Apps in Management
of Child Behavior: A Pilot Study." International Journal of Pedodontic Rehabilitation,
vol. 2, no. 1, pp. 14-18.

Children have become obsessed with phone applications and browsing the web. Pediatric
dentistry has not taken advantage of the opportunity to educate the public about treatments.
Dental visits at a young age define the quality of future dental appointments. Patients are anxious
and stressed about the treatment. If behavioral management techniques are used, the child is
more likely to have a higher quality of dental care in the future. Without the techniques patients
can develop more severe dental fear or anxiety. Dental fear or anxiety can lead to poor oral
health and an increased chance that a patient will skip an appointment. Behavior management
techniques are vital to ensure the child is not terrified and scarred for future treatments.
Distractions are a method of behavior management. With the increased reliance on technology,
dental apps on phones can be used to distract the patient and educate them about pediatric dental
care. In the study patients played a game called “My Little Dentist”. The game provides a basic
description of the check up while also engaging the child with games. Anxiety levels were
monitored before and after the child played the game.The reduction in anxiety can be seen across
boys and girls. By using a fun form of media to capture the child’s attention and educate them,
dentists will be able to promote the importance of oral health care to a receptive audience. The
games help by desensitizing the child to the procedure just like the tell-show-do method. It
allows the child to feel like they have control.
The article is very helpful for my research. It highlights two critical behavioral
management techniques: distractions and desensitization. It prevents treatments, that are
oftentimes seen as scary, in a better light. The games are simple, so children of all ages can
follow along. The goal of the games is not to inspire the next generation of dentists, but to inform
and promote the importance of dental care in a fun form of media. It is a cost effective strategy
for managing a serious condition that could potentially evolve to dental fear or anxiety.

Samir, P., and Sandeep Suresh Fere. "Nitrous Oxide-Oxygen Inhalation Sedation: A Light on Its
Safety and Efficacy." International Journal of Advanced Health Sciences, vol. 2, no. 4,
Aug. 2015, pp. 4-10.
 Non pharmacological behavioral management techniques are used in pediatric dental
offices to console a difficult patient and establish a connection between the dentist and patient.
This connection can not always be made. If a patient is being resistant or poses a threat to the
dentist, the hygienists, or himself sedation may be used. Sedation by the inhalation of nitrous
oxide is a common technique. It can also be used if a patient is nervous or scared. Nitrous oxide
effects the patient quickly and wears away with minimal side effects. Sedation is divided into
conscious sedation, deep sedation, and general anesthesia. Most pediatric dental offices are only
equipped to handle conscious sedation. Deep sedation and general anesthesia must be used in a
hospital setting. The air is sweet and patients can chose a particular flavor nosepiece to wear.
Because nitrous oxide does not bind with blood molecules, the effect wears off quickly.
Depending on the reaction a the child different administration techniques can be used. The slow
induction and rapid induction technique are the most common. Oxygen can also be released to
speed up the recovery period. There are different levels of analgesia, referred to as the planes of
analgesia. In the first plane the child could feel tingling around their body. All senses are
functioning, but they are reduced. On the second plane the child will experience a warmth
followed by humming and a feeling of lightheadedness. Plane 3 is when the patient enters a
dream like state. At this stage patients will lose the ability to open their mouth and control tongue
movement. If a child appears to be suffering from a hypoxia related symptom oxygen can replace
nitrous oxide in the flow and saturate the patient’s blood. Some of the hypoxic events include
nausea, vomiting, and dizziness.
The article is helpful for my research. It provides an indepth look at a utilitarian
pharmacological behavioral management technique. The wide range of uses and lack of major
restrictions make it feasible for many treatments. It is not suitable for all scenarios, but most
procedures in a standard pediatric dental office can be managed with nitrous oxide. The side
effects are not severe when compared to other sedation alternatives. Hypoxic events can be
prevented and reversed quickly by the release of oxygen into the bloodstream. Nitrous oxide is
an inexpensive option for treatment.

Smiles4children. www.smiles4children.net/index.htm. Accessed 7 Oct. 2017.

The smiles4children website gives an overview of pediatric dentistry, patient information,

the team members, and contact information for the different offices. In the pediatric dentistry
section, the website has a overview of the education requirements to become a pediatric dentist
and the importance of starting dental care around the child’s first birthday. The page also
discusses what the first visit will involve. The patient information section covers appointment
flexibility and the consequences for missed appointments. The page also includes an extensive
review of insurance and financial policies. The meet the team page has photos and brief
biographies for each of the partners. The biographies include their level of education,
contributions to pediatric dentistry, and interests outside of dentistry. The contact information for
the three offices can be found on the home page and the bottom of each section. It also has
dentistry themed games including coloring, crossword puzzles, animated videos, and teeth
brushing guides.
This source is moderately helpful to me, as it is the website for the practices I intern at.
The website focuses on providing parents with clear and concise information regarding their
child’s treatment at smiles4children.The layout of the page is simple and easy to follow. Each
section reinforces the relaxed atmosphere of the offices and experience of the dentists. The page
lacks in depth information about behavioral management because the intended audience is
parents or guardians of children, not researchers. The website is an example of practice
management techniques in action. I can use the website to analyze the effectiveness of the
techniques on parents.

Tinanoff, Dr. Norman. Personal Interview. 24 Oct. 2017.

Dr. Norman Tinanoff has practiced and taught pediatric dentistry for 46 years. He
graduated from the University of Maryland School of Dentistry in 1971. Dr. Tinanoff worked at
the university of Connecticut Health Center for 23 years and served as the director of the
Department of Pediatric Program for 16 years. He was the chairman of the Department of
Pediatric Dentistry at the University of Maryland Dental School in 1999. Dr. Tinanoff has
published countless articles on the prevention of dental caries and oral health access for
underdeveloped populations that lack care.