Sunday, 30 April 2017

Extractions in children: Top 8 Tips

So far this year in community I have learnt so many new tricks in the management of children (like how to take radiographs). One of the most feared procedures to perform in children are extractions. Indeed perhaps that may be why extractions under general anaesthetic are becoming a national public health concern. Here are some tips I've picked up so far...

A monster E I took out recently


1. Be honest

Never lie to a child when providing treatment: you will lose their trust completely and they will become uncooperative. The most common situation where it can be tempting is always the question 'Will it hurt?'. Delivering local anaesthetic is almost always uncomfortable and you need to communicate this to the child in a way that doesn't instantly put them off. 

Parents sometimes try to lead you in becoming misleading or tricking the patient; I remember one child who refused to let me use a handpiece but was otherwise compliant. During treatment (which she was let me do), her dad kept gesturing for me to use the handpiece. This is sure fire way to lose compliance. 

2. Consider the use of articaine

Historically there has been some controversy about the use of articaine in children and many clinicians prefer the use of traditional lidocaine. However, there are some situations that I find articaine particularly useful. For instance, you can avoid ID blocks for lower teeth and because articaine diffuses really well, in some cases you can avoid palatal infiltrations. 

There is evidence that shows articaine (in smaller doses) is safe in all ages. The only precaution is to warn the child and parent about the more profound anaesthesia that can increase the risk of self-mutilation post-operatively. 

3. Topical is a must

Always always use topical! Not just for its pharmacological effect, but also as a distraction technique. Sometimes if there is a very mobile baby tooth, I would not even use LA but just topical. I call topical my 'magic cream' or 'sleepy cream'. Some tips on using topical are:
  • Dry the mucosa first with cotton wool to make sure the topical is not diluted by saliva
  • Don't over do it. Using too much can put off children too as it can numb their tongue/throat and other areas
  • Leave the topical in for a couple of minutes, not long enough and it won't work but too long the patient will get distracted and saliva can disperse the effect
  • I sometimes ask the patient to hold the cotton wool roll with the topical on it in place, it helps them to feel in control
  • There are different flavours available from mint to bubblegum, explain this to the child before you apply
  • Don't delay administering the LA after you remove the topical or the effect will wear off. 
  • I also use the end of the cotton wool roll to rub the topical into the gum. This is not evidence based but I feel like it helps the topical penetrate, you may get a gate control effect (i.e. activating Aβ fibres and inhibiting C fibres) and it also acclimatises the patient to the feeling of numbness if they haven't experienced it before. 


4. Explain in a way they understand

Stick to child friendly language and analogies. Avoid fearful words like 'needle' and 'injection' (although parents will often drop you in it by using these words). Some examples I use are:
  • Sleepy cream for topical and sleepy juice for LA
  • 'Putting your tooth to sleep'
  • When I check anaesthesia I check by 'tickling the tooth'
  • Wiggle wiggle the tooth out

5. Involve the parent

As I mentioned above, sometimes parents can make your life more difficult. But in majority of cases, parents can be very helpful  in helping the patient comply with what you're trying to do and I always recommend having them stay in the surgery. First, check the parent is ok staying (I've had more than one faint on me previously) and I usually ask them to sit close to the chair to reassure the patient by holding their hand or whatever the patient finds reassuring. 

The parent is then close to reassure and encourage the patient during the treatment.

6. Delivering LA 

Sometimes the biggest obstacle in performing an extraction is delivering the LA. Of course if you have equipment like The Wand or can provide inhalation sedation these will make your life easier, but often these are not available. In these cases here are some of my top tips:

  • Try not to show the syringe to the patient, keep it off your bracket tablet covered by a tissue or something else until you need it
  • Try to make sure your LA is not cold, ask your nurse to hold it in their hands to warm it up slightly as it will feel less uncomfortable when you administer it
  • Ask the patient to close their eyes when delivering the LA so they don't see the syringe. I say so I don't get sleepy juice in their eyes and send them off to sleep!
  • Explain that you keep the sleepy juice in the freezer so it can feel cold when putting it in
  • Emphasise the need to stay still when delivering the LA. If they move it can be unsafe and also hurt them more 
  • Deliver SLOWLY!! It's tempting to get it over and done with, but if you deliver the LA quickly then it will be more painful
  • I always try to avoid palatal infiltrations or even lingual ones but doing a buccal infltration and then walking around then finally through the papillae distally. You should look out for the blanching of the palatal mucosa with this technique. You could also use articaine which I mentioned above. Here is a good video of how to use this technique. 
  • Use suction if needed to remove any extruding LA. LA tastes horrible and children really dislike it (although it can distract the patient at the same time) 


7. Don't go digging

Some dentists will really hate the idea of leaving anything behind when doing extractions. Sometimes in children I would recommend avoid digging deep to try and get that final bit of apex out. Firstly it's not nice for the patient and sometimes you can lose compliance this way, but also remember there will be a successor tooth underneath somewhere. You may inadvertadley damage the successor if you slip. 

Baby teeth have spindly roots (sometimes these can be quite long, like in the picture above) and little apical portions can easily fracture off during the procedure. These will more often than not, exfoliate by themselves uneventfully as the socket heals or the adult tooth pushes through. Also remember not to mistake root resorption for a fractured apex. If the tooth is close to exfoliation or there is long standing infection, their roots may be resorbed. 

8. Keep going

I say this, but this can depend completely on the situation and the patient. What I mean is that more often than not, when I take a tooth out even when I know that the tooth is completely numb, the child still yelps a little or sometimes even yells. This often happens because of the feeling of the pressure as the tooth comes out and the surprise if they've not had the experience before. Taking baby teeth out often takes seconds and if you stopped, the child may not let you back in their mouth to finish off the treatment. 

Sometimes this can feel horrible especially when the child is crying, but overall you are acting in the patient's best interests and the treatment needs to be done. I always reassure the parents afterwards as they can often can be worried that you are hurting their child and I always praise the child after and give them a reward (usually a sticker). Children can surprise you, they often bounce back very quickly and with good behaviour management you won't lose their compliance for the future. I always try to distract them by asking them how much the tooth fairy will leave them and what they will spend the money on! 


These are just some of the tips I've picked up from managing anxious or uncooperative children. Of course this approach doesn't always work and you'll have to think of plan B e.g. referring for inhalation sedation or in the worse case general anaesthetic. With the changes in how the community dental services are changing (look out for a future blog post), GDPs need to be seen to at least try if a child requires extractions before referring on, otherwise their referral may not be accepted any longer. 



What tips do you have when performing child extractions? Leave them in the comments section.



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