Monday, March 31, 2014

Vitamin D-dependent Rickets and Stevens-Johnson Syndrome

Vitamin D-dependent Rickets

Overview: a disease of childhood where growing bones fail to mineralize.

Etiology: as opposed to nutritional Rickets (results from inadequate sunlight exposure or inadequate intake of dietary vitamin D, calcium, or phosphorus), vitamin D-dependent rickets is secondary to a gene defect that codes for the receptor for vitamin D in the gut.  A metabolite of vitamin D is a hormone that is responsible for regulation of calcium release and uptake from bones.

Diagnosis: is through 1) blood tests: serum calcium (low), serum phosphorus (low) and 2) through bone biopsy (rarely performed, but will confirm Rickets diagnosis).

Oral Manifestations:
Accounts of “spontaneous” dental abscesses resulting in pulp infection through abnormally mineralized dentin.
Radiographic Appearance:
-       Thinning of inferior mandibular cortex
-       Reduction in density, number, and thickness of trabeculae in cancellous bone
-       Thinning/missing lamina dura
-       Delayed tooth eruption

Clinical Features:
-       Short stature
-       Soft, pliable bones
-       Bowed legs, increased incidence of greenstick fractures
-       Widening/fraying of epiphyses of long bones
-       Fronto-parietal bossing of skull

Special dental considerations/needs: Early dental treatment/prevention is necessary to prevent spontaneous pulpal necrosis in primary and permanent teeth.


Resources:
Seow WK, et al. Pedatric Dentistry Vol 8, No 3 (1996): 245-250
Nield, LS, et al. Am Fam Physician. 2006 Aug 15;74(4):619-626


Stevens-Johnson Syndrome (Erythema Multiforme Major)

Overview: SJS is a life threatening condition of the skin in which cell death causes the epidermis to separate from the dermis. SJS is the more severe muco-cuteaneous form of erythema multiforme and is considered a dematological emergency.

Etiology: SJS is thought to arise from a disorder of the immune system and can be due to a viral infection (HSV, mumps, influenza) OR a drug-induced reaction from the use of antibiotics and sulfa drugs.

Diagnosis: Usually a diagnosis of exclusion (differential diagnoses usually include mucous membrane pemphigoid, pemphigus, and lichen planus). A biopsy is necessary to make a definitive diagnosis. Patients with Lupus and HIV are at higher risk. Overall incidence is relatively low (6:1,000,000). More common in adults than children, women:men (2:1).

Oral Manifestations and Clinical Features:
Begins with fever, sore throat, and fatigue. Conjunctivitis occurs in 30% of children with SJS. The rash that develops on the skin is widespread and appears as red, round macules, vesicles, bullae, and ulcers that have a characteristic “target” or “iris” appearance. Lesions in the mouth are the most common sign of the syndrome and present as erythematous and edematous blisters that rupture leaving painful ulcers/erosions. These erosions are covered by yellowish white pseudomembranes or hemorrhagic crusts.

Special dental considerations/needs: Defer treatment until lesions have completely resolved.


Resources:
Kempton, et al. Misdiagnosis of Erythema Multiforme: A Literature Review and Case Report, Pediatric Dentistry July/Aug 2012

Stitt, VJ. Stevens-Johnson Sydrome: A Review of the Literature. J Natl Med Assoc. Jane 1988; 80(1):104-108.




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Wednesday, March 26, 2014

Treatment of Mucocele of the Lower Lip With Diode Laser in Pediatric Patients: Presentation of 2 Clinical Cases

Resident: Mackenzie Craik

Article: Treatment of Mucocele of the Lower Lip With Diode Laser in Pediatric Patients: Presentation of 2 Clinical Cases

Author: Irineu Gregnanin Pedron, DDS, MS, et al.

Journal: Pediatric Dentistry, Nov/Dec 2010.

Introduction/Main Purpose: Mucoceles are common benign lesions of the oral cavity that develop following extravasation or retention of mucous material from salivary glands in the subepithelial tissue.  Most dental literature reports a higher incidence of mucocele in young patients, with trauma being a leading cause.  Treatment may be performed by conventional surgery, cryotherapy, and more recently, laser surgery and laser vaporization.  The purpose of this report was to describe d2 clinical cases of lower-lip mucoceles treated by excision with a high intensity diode laser in pediatric patients.  Diode laser surgery was rapid, bloodless, and well accepted by patients.  Postoperative problems, discomfort, and scarring were minimal.  Treatment of mucoceles with high-intensity diode laser provided satisfactory results in the cases presented and allowed for a histopathological examination of the excised tissue. 

Study: In this study, 2 mucoceles in young patients were treated with diode laser.  A nine year old boy complained of swelling on the lower lip mucosa.  The patient had reported an acute trauma 1 month prior. 

A 10-year old boy presented with painless, translucent nodule on the lower lip mucosa near the left commissure, it was approximately 1 cm in size and 1 year in duration.  The lesion had been growing for the last two days. 

Management: Removal of mucoceles was performed under local anesthesia and with the use of a diode laser at continuous mode. 

Postoperative care included 0.15% benzidamine hydrocloride mouthwash 3x/day. 

Patients were followed until healing was complete at 30 days post surgery.  Patients have been under observation for 12 months and have not shown signs of recurrence.  Excised mucoceles were analyzed histologically and were confirmed as mucoceles by the presence of mucus in the lamina propria, which was surrounded by inflammatory cells and an immature granulation tissue. 

Discussion: Several techniques hae been proposed for the treatment of a mucocele, such as cryosurgery, micromarsupialization, and marsupialization.  The most common treatment, however, is complete removal of the lesion and salivary gland involved via surgical excision.

Frequency of mesiodens in the pediatric population in North India: A radiographic study.


Frequency of mesiodens in the pediatric population in North India: A radiographic study.

Patil S1Pachori Y2Kaswan S3Khandelwal S4Likhyani L5Maheshwari S1.
Resident: Margaret Maclin



OBJECTIVES:


Mesiodens are the most common supernumerary teeth, occurring in 0.15% to 2.2% of the population. The aim of the present study was to analyze the frequency and radiological features of mesiodens in the pediatric population.

MATERIAL AND METHODS:


The study was based on the radiographic evaluation of 4133 pediatric patients of the age range of 4-15 years, attending the Department of Oral Medicine and Radiology during the time period between September 2008 to December 2012. In addition to the presence of a supernumerary tooth between the 2 central incisors, data regarding the number, position, shape and associated complications were also recorded.

RESULTS:


The prevalence of mesiodens in the present study was 1.4%. The prevalence was estimated using a 95% confidence interval. The ratio of boys to girls was 1.8:1 and majority of cases (89.7%) had 1 mesiodens. Most of the mesiodens (59.6%) were aligned in a vertical position. 39mesiodens (62.9%) were impacted, while 14 (22.6%) were partially erupted and only 9 (14.5%) were completely erupted into occlusion. The main complication associated with the mesiodens was midline diastema (28.6%) and 16 patients were asymptomatic.

CONCLUSION:


Mesiodens can result in spacing in the arch, delayed or ectopic eruption of the permanent incisors, further altering the occlusion and esthetics of the patient or may remain asymptomatic. It is therefore important for the practitioners to diagnose a mesiodens early in development to allow for optimal treatment plan. Key words:Mesiodens, prevalence, pediatric population, midline diastema.

Ankyloglossia in the Infant and Young Child: Clinical Suggestions for Diagnosis and Management

Resident: Derek Nobrega
TitleAnkyloglossia in the Infant and Young Child: Clinical Suggestions for Diagnosis and Management
AuthorsAri Kupietzky, DMD, MSc Eyal Botzer, DMD
Journal: Pediatric Dentistry – 27:1, 2005, 40-46

Main Purpose: The purposes of this report are to describe ankyloglossia, its clinical significance, and the timing of treatment.

Background: Ankyloglossia (AG) is a congenital anomaly characterized by an abnormally short lingual frenum, which may restrict tongue tip mobility. AG incidence varies from 0.02% to 5%, depending on the study, its definition of AG, and population examined. The incidence among outpatients of a children’s hospital with breast-feeding problems was almost 3 times higher. The possible sequlae of AG remain controversial, and the range of suggested complications is great. Among the suggestions found in the literature are: (1) lower incisor deformity, (2) gingival recession, and (3) malocclusions. The existence of AG in the newborn may result in breastfeeding difficulties, including ineffective latch, inadequate milk transfer, and maternal nipple pain. AG is not a cause of a delay in speech onset, however AG may interfere with articulation.

Treatment Options:
Several AG treatment methods have been suggested. Management approaches range from very early treatment without anesthesia to the other extreme—that AG should never be treated. Treatment options such as observation, speech therapy, frenotomy without anesthesia, and frenectomy under GA have all been suggested in the literature.
1. Frenomtomy
The frenotomy procedure is defined as the cutting or division of the frenum. Only a thin and membranous frenum can be corrected by frenotomy. The procedure may be accomplished without local anesthesia and with minimal discomfort to the infant. The frenum is then divided with small sterile scissors at its thinnest portion. The incision begins at the frenum’s free border and proceeds posteriorly, adjacent to the tongue. The frenum is poorly vascularized and innervated, allowing the clinician to accomplish the procedure without any complications. There should be minimal blood loss and the incision is not sutured.
2. Frenectomy
The frenectomy procedure is defined as the excision or removal of the frenum. Frenectomy is the preferred procedure for patients with a thick and vascular frenum where severe bleeding may be expected, and in some cases, reattachment of the frenum by scar tissue may occur. The wound is sutured with a z-plasty flap closure.

Assessment:
Since being here, I have seen multiple infants referred for lingual frenectomy. Often times, when asking the parents, the patients have had no problems with feeding. Often, they are too young to speak, so have no articulation issues. As there are different approaches to treatment, it's important for us to have guidelines we follow. Since treating an infant would likely require GA, I believe it is wise to continue to observe the patient that has no issues with feeding until they have been evaluated by a speech pathologist. If there are problems with articulation related to ankyloglossia, I believe that is an indication to treat. Additionally, if the patient has problems feeding from birth, this is obviously an indication to treat. 

Evaluation of bleeding risk and measurment methods in dental patients

Resident: Todd Bushman
Title: Evaluation of bleeding risk and measurment methods in dental patients
Author(s): Canigral et al.
Journal: Med Oral Patol Oral Cir Bucal Volume 2010. 15. 863-8. 

Main Purpose: The purpose of this study was to explore bleeding manifestations in dental surgical procedures, evaluate the influence of antithrombotic drugs upon bleeding risk, and validate the efficiency of a clinical method for the measurement of bleeding after dental extraction or surgery.

Method :
Prospective observational study of 99 patients taking antithrombotic medications seen in the Stomatology Units of Dr. Peset University Hospital (Spain) and Castellon General Hospital (Spain). Patients scheduled for simple tooth extraction had no modification of antiplatelet medication. Simple extraction only carried out if INR proved compatible with the surgery. Patients scheduled for complex procedures (multiple extractions, impacted dental surgery, biopsies) or combined antiplatelet treatment were referred to the Service of Hematology to plan the management approach.
On the first visit, clinical history was compiled and blood tests requested, including a complete blood count, Quick index, INR, aPPT, fibrinogen and platelet function tests (TRAP test, ASPI test, ADP test, ADPHS test). For data collection, a form was developed documenting different demographic parameters, medical history, acquired and congenital bleeding risk factors, simple or complete procedure, bleeding manifestations, complications, and range of laboratory test data. Three levels of bleeding intensity after dental surgery were defined: MILD (subsides in under 10 minutes with sterile gauze tamponade), MODERATE (subsides with tamponade plus local hemostatic treatment in under 60 minutes), and SEVERE (bleeding for over 60 minutes and requiring other medical or surgical management).

Findings:
The age of the patients ranged form 15-93, with mean age of 58. Most common problems in medical history included cardiovascular diseases, arterial hypertension, diabetes, renal failure, neoplastic processes, and thromboembolic complications. Mean number of drugs per patient was 3. Patients were taking a range of antithrombotic medications including aspirin, plavix, combination of aspirin and plavix, oral anticoagulants, LMWH, and NSAIDs.
Most of the bleeding manifestations were mild (92%). 8% had moderate bleeding episodes, which correlated to the ASPI platelet function test and advanced patient age. No significant correlation was found between the complexity of the procedure and bleeding risk.
In conclusion, the results of this study suggest the incorporation of the new platelet function tests to the preoperative workup of certain complex dental patients may increase safety of surgical procedures.

Assessment of Article: This was very applicable to what we do and highlights the precautions we must take with extractions.

Benign Teratoma of the Tongue in a Neonate: A Case Report and Review of the Literature

Resident’s Name: Jeff Higbee
Article title: Benign Teratoma of the Tongue in a Neonate: A Case Report and Review of the Literature

Author(s): Shetty et al.
Journal: Pediatric Dentistry

Case Report

Background:
Teratomas are neoplasms with the ability to grow continuously and are the most common extragonadal germ cell tumors of childhood. The cause of these neoplasms are unknown. Teratomas of the tongue are very rare and may develop from misplaced cells from the tuberculum impar.

Case Report:
A 6-week-old male presented in India for evaluation of a congenital lesion that had remained unchanged since birth. He was experiencing difficulty swallowing and breast-feeding, but no breathing problems. Clinical exam revealed a 2x1.5x1.5 cm pedunculated mass with smooth surface and normal coloring on the anterior 2/3 of the dorsum of the tongue. The patient experienced severe ankyloglossia and also polydactyly in all 4 limbs.
A team of oral and maxillofacial surgeons and pediatric dentists excised the mass under nasotracheal intubation with a circumferential incision including a few millimeters of healthy tissue. The lesion was cauterized and primary closure was obtained and a frenectomy was performed to correct the ankyloglossia. Histopathological exam revealed fibrous connective tissue, adipose tissue, mixed salivary glands, sebaceous glands, striated muscle, chondroid tissue and blood vessels and there was no evidence of malignancy.

Discussion:
Teratomas are classified into 4 different types:
1. dermoid- epidermal and mesodermal elements, most common
2. teratoid- ectodermal, mesodermal and endodermal, but poorly differentiated
3. true teratoma- 3 germ layers and differentiated
4. epignathus- highly differentiated into recognizable organs/limbs, high mortality rate
There have only been 20 documented cases of tongue teratoma since 1966. 75% experienced difficulty eating, but only 35% had problems breathing. Although the majority of cases are benign, 20% possessed histological evidence of malignancy.
Differential diagnosis: lymphangioma, hemangioma, granular cell myoblastoma, gastric mucosal cyst, lingual thyroid, thyroglossal duct cyst, ectodermal inclusion body, heterotropic gastric mucosal mucosal cyst, congenital rhabdomyosarcoma, encephalocele, glioma and neurofibromatosis.
Surgical excision is the treatment of choice and recurrence is rare.

Assessment of Article:
A well written article and good overview of teratomas, their clinical presentation, differential diagnosis and treatment.

Pediatric Oral Surgery




Pediatric SCC: A Case Report

Resident: Avani Khera

Article Title: Pediatric Squamos Cell Carcinoma: Case Report and Literature Review

Authors: Sidell MD, et al.
Journal: The Laryngoscope, 119; August 2009

Purpose: The purpose of the article was to describe a rare pediatric malignancy, including clinical, diagnostic, therapeutic differences between SCC of adult/child patients.

Background: SCC of oral cavity is extremely rare in pediatric population. In pediatric patients, the pathological process is different than with adults, the disease is harder to diagnose pathologically, and it is more aggressive.  Treatment usually includes wide local excision with avoidance of radiotherapy.

6 yo male referred to UCLA head and neck clinic by oral surgery with 2 month history of enlarging oral lesion involving the anterior gingiva with extension to hard palate.  The child’s dentist initially noticed the lesion while extracting a tooth in the area.  The lesion persisted and the child was referred for biopsy.  Results were initially interpreted as SCC.  The mass was 2.7 X 3.0 cm in size with irregular margins. Upon presentation, the patient denied dysphagia, pain, weight loss, bleeding, or loosening of the teeth.  The patient was referred for surgical maxillectomy.

Discussion:  Pediatric oral malignancy is so rare that it is often not included on the differential when we see a lesion.  SCC of the oral cavity primarily affects adults in the 6th-7th decades, with only 4% of all oral cancers occurring in patients under 40.  Among kids, SCC accounts for fewer than 2% of all head and neck malignancies. It is even more rare to find it in the mouth, and only a few case reports exist.

Etiology:  Some genetic conditions are associated with increased incidence of carcinomas (Fanconi anemia, xeroderma pigmentosus, keratitis, icthyosis, and deafness syndrome).   It can be hard to differentiate between SCC and other inflammatory or reactive cellular processes histologically. 

Most common location in children: Tongue and lip

Treatment:  Wide local excision; avoid radiotherapy (and possible sequelae such as secondary malignancy)

Tuesday, March 25, 2014

Pediatric Oral Surgery

Guideline on Pediatric Oral Surgery
Resident: Hofelich

Purpose: The American Academy of Pediatric Dentistry intends this guideline to define, describe clinical presentation, and set forth general criteria and therapeutic goals for common pe-diatric oral surgery procedures that have been presented in considerably more detail in textbooks and the dental/medical literature.


Preoperative evaluation
Medical
  • obtain a thorough medical history, 
  • obtain appropriate medical and dental consultations
  • anticipate and prevent emergency situations
  • be prepared to treat emergency situations

Dental

  • perform a thorough clinical and radiographic preoperative evaluation of the dentition as well as extraoral and intraoral soft tissues
  • radiographs can include intraoral films and extraoral imaging if the area of interest extends beyond the dentoalveolar complex

Odontogenic infections
  • Untreated odontogenic infections can lead to pain, abscess, and cellulitis
  • children are prone to dehydration—especially if they are not eating well due to pain and malaise
  • Infections of odontogenic origin with systemic manifestations (eg, elevated temperature of 102 degrees Fahrenheit to 104 degrees Fahrenheit, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea) require antibiotic therapy
  • Severe but rare complications of odontogenic infections include cavernous sinus thrombosis and Ludwig’s angina
    • These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon

Fractured primary tooth roots
  • removing the root tip may cause damage to the succedaneous tooth, while leaving the root tip may in-crease the chance for postoperative infection and delay eruption of the permanent successor
  • The literature suggests that if the fractured root tip can be removed easily, it should be removed
  • If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed

Impaction

  • Routine evaluation of patients in mid-mixed dentition should involve identifying signs such as lack of canine bulges and asymmetry in pattern of exfoliation
  • When the cusp tip of the permanent canine is just mesial to or overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine palatal impaction usually occurs
  • Extraction of the primary canines is the treatment of choice when malformation or ankylosis is present, when the risk of resorption of the adjacent tooth is evident, or when trying to correct palatally impacted canines, provided there are normal space conditions and no incisor resorption.
  • One study showed that 78 percent of ectopically-erupting permanent canines normalized within 12 months after removal of the primary canines; 64 percent normalized when the starting canine position over-lapped the lateral incisor by more than half of the root and 91 percent normalized when the starting canine position over-lapped the lateral incisor by less than half of the root
  • If no improvement in canine position occurs in a year, surgical and/or orthodontic treatment are suggested

Thirds
  • AAOMS recommends that a decision to remove or retain third molars should be made before the middle of the third decade 
  • removal of disease-free third molars is not indicated, consideration should be given to removal by the third decade when there is a high probability of disease or pathology and/or the risks associated with early removal are less than the risks of later removal

Supernumerary Teeth

  • thought to be related to disturbances in the initiation and proliferation stages of dental development
  • some supernumerary teeth may be syndrome associated (eg, cleidocranial dysplasia) or of familial inheritance pattern
  • most supernumerary teeth occur as isolated events
  • In 33 percent of the cases, a supernumerary tooth in the primary dentition is followed by the supernumerary tooth complement in the permanent dentition
  • Reports in incidence of supernumerary teeth can be as high as three percent, with the permanent dentition being affected five times more frequently than the primary dentition and males being affected twice as frequently as females
  • will occur 10 times more often in the maxillary arch versus the mandibular arch
  • strong predilection to the anterior region
  • most common is a mesiodens, the second most common site is the maxillary molar area, with the tooth known as a paramolar
  • mesiodens can be suspected if there is an asymmetric eruption pattern of the maxillary incisors, delayed eruption of the maxillary incisors with or without any over-retained primary incisors, or ectopic eruption of a maxillary incisor
  • only 25 percent of all mesiodens erupt spontaneously
  • surgical management often is necessary
  • A mesiodens that is conical in shape and is not inverted has a better chance for eruption than a mesiodens that is tubercular in shape and is inverted
  • Extraction of an unerupted primary or permanent mesiodens is recommended during the mixed dentition to allow the normal eruptive force of the permanent incisor to bring itself into the oral cavity
  • Waiting until the adjacent incisors have at least two-thirds root development will present less risk to the developing teeth but still allow spontaneous eruption of the incisors.

Frena
  • Treatment is suggested when the attachment exerts a traumatic force on the gingiva causing the papilla to blanch when the upper lip is pulled or if or it causes a diastema to remain after eruption of the permanent canines
  • Ankyloglossia is a developmental anomaly of the tongue characterized by a short, thick lingual frenum resulting in limitation of tongue movement (partial ankyloglossia) or by the tongue appearing to be fused to the floor of the mouth (total ankyloglossia)


Frenectomy techniques
  • Frenectomy involves surgical incision, establishing hemostasis, and suturing of the wound
  • Dressing placement or the use of antibiotics is not necessary
  • Recommendations include maintaining a soft diet, regular oral hygiene, and analgesics as needed
  • the use of laser technology and electrosurgery for frenectomies have demonstrated a shorter operative working time, the ability to control bleeding quickly, reduced pain and discomfort, fewer postoperative complications (eg, pain, swelling, infection), and no need for suture removal, as well as increasing patient acceptance
Natal Teeth


  • If the tooth is not excessively mobile or causing feeding problems, it should be preserved and maintained in a healthy condition if at all possible
  • Close monitoring is indicated to ensure that the tooth remains stable 
  • Riga-Fede disease is a condition caused by the natal or neonatal tooth rubbing the ventral surface of the tongue during feeding leading to ulceration
  • Failure to diagnose and properly treat this lesion can result in dehydration and inadequate nutrient intake for the infant
  • Treatment should be conservative and focus on creating round, smooth incisal edges
  • If conservative treatment does not correct the condition, extraction is the treatment of choice





Saturday, March 22, 2014

Pinkham Chapter 28 – Local Anesthesia and Oral Surgery in Children

Stephen Wilson
Resident: Anna Abrahamian

Local Anesthesia In Children
Topical Anesthesia: used to lessen pain from injection. It’s usefulness has been debated – some argue that the taste of the topical may produce anticipation of the needle (conditioned response). Technique of topical anesthestic application is important: use gel sparingly and only on a very dry mucosal surface for at least 2 minutes.
Local Anesthesia: Technique is important in limiting pain – the operator can use verbal distraction, counter-irritation (vibratory stimuli or cotton swab pressure), and slow injection (a single carpule should take at least 1 minute to deposit).
Maxillary Primary And Permanent Molar Anesthesia: Innervation of these teeth is through the Posterior Superior Alveolar Nerve and the Middle Superior Alveolar Nerve.  Injection should penetrate the muccobuccal fold to a depth that approximates the apices of the buccal roots.
Maxillary Primary and Permanent Incisor and Canine Anesthesia: Innervation is through the Anterosuperior Alveolar Branch of the maxillary nerve. Injection can be given as an infiltration in the muccobuccal fold to the depth of the apices or an infraorbital block.
Palatal Tissue Anesthesia: Innervation is through the Anterior Palatine, Nasopalatine Nerve,  and Greater Palatine Nerves. These are very painful and should only be used if necessary to get full palatal anesthesia.
Mandibular Tooth Anesthesia: Innervation is via the Inferior Alveolar Nerve.  The nerve enters the mandible on the foramen on the lingual aspect f the mandible. The position of the foramen changes by remodeling more superiorly from the occlusal plane as a child matures into adulthood. IAN blocks can be used where the insertion is between the internal oblique ridge and the pterygomandibular raphe at the level of the occlusion. If missed, go slightly higher.  The Long Buccal Nerve supplies the molar buccal gingiva and may also provide accessory innervation of the teeth. Some advocate the use of a periodontal ligament injection for anesthestizing singular teeth, bug some evidence has shown that this can cause hypoplasia and decalfication of succadaneous teeth.
Complications of Local Anesthesia: Masticatory trauma, hematomas, infections, trismus. Phentolamine mesylate (OraVerse) is a competitive alpha-adrenergic antagonist and vasodilator that has been shown to clear local anesthestic for the area of injection to reduce time of soft tissue paresthesia. Manufacturer recommends that PM not be used in children younger than 6 years old or weighing less than 15 kg.
Alternative Anesthesia Systems: Single Tooth Anesthesia (STA) Units are computer-controlled systems to deliver anesthetic at a slow rate and constant pressure with a wand- or pen-like syringe (less threatening).


Oral Surgery in Children
Considerations: Obtain a good medical history and consultations, anticipate emergency situations and be prepared for them, and choose proper instrumentation – use pediatric extraction forceps like 150S and 151S because they allow for easier placement in the smaller oral cavity of children AND the beaks adapt better to the anatomy of primary teeth.
Technique: Prepare child and parent for the procedure. Use throat guard or rubber dam to prevent aspiration. Support the jaw on mandibular extractions. Separate the marginal gingiva then luxate with elevation before using extraction forceps.
Maxillary Molar Extractions:  Roots tend to be divergent and small in diameter – root fracture is possible and likely with these teeth, so they should be luxated palatally first then buccally.
Maxillary Anterior Teeth Extractions: Often have single conical roots that are less likely to fracture and allows for more rotational movement during extraction than is possible with multi-rooted teeth.
Mandibular Molar Extractions: Support the mandible with the nonextraction hand to prevent injury to the TM joints.
Mandibular Anterior Teeth Extractions: Be careful not to displace adjacent teeth due to conical roots. Rotational force used to extract.
Management of Fractured Primary Tooth Roots: A common sense approach must be taken. If the root can be accessed and is visible, then an effort should be made to extract it. If the fragment is very small or inaccessible, it is better to leave the root fragment to prevent damage to the developing permanent tooth.
Soft Tissue Surgical Procedures:
-       Biopsies: If the lesion is <0.5cm, an excisional biopsy is best. Consideration must be taken if the lesion appears vascular and can be checked with aspiration. Some areas require sedation for biopsy due to sensitivity (ex: tongue). Resorbably sutures are preferred.
-       Frenectomies: Maxillary labial frenectomies should only be performed if the frenum is a causative factor in maintaining a diastema. This cannot be determined until the permanent canines have erupted. Lingual frenectomies should only be considered after evaluation by a speech therapist and only the most severe cases qualify

-       Facial fractures: Signs and symptoms to look for include: altered occlusion, numbness in the infraorbital nerve distribution, double vision, peri-orbital ecchymosis, facial asymmetry, limied mandibular opening, subcutaneous emphysema, nasal bleeding, mobility or crepitus of the maxilla or mandible.  Initial management should be directed toward the immobilization of fractured segments, early antibiotic therapy for open fractures, and pain control. Always refer to a qualified specialist for definitive treatment.