Dental abnormalities, including dental caries and soft-tissue and hard-tissue anomalies, are common in children. Although the prevalence of dental caries in children has reportedly decreased over the past 5 decades,(17, 51) evidence suggests a disproportionate and alarming increase in the prevalence of caries involving primarily preschool-aged children of low socioeconomic class.(17) This subgroup is estimated to account for 25% to 50% of all carious lesions in children. This estimate is significant because children are most challenging for dentists in terms of management. The proportion of children requiring physical restraint or pharmacologic management during delivery of dental care is estimated at 10% to 25%.(42, 73) This type of management is indicated for several important reasons, including the technical complexity of the treatment, operative safety issues, pain control, and potential psychic trauma. Often, the dentistry required to restore carious teeth is technically complex and requires excellent patient cooperation. Even under optimal conditions with older cooperative patients, restorative techniques can be challenging for dentists when the desired outcome is excellent esthetics and freedom from discomfort. Several aspects of delivering dental care may be dangerous for clinicians and patients. For instance, in children who are struggling and unrestrained, the injection of local anesthesia is critical and may result in injury to the eye, cheek, lip, or limbs, depending on the degree of struggling. Even if the needle is inserted into the proper tissue, struggling patients may cause significant pain and bruising around the insertion site or even breakage of the needle in the tissue. Protecting children from these adverse outcomes often requires restraint, including the limbs and head, whether mediated by a device (e.g., Paposse Board [Olympic Medical Company Seattle, WA]), parent or other personnel, or pharmacologic agent (e.g., sedatives). Despite careful technique, it is not always possible to obtain adequate local anesthesia for dental procedures. Two major factors causing inadequate anesthesia are (1) the pH of the tissue bed into which the local anesthetic diffuses (i.e., it is difficult to obtain profound anesthesia for the removal of abscessed teeth) and (2) anatomic variations in nerve distribution. The risk for inducing situational psychic trauma as a result of receiving dental care also should be considered, but the author is unaware of any large body of systematically studied and documented evidence concerning development of situational psychic trauma in children during dental procedures. The author has witnessed some children who required restraint for the removal of abscessed teeth and who, on return for routine care, display uncontrollable situational anxiety and fear despite extreme efforts to assist these children in coping with the appointment. Specific focusing on and fear of certain procedures or equipment are notable (e.g., fear of suffocation from the application of a rubber dam, needle phobia, and fear of handpiece noise and sensations). The most common modes of pharmacologic behavior management in pediatric dental practice are oral sedation and general anesthesia. Nitrous oxide (N2O) alone or in combination with oral sedatives is most common.(73) General anesthesia may be administered in the dental office by a qualified provider (e.g., dental or medical anesthesiologist), in an ambulatory care facility, or in a hospital.
