Beltway Bambinos

Dr. Karen Benitez, founder & designer, board certified pediatric dentist at Chevy Chase Pediatric Dentistry will be writing a series of guest posts related to adolescent dentistry and questions she frequently receives from patients that may be of interest to you. If you have a topic you’d like to see her feature, leave it in the comments. 

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post addresses the topic of why x-rays are important for your child to have. The last post explained why your child may be referred to an orthodontist at what may seem like a young age. 

Upon learning that your child has cavities, most parents want to learn what the next steps would be towards treatment. The variety of treatment approaches is a complex subject matter because it varies vastly per patient and situation, as well as within a family. These options are specific to each child and as we all know, our kids can be different.

As a general rule, I prefer not discussing cavities in the presence of your young or nervous child. Some kids are upset by the news of cavities and to alleviate this, we maintain a distance in the conversation and phrase their upcoming visit in very friendly terms.

I begin by outlining possible treatment approaches. Some common options include: deferred treatment (with or without fluoride varnish or silver diamine fluoride), treatment with or without nitrous oxide (laughing gas), mild sedation or general anesthesia.

The first step is determining if we should take an active role in treating these cavities in the current time or monitor them. Monitoring of cavities is often used if the cavities are smaller in size. Starter cavities are called incipient cavities. Depending on the number of incipient cavities seen, I may have your child be seen every 3 months to monitor.

If the cavity grows in size but perhaps your child is not yet ready for the steps involved in restoring the teeth, another option is proposed. In select situations such as these, where the rate of growth of cavities can be controlled, I propose deferred treatment. This option does not suggest that we are never going to restore the cavities, but that we are tracking your child’s development, as well as cavity growth, to determine a better time in the near future to approach treatment. I schedule your child for limited exams every 3 months until a more definitive plan is made.

Deferred treatment can involve the use of materials proven to slow down the growth rate of the cavity-causing bacteria. These materials include fluoride varnish or silver diamine fluoride (SDF). The latest option of silver diamine fluoride (SDF) is of increased discussion and use with larger cavities in a child not yet ready to undergo dental treatment, because it is proven to be more effective than fluoride varnish. It is a clear, liquid material, similar to the bonding agent used for white fillings, that helps to stop the growth of the cavity. One caveat in the use of this material is that it turns the lesion black and yes, it is noticeable, but effective for its intended use! It is generally followed with the application of fluoride varnish. The use of SDF is often used to gain time for the child to develop to better tolerate treatment at a later time.

For kids who are on path to receive dental treatment my first line of treatment is to determine whether nitrous oxide (laughing gas) would be used or not. Some kids are fully prepared for no agent to be used to modify their tolerance of treatment. These kids bypass the use of nitrous oxide, whereas others would benefit from additional support—introducing nitrous oxide.

So what is nitrous and why is it used? Nitrous oxide is a common inhaled gas used in dentistry because of its ease of use and tolerance by the vast population. It’s an air that is breathed through a nose piece connected to the source of the mixed agents of nitrous oxide and oxygen. It is used as a mild to moderate sedative because of its potential to be titrated (increased or decreased for effect), with caution. It is proven to have both analgesic (numbing) and anxiolytic (anxiety-reducing) properties, so it works great in cases with moderate treatment needs. In some cases, the analgesic component is sufficient enough to not use local anesthetic, however, be aware that we are talking limited situations of small cavities. Nitrous oxide is not metabolized by the body, so at the end of treatment 100% oxygen is breathed in, as the effects of the nitrous oxide are being eliminated. Unlike medicines, nitrous does not go through the digestive system, being excreted in hours to come. It is the easiest, least invasive option in helping kids tolerate some uncomfortable procedures.

If your child is neither a candidate for treatment with or without nitrous, and would benefit from additional support for their dental treatment, a step up in my “tool box” is a mild sedation. I offer this option when I find that your child is a good candidate for it. Not all children can be given an oral sedative, based on their age, medical history and cavity presentation. The goal of a mild sedation is to protect the child’s mental awareness of the treatment and most certainly to maintain a safe measure for treatment. The options vary per dentist, but this option utilizes a weight-based dosage of sedative medications targeted for a MILD response. A mild sedation functions by suppressing the central nervous system, allowing relief of anxiety to your child, providing a timely treatment option. Some children are exceptionally nervous for treatment and without using further agents to make them more calm and comfortable, even treatment with nitrous is not accepted by them. I have had children who will not even sit in the dental chair but have cavities beyond the size of monitoring or deferring treatment. Having the option of an oral sedative has truly helped these children, and their parents, who are not ready for the most advanced option of general anesthesia. Your child IS NOT ASLEEP with an oral sedative. In fact, I am very clear, that the dosage is provided to suffice a mild effect. The goal is for your child and I to remain in conversation about what is happening and to alter their perception of what they imagine is going to happen. I often find that my patients who have had favorable dental experiences in this manner really do better tolerate dental treatment in the future with less apprehensions. Their confidence is elevated in their successful treatment!

Keep in mind that the more advanced routes now being discussed do carry increases in risks. When medications are administered, the risks involve respiratory (breathing) and cardiac (heart) function. A sedation uses nitrous oxide, in most cases, as well as monitoring of your child’s heart rate and breathing via a pulse oximeter with capacity to include carbon dioxide monitoring and a precordial stethoscope. All medications used have a reversal agent and all calculations are prepared beforehand. Safety margins are maintained through the appropriate selection of medications, adherence to dose recommendations, as well as the assessment of qualifying patients. As a Pediatric Dentist, we receive training in mild sedation as an alternative for your child to tolerate treatment. In order to provide mild sedation as a service in my office, both myself as a practitioner and my office are licensed by the Maryland State Board through an oral exam and site assessment. Again, not all children are candidates for this option, or perhaps still require a more advanced method to tolerate their dental needs, hence another option is available.

For children who are unable to receive dental treatment in the most straightforward of manners (with or without nitrous oxide), nor a candidate for a mild sedation, there exists the option of general anesthesia. This is a treatment option in which your child is fully asleep and is routinely performed in a hospital or surgical center by an anesthesiologist. It is the greatest depth of sedation that can be provided and is my last alternative in most cases, with various exceptions. This treatment approach is generally considered the most advanced due to the depth of suppression of the central nervous system. Only qualified doctors or nurse anesthetists provide this medical care. It is an environment in which very limited persons are allowed. Only the anesthesiologist, the dentist, the dental assistant and the surgical nurse are in the operating suite, working together to ensure a safe and prompt procedure for your child. In the case of general anesthesia, our practice philosophy is generally to provide any and all treatment needs to avoid further dental needs in the dental office setting. In other words, some providers are more in line with treating even smaller cavities that would grow over time.

Neither a mild sedation nor hospital dentistry are a provider’s first choice of treatment, however, given the significant rise in cavities seen in younger and younger patients, we all have experienced an increasing need in such options for children to be able to restore their teeth.

Many in the general population ask, “But they are just baby teeth, won’t they all fall out?”. It is true that most baby teeth are shed to be replaced by a permanent tooth, but this occurs over the course of approximately 6 years, beginning around 6-7 years age. Not all permanent teeth formulate, hence maintenance of the baby tooth is more critical to the child, and the number of cavities seen does increase the risk of baby teeth becoming infected, causing pain and early loss. Younger children are seen with cavities as well. I really wish to change the thought that baby teeth are not so important because they really are and keeping your child cavity-free or minimal cavities, is my primary goal. These options discussed are for managing already existing cavities, or other dental needs, that if left untreated, can cause pain and infection for your child.

It is my hope that this helps you to understand steps involved in the decision-making process of how to provide dental treatment for your young ones. Furthermore, I hope that this helps to realize the importance of regular check-ups and establishing a relationship with a dental provider that you can really learn from and grow together in best interest for your child. These early habits of prevention are learned just as much as other hygiene and dietary practices are. Help us grow strong, healthy kids, with smiles designed to last a lifetime!

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

You can also find us as Bethesda Magazine’s Face of Pediatric Dentistry, view our Top Docs video and read our stellar reviews on Yelp, GoogleandZocDoc.  Follow us on Facebook to learn more about what Chevy Chase Pediatric Dentistry is all about…Focusing on your kids.

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246