PAIN MANAGEMENT IN PAEDIATRIC DENTISTRY.pptx

1. I. PREMEDICATION AND PAIN CONTROL AGENTS
II. COMMON DRUGS USED IN PAIN CONTROL
III. LOCAL ANAESTHESIA TECHNIQUES
GROUP C
12/02/2024

2. PAIN MANAGEMENT IN PAEDIATRIC DENTISTRY
contents
• definition
• causes of pain
• impacts of dental pain
• pain assesment
• pain management
• dosage calculations
• LA

3. definiton
• An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage.” According
to the International Association for the Study of Pain (IASP) in 1986.
• An unpleasant sensory and emotional experience associated with, or
resembling that associated with, actual or potential tissue
damage.According to the International Association for the Study of Pain
(IASP) 2020.

4. causes of pain in paediatric dentistry
• Dental caries especially deep lesions
• Tooth eruption
• Trauma to the teeth
• Dental abscess
• Bruxism
• Loose teeth
• Gum disease

5. Impacts of dental pain
• difficulty in sleeping
• difficulty eating
• difficulty in brushing teeth
• concentrating in activities
• school absenteeism
• negatively affected their
• families i.e. disruption in physical activities (e.g., performing household
activities), social activities (e.g., visiting friends and relatives), psychological
activities (e.g., waking up at night, emotional stability, family relationship), and
economic impacts (e.g., work loss, effect on family budget due to expenditure on
pain relief)

6. Pain assessment
• Difficulty in identifying and assessing pain in children is one of the barriers to its
management.
• use of pain evaluation tools which differ according to the age of the child ,is generally
necessary to confirm the existence of pain, assess its intensity, determine the
analgesic means required, and evaluate the effectiveness of the treatment instituted.
• pain evaluation in children can be done using various scales i.e. Visual Analogue Scale
(VAS),Wong-Baker Face Pain Rating Scale( WBFPS),Children's Hospital of Eastern
Ontario Pain Scale (CHEOPS).
• A systematic review of the literature on face scales (Self-evaluation scale) concluded
that children preferred the WBFPS scale because the faces used are close to those of
children, which further promotes their cooperation.
(Elasmar, M. (2021). Evaluation and management of dental pain in children Motivating emergency consultation at the
Dental Consultation and Treatment Center of Casablanca. Journal of Pediatric Dentistry.
https://doi.org/10.14744/jpd.2021.06_36)

7. (Wong-Baker FACES Foundation. (2020, April 28). Home - Wong-Baker FACES
Foundation. https://wongbakerfaces.org/)

8. pain management
• range from nonpharmacologic modalities to pharmacological treatment.
Nonpharmacologic therapy
1. calm environment
2. encouraging deep breathing
3. employing guided imagery
4. distraction,
5. play therapy
6. hypnotherapy
7. virtual reality,
8. other (e.g.,acupuncture, transcutaneous nerve stimulation)

9. pharmacological
• consist of administration of topical and local anesthesia, analgesic medications, and/or
mild,moderate, or deep sedation regimens.
• Analgesic selection depends on the individual patient, the extent of treatment, the
duration of the procedure, psychological factors, and the patient’s medical history.
• therapeutics available for the prevention of pain include acetaminophen,nonsteroidal
anti-inflammatory drugs(NSAIDs) and opioids.
• A guideline panel determined that, when used as directed, acetaminophen alone, NSAIDs
(like ibuprofen) alone or acetaminophen in combination with NSAIDS can effectively
manage a child’s pain after a tooth extraction or during a toothache when dental care is
not immediately available.
(ADA Media Relations. (n.d.). New guideline details dental pain management strategies for pediatric patients. American Dental
Association. https://www.ada.org/en/about/press-releases/new-guideline-details-dental-pain-management-strategies-for-
pediatric-patients)

10. Acute dental pain
• Evidence-Based Clinical Practice Guideline for the Management of Acute Dental Pain: Postoperative Pain after 1 or More Simple or
Surgical Tooth Extractions in Children
1. For the management of acute postoperative dental pain in children undergoing 1 or more simple or surgical
tooth extractions,
• the guideline panel suggests initiating the pain management scheme using ibuprofen alone, naproxen (>2 years)
alone, OR either of the two in combination with acetaminophen over the use of acetaminophen alone.
• 1.1. If postprocedural (that is, simple or surgical tooth extraction) pain control using NSAIDs alone is inadequate,
the guideline panel suggests the addition of acetaminophen
• 1.2. When NSAIDs are contraindicated, the guideline panel suggests the use of acetaminophen alone.
.
2. For the management of acute postoperative dental pain in children undergoing 1 or more surgical tooth
extractions, the panel will not formulate recommendations for or against corticosteroids due to a paucity of
evidence.
Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BS, Schwartz PJ,
Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical
practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science
and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the
University of Pennsylvania. J Am Dent Assoc. 2023 Sep;154(9):814-825.e2. doi: 10.1016/j.adaj.2023.06.014. PMID: 37634915.

11. Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BS, Schwartz PJ, Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A,
Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association
Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. J Am Dent Assoc. 2023 Sep;154(9):814-
825.e2. doi: 10.1016/j.adaj.2023.06.014. PMID: 37634915.

12. paediatric pulpitis
• Recommendations and good practice statements for the temporary pharmacologic management of toothache in
children with no immediate access to definitive dental treatment.
1.For the temporary management of toothache (symptomatic pulpitis [that is, reversible or symptomatic irreversible pulpitis with or
without symptomatic apical periodontitis or symptomatic periapical or furcation involvement] or pulp necrosis with symptomatic apical
periodontitis or periapical or furcation pathosis, or acute apical abscess) before definitive dental treatment in children,
• the guideline panel suggests the use of ibuprofen alone,naproxen (> 2 years) alone,or either of the 2 in combination with
acetaminophen
• When nonsteroidal anti-inflammatory drugs are contraindicated,the guideline panel suggests the use of acetaminophen alone .
• ∗These recommendations are applicable only to settings in which definitive dental treatment is not available. Definitive dental
treatment includes pulpectomy, nonsurgical root canal treatment, incision for drainage of abscess, and tooth extraction. Patients or
their caregivers should be instructed to call if their pain fails to lessen over time or to call if the referral to receive definitive dental
treatment within 2 through 3 days is not possible.
• These pharmacologic strategies will alleviate dental pain temporarily until a referral for definitive dental treatment is in place.
• According to the US Food and Drug Administration, codeine and tramadol are contraindicated¶in children younger than 12 years. In
addition, topical benzocaine should not be used in infants or young children owing to the high risk of methemoglobinemia.
• Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BS, Schwartz PJ, Suda KJ, Turturro
MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic
management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental
Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. J Am Dent Assoc. 2023 Sep;154(9):814-825.e2. doi:
10.1016/j.adaj.2023.06.014. PMID: 37634915.

14. opioids
• effective for moderate to severe postoperative pain
• potential adverse effects (e.g., nausea, emesis, constipation, sedation, respiratory
depression) and diversion has steadily deacreased its dispensation in paediatrics.
• a combination of acetaminophen and ibuprofen provided effective analgesia without the
adverse side effects associated with opioids.
• In 2017, the United States Food and Drug Administration (FDA) issued a warning to restrict
the use of codeine and tramadol in children and breastfeeding mothers.
(ADA Media Relations. (n.d.). New guideline details dental pain management strategies for pediatric patients. American Dental
Association. https://www.ada.org/en/about/press-releases/new-guideline-details-dental-pain-management-strategies-for-
pediatric-patients)

15. Dosage calculations
• when giving a drug to a child it may be required that you adjust the dosage based on how much they
weigh, as assigning a dosage based on age could result in the child taking too much or too little of the drug.
• Dosages may not necessarily be given per day. They could be per hour, or any time frame.
About yorksj.ac.uk/media/content-assets/study-skills/Maths-and-statistics/Nursing-maths/Dosage-Calculations-
per-KG-Factsheet.docx - Google Search. (n.d.).
https://www.google.com/search?q=About+https://www.yorksj.ac.uk/media/content-assets/study-skills/maths-
and-statistics/nursing-maths/Dosage-Calculations-per-kg-
Factsheet.docx&tbm=ilp&sa=X&ved=2ahUKEwiM2sbdkreEAxWGygIHHV93AIIQv5AHegQIABAD

17. Example
• A patient is prescribed a drug. The dosage of the drug is 3mg/kg of body weight/day, and the patient
weighs 40kg. The drug comes in liquid form with a concentration of 2mg/ml. What volume of the drug
should the patient be given in a single dose if they must take the drug 2 times per day?

18. OUTLINE;
1. DEFINITION
2. TOPICAL ANESTHESIA;
- Formulations
- Techniques
- Types; Benzocaine, Lidocaine, EMLA
- Recent Advances; Dentipatch
3. REGIONAL ANESTHESIA;
- Types
- Recent Advances
- Complications

19. DEFINITION;
• A loss of sensation in a circumscribed area of the body caused by a
depression of excitation in nerve endings or an inhibition of the
conduction process in peripheral nerves.
( Malamed, 1980)

20. LOCAL ANAESTHETIC AGENTS;
Esters;
• Esters of Benzoic Acid; Cocaine, Butacaine, Benzocaine, Tetracaine
• Esters of Para Aminobenzoic Acid; Procaine, Chloroprocaine,
Propoxycaine
Amides;
• Bupivacaine, Lidocaine, Articaine, Prilocaine, Mepivacaine,
Ropivacaine
Quinolones; ( not used anymore)
• Centbucridine

21. TOPICAL ANESTHESIA;
• Available in different forms:
- Gel; Benzocaine 20% ( most effective type).
- Liquid
- Spray; Lidocaine 15%

22. • Gel is the most desired;
i. Easy to control application to the oral mucosa
ii. Most of the have pleasant flavours
• Benzocaine liquid, ointment, or gel preparations are best suited for
topical anesthesia;
i. They offer a more rapid onset
ii. Longer duration of anesthesia than other topical agents
iii. Not known to produce systemic toxicity; low aqueous solubility
making its absorption slow

23. TECHNIQUE;
• The mucosa at the site of the intended needle insertion is dried
with gauze.
• A small amount of the topical anesthetic agent is applied to the
tissue with a cotton swab.
• Topical anesthesia should be produced in 30 seconds.
• The dentist should prepare the child for the injection
• Mucosa should appear white and wrinkled
• Effective to a depth of 2-3 mm .

24. BENZOCAINE;
Formulations;
i. Solutions, Sprays; 5%, 10%, 20%
ii. Oral preparations; 7.5% – 20%
Most widely used;
i. Fast action
ii. Acceptable taste
iii. Lack of systemic absorption

25. INDICATIONS;
1. Oral ulcers, mucositis
2. Pain during teething
3. Periodontal irritation
4. Reduce discomfort caused by
the needle
5. Orthodontic banding
CONTRAINDICATIONS;
1. Pts with congenital
methemoglobinemia
2. Pts with deep wounds,
injuries, severe burns
3. Pts allergic to benzocaine

26. ADVERSE EFFECTS;
1. Methemoglobinemia when high concentrations are used; Cyanosis,
Hypoxia, Dyspnea
2. CVS; Hypotension, Bradycardia, Cardiac arrest
3. CNS; Seizures, Drowsiness, Dizziness
4. Allergic reactions

27. LIDOCAINE;
Formulations;
i. Gel, patches; 2-5 %
ii. Ointment; 5%
iii. Spray; 10%
ADVANTAGES;
1. High safety margin before
reaching its toxic levels
DISADVANTAGES;
1. Has an unpleasant taste
2. Only relieves pain caused by
needle insertion but not the
injection itself

28. INDICATIONS;
1. To reduce the discomfort of the initial penetration of the needle
into the mucosa.
2. Oral ulcers
3. Orthodontic banding
4. During teething

29. EUTECTIC MIXTURE OF LOCAL ANESTHESIA;
• Oil in water emulsion of 2.5% lidocaine an 2.5% prilocaine
• Available in concentration of 2.5 -5%
• Duration of action of 2-10 minutes
• Available in;
i. Foams
ii. Ointments
iii. Pastes
iv. Gels
v. Creams
vi. Patches

30. INDICATIONS;
i. Small mucosal biopsies
ii. During placement of
orthodontic spacers
iii. Children with needle phobia
iv. When elastomeric orthodontic
separators are to be used
DISADVANTAGES;
i. Don’t provide sustained action
due to their short retention
time
ii. Act on non targeted parts;
numbness of the mouth and
throat, choking

31. RECENT ADVANCES;
• DentiPatch (Noven Pharmaceuticals, Inc., Miami, Fla), a lidocaine
transoral delivery system.
• This system seems to be designed primarily for situations in which
superficial oral tissue anesthesia is desired for several minutes rather
than the shorter time required for local anesthetic injections.
• Use of this product has not yet been shown to be convenient or
efficacious in young children

32. REGIONAL ANESTHESIA;
• There are two basic differences in the craniofacial complex of children
when compared to adults:
1. The jawbones are less dense
2. The smaller size of oral structures in children
3. Position of the mandibular foramen

33. TYPES OF REGIONAL LA;
1.Nerve block: Depositing the LA solution within close proximity to
a main nerve trunk.
2.Field block: Depositing LA in proximity to the larger nerve branches.
3.Local infiltration: Small terminal nerve endings are
anaesthetized.

34. COMMONLY USED LA AGENTS;

35. MANDIBULAR ANESTHESIA;
INFERIOR ALVEOLAR NERVE
BLOCK;
• Provides anesthesia to;
1. IAN and its terminal branches
2. Lingual nerve
3. Long buccal nerve
TECHNIQUES;
1. Conventional IANB
2. Vazirani-Akinosi Technique
3. Gow-Gates Technique

36. • The mandibular foramen is situated at a level lower
than the occlusal plane of the primary teeth of the
pediatric patient.
• The injection must be made slightly lower and more
posteriorly than for an adult patient.
BELOW 6 YEARS 6 – 12 YEARS ABOVE 12 YEARS

37. Areas anesthetized;
• Mandibular teeth of the
injected side.
• Body of the mandible, inferior
portion of the ramus.
• Buccal mucoperiosteum,
mucous membrane anterior to
the mandibular 1st molar.
• Anterior 2/3rd of tongue and
floor of the mouth.
• Lingual soft tissue and
periosteum.
Indications;
i. More than 1 tooth filling,
extraction
ii. Pulp therapy
iii. Difficulty in achieving a mental
block due to infection.

38. MENTAL NERVE BLOCK;
• Provides anesthesia to;
• Labial mucous membrane
• Pulpal tissues from the first premolar to the midline
• Periodontium
• Skin of lower lip, chin

40. LONG BUCCAL NERVE BLOCK;
Site Of Injection;
• Mucous membrane distal and
buccal to the most distal molar
tooth in the arch.
Area Anesthetized;
• Soft tissue and periosteum
buccal to the mandibular molar
teeth.

41. INFILTRATION FOR MANDIBULAR INCISORS;
• The terminal ends of the
inferior alveolar nerves cross
over the mandibular midline
slightly and provide conjoined
innervation of the mandibular
incisors.
• The labial bone overlying the
mandibular incisors is usually thin
enough for supraperiosteal
anesthesia techniques to be
effective.

42. SUPRAPERIOSTIAL TECHNIQUE (LOCAL
INFILTRATION)
• Most frequently used for obtaining pulpal anesthesia in
maxillary teeth.
• Indicated whenever dental procedures are confined to only
one or two teeth.
• Landmark: Insertion at 45 to the long axis of the tooth
1. Mucobuccal fold.
2. Crown of the tooth.
3. Root contour of the tooth.

43. Areas Anesthetized;
1. Pulp and root area of the tooth.
2. Buccal periosteum.
3. Connective tissue.
4. Mucous membrane.

44. GREATER PALATINE NERVE BLOCK:
• Anesthetizes the
mucoperiosteum of the palate
from the tuberosity to the
canine region and from the
median line to the gingival crest
on the injected side.

45. NASOPALATINE NERVE BLOCK;
• Palatal soft and osseous tissue
management from canine to
canine bilaterally

46. OTHER NERVE BLOCKS;
1. Posterior Superior Alveolar NB;
• Management of several molar teeth in one quadrant
2. Middle Superior Alveolar NB;
• Management of premolars in one quadrant
3. Anterior Superior Alveolar NB;
• Management of anterior teeth in one quadrant

47. SUPPLEMENTAL INJECTION TECHNIQUES;
1. PERIODONTAL LIGAMENT
INJECTION;
• The needle is placed in the gingival
sulcus, and advanced along the root
surface until resistance is met.
• Then approximately 0.2 mL of
anesthetic is deposited into the
periodontal ligament.
• Pressure is necessary ( by the
injection)to express the anesthetic
solution.
Indications;
i. In single tooth procedures
ii. In bleeding disorders
iii. In young handicapped patients
where lip biting may be a
problem

48. Advantages of Periodontal Ligament Anesthesia:
1. It provides reliable pain control rapidly and easily.
2. It provides pulpal anesthesia for 30 to 45 minutes.
3.It is no more uncomfortable than other local anesthesia techniques.
4. It is completely painless if used adjunctively.
5. It requires very small quantities of anesthetic solution.
6. It does not require aspiration before injection.
7. It may be performed without removal of the rubber dam.
8. It may be useful in patients with bleeding disorders that contraindicate use
of other injections.
9.It may be useful in young or disabled patients in whom the possibility of
postoperative trauma to the lips or tongue is a concern.

49. 2. INTRASEPTAL;
• Used to reinforce analgesia produced by infiltration and is primarily
used for mandibular primary molars
Technique;
1. Give a submucosal injection buccally
2. When the soft tissue anaesthesi is effective, inject LA through the
interdental papilla into the interdental bone mesially and distally
and deposit about 0.1 ml of the LA

50. 3. INTRAPULPAL;
• Indicated in pulp therapy when other techniques of la have failed
• The needle is bent and deposited into the pulp tissue

51. 4. INTRAPAPILLARY;
• Produces analgesia of palatal and lingual tissues to avoid more painful
injections.

52. RECENT ADVANCES;
1. JET INECTOR;
• Based on the principle of using a
mechanical energy source to
create a pressure sufficient to
push a liquid medication
through a very small orifice, that
it can penetrate into the
subcutaneous tissues without a
needle.

53. Advantages;
i. Painless technique
ii. Less tissue damage
iii. Faster injection
iv. Faster rate of drug absorption
into the tissues
Disadvantages;
i. It cannot be used for nerve
blocks, only infiltration and
surface anesthesia are possible

54. 2. COMPUTER CONTROLLED ADMINISTERING
OF LA;
• These devices consist of an
electronic unit, a footswitch (The
Wand-STA™, Sleeper One™,
CCS™), or a hand switch
(Dentapen™), needing a needle
(specialized or not) connected to
the device (. Fig. 7.3).
• Pen-shaped C-CLAD injectors
(The Wand-STA™, Sleeper One™,
CCS™, Dentapen™) allow good
support points.

55. Advantages;
i. It allows a drop-by-drop delivery
during the first seconds of
injection which is very difficult to
perform using traditional
syringes [32].
ii. Injection is continuous and
stable or increases slowly after
the first seconds: it therefore
avoids pulses of anesthetics that
are associated to high
intratissular pressure around the
needle and therefore to pain.
iii. The different appearance of the
needle and syringe, when pen-
shaped, appears to reduce fear
and pain in patients
Disadvantages;
i. Using C-CLAD devices takes
more time than regular
anesthesia
ii. It comes at a higher cost, so
much as to initial purchase as to
buying specific consumables

56. 3. VIBROTACTILE DEVICES;
• These devices work on the principle of 'gate control' theory thereby
reduces pain
• It acts based on the fact that the vibration message is carried to brain
through insulated nerves and pain message through smaller
uninsulated nerves.
• The insulated nerves overrule the smaller uninsulated nerves.
• The devices are: VibraJect, Dental Vibe, Accupal

58. 4. COMFORT CONTROL SYRINGE;
•This syringe (Dentsply) is an electronic pre programmed anesthesia
delivery device that uses a a-stage delivery rate.
•The rate of injection varies based on the injection technique chosen.
•It begins with as low rate; the flow the increases to a pre
programmed technique-specific rate selected by the dentist.
•The operation of this syringe (initiation and termination of the
injection, controlled aspiration and flow rate) is controlled by a button
on the handpiece.
•A disposable cartridges heath is required for each patient, but a
standard dental needle and anesthetic cartridge can be used

61. COMPLICATIONS OF LA;
1. ANAESTHESIA TOXICITY
• Young children are more likely to experience toxic reactions because of
their lower body weight.
• It is most important for dentists who treat children to be acutely aware of
the maximum recommended dosages of the anesthetic agents they use,
because allowable dosages are based on the patient’s weight
• LA toxicity causes suppression of cardiovascular and central nervous
system.
• Symptoms include tremors, shivering, spasms, suppression of breathing,
and even fainting

63. 2. SOFT TISSUE TRAUMA;
• The children should be observed carefully so that they will not
purposely or inadvertently bite the tissue especially the lip, tongue, or
inner surface of the cheek.
• In some cases, the child chews the area, and the result 24 hours later
is an ulceration, often termed a traumatic ulcer
• Management; The child should be seen in 24 hours, and a warm
saline mouth rinse is helpful in keeping the area clean.

64. 3. NEEDLE BREAKAGE;
• A particularly rare occurrence
• The main cause of this complication is a sudden movement from the
patient as the needle bores the muscular substrate or is in contact
with the periosteum.
• Thinner needles are more sensitive as are those which have been
previously bent by the dentist.
• Prevention; Changing needle direction should be avoided once it is
inside the tissues, while the hand holding the syringe should remain
stable
• Management; Have the patient keep opening wide and remove it if
visible
• If not visible clinically, locate the retained fragment through
computed tomographic scanning

65. 4. PAIN & A BURNING SENSATION;
Prevention;
i. Use of topical anesthesia and slow injection of the anesthetic
solution are essential.
ii. LA Solution should be between room and environmental
temperature
5. PARASTHESIA;
• In rare instances, in infiltration techniques, prolonged anesthesia
relating to burrowing of the nerve by the needle (felt as an electric
shock in the neural region) or hemorrhaging around the nerve can
occur
• This usually recedes within 2 months.

66. 6. HEMATOMA;
Causes; A hematoma is created intraorally from extravasation of blood
due to injury caused by the needle.
• It rarely causes any problems beyond a change in color of the
mucosa.
Management;
• Direct pressure applied to the hemorrhaging area helps control the
extent of the hematoma, which usually recedes without intervention
within 7–14 days.
• The use of analgesics to control pain is advised,
• Avoidance of hot foods several hours post op

67. 7. TRISMUS;
Causes; Muscle and vessel trauma, low-level infections, multiple
needle insertions, and large doses of anesthetic
Management ;
• Heat therapy, warm saline rinses, analgesics, muscle relaxants
• Diazepam (muscle relaxant)10mg twice daily
• Chewing gum (lateral movement of temporomandibular joint)
• Referred to oral surgeons for evaluation.

68. REFERENCES;
• Alvarez, G. G., Romero, C. C., Gonzalez, G. I., Hernanadez, G. R., Morteo, L. T.,
Reyes, L. P., . . . Soto, J. M. (2022). Topical Anesthetics in Pediatric Dentistry; A
Literature Review. International Journal of Applied Dental Sciences, 8(3), 283-286.
doi:https://doi.org/10.22271/oral.2022.v8.i3c.1604
• Dean, J. A. (2016). McDonald and Avery's Dentistry for the Child and Adolescent
(10 ed.). Elsevier Inc.
• Kotsanos, N., Sarnat, H., & Park, K. (Eds.). (2015). Textbooks in Prosthetic
Dentistry: Pediatric Dentistry (11th ed.). Thessaloniki: Fylatos Publishing.
doi:https://doi.org/10.10007/978--030-78003-6
• Tandon, S. (2018). Shoba Tandon Pediatric Dentistry (3rd ed., Vol. 2). Paras
Medical Publisher.

69. Thank You!