Shift magazine - Issues in Pediatric Dentistry

MEDICAL
EMERGENCIES
Sedation and Medical
Emergencies in the
Pediatric Patient.
more on Page 32
10
ESSENTIALS
For a dynamic,
successful pediatric
practice.
more on Page 40
You're covered A Q&A with Industry Experts on Expanding
Insurance Coverage for Prefabricated Zirconia
Crowns. Page 28
Pulp
Fiction
Top Ten
Myths of
the Primary
Dental
Pulp.
SEPTEMBER 2016
on
restoring badly
broken-down
anterior teeth
Improve your technique
while learning some
yiddish vocabulary.
Tips

PROGRAM DESTINATIONS FOR 2017PROGRAM DESTINATIONS FOR 2017
DALLAS 1/27 DENVER 2/24 ATLANTA 3/31 LAS VEGAS 4/21 CHICAGO 5/12

EZPEDO Magazine / September 2016 1
EZPUEZPEDO UNIVERSITY
2017
PHILADELPHIA 8/4 SAN FRANCISCO 11/3 SCOTTSDALE 12/8HONOLULU 6/23

2 EZPEDO Magazine / September 2016
4010 ESSENTIALS
For a dynamic, successful
pediatric practice.
28YOU’RE COVERED
A Q&A with industry experts on
expanding insurance coverage for
prefabricated Zirconia crowns.
50INFLUENCE
How I found my unique
humanitarian role in
story telling.
Table of Contents
20PULP FICTION
Top ten myths of the primary
dental pulp.

15WHAT PARENTS
ARE LOOKING FOR
One mom's experience finding a
dentist for her kids.
58TIPS ON RESTORING
BADLY BROKEN-DOWN
ANTERIOR TEETH
Improve your technique while
learning some Yiddish vocabulary.
32MEDICAL
EMERGENCIES
Sedation and medical
emergencies in the pediatric
patient.
TABLE OF CONTENTS
—
Pages 15–17
WHAT PARENTS ARE LOOKING FOR
BY KARALEE – KARI'S MOM
One mom's experience finding a dentist for her kids.
Page 18
HELPFUL HINTS
BY SARAH JOHNSON
What an assistant tries and do for her doctor to make
things go just a little smoother.
Pages 20–27
PULP FICTION
BY JAROD JOHNSON, DDS
Top ten myths of the primary dental pulp.
Pages 28–31
YOU'RE COVERED
EZPEDO INTERVIEWS INDUSTRY EXPERTS
A Q&A with industry experts on expanding insurance
coverage for prefabricated Zirconia crowns.
Pages 32–39
MEDICAL EMERGENCIES
BY DAVID ROTHMAN, DDS
Sedation and medical emergencies in the pediatric patient.
Pages 40–47
10 ESSENTIALS
BY CATHY JAMESON, PhD
For a dynamic, successful pediatric practice.
Pages 50–57
INFLUENCE
BY DANIEL VAKARYUK
How I found my unique humanitarian role in story telling.
Pages 58–59
TIPS ON RESTORING BADLY BROKEN-DOWN
ANTERIOR TEETH
BY LEVI PALMER, DDS
Improve your technique while learning some
Yiddish vocabulary.

EZPEDO
EZPEDO KNOWS PEDIATRIC ZIRCONIA
CROWNS BETTER THAN ANYONE.

EZPEDOEZPEDO IS HELPING AN INDUSTRY
TRANSFORM FROM LEGACY TO NEXT
GENERATION TECHNOLOGY.

David Rothman, DDS
David Rothman, DDS, is a board
certified pediatric dentist in practce in
San Francisco and associate clinical
professor at CWRU. He completed
GPR and anesthesia residencies prior
to his specialty training. He is past chair
of pediatric dentistry at UOP and active
in organized dentistry. He is a member
of OKU, Pierre Fauchard, ICD and
ACD. He speaks on pediatric dentistry,
anesthesia and sedation.
Cathy Jameson, PhD
Cathy Jameson, PhD, is founder of
Jameson Management, a management,
marketing and hygiene coaching firm,
helping dentists and teams increase
productivity and profitability. As a
speaker, she delivers entertaining and
educational programs to audiences
worldwide. Cathy is a best-selling author.
Her most recent title is Creating a
Healthy Work Environment.
Daniel Vakaryuk
Daniel Vakaryuk born in the small European
country of Moldova, now resides in Loomis,
California, where he works for EZPEDO as
a digital media specialist. Prior to joining the
EZPEDO team, he worked as a freelance
storyteller. Whether doing videography or
photography, his passion has always been
behind the camera, sharing the unique
stories of people from all different
regions of the world.
Aubrey Gooden, MS
Aubrey Gooden is a communications
professional based in Boston. She is a
graduate of Oklahoma State University
and earned her master’s degree from
New York University. Currently she is a
senior director at Gooden Group.
Sarah Johnson
Sarah Johnson works as a dental
assistant with Dr. Joelle Speed at the
Smile Gallery in Roseville, California. She
has enjoyed working chair side with
children for the last 15 years. Sarah and
her teenage daughter love the outdoors
and share an
active lifestyle.
Karalee –
Kari's mom
Karalee wrote “What Parents Are Looking
For” to share her personal experience
in finding a dentist for her kids and her
perspective on what a parent looks for
when searching for a dentist.
Contributors
Levi Palmer, DDS
Dr. Levi Palmer, DDS, acquired a degree
in nutrition from UC Davis. After two years
of surgical research at the UC Davis
Medical Center, he completed his dental
degree at USC School of Dentistry. He
took his pediatric dentistry residency at
the University of Colorado Children’s
Hospital. Dr. Palmer practices in Chico,
California, where he lives with his wife and
two children.
Jarod Johnson, DDS, earned his
Bachelor of Science in biomedical
engineering and Doctor of Dental Surgery
from the University of Iowa. He recently
completed a certificate in pediatric
dentistry at The University of Nevada, Las
Vegas, School of Dental Medicine. He
is currently working in private practice in
Muscatine, Iowa.
Jarod Johnson, DDS

Keeping
Your Eyes
Open
LIFELONG LEARNING THROUGH
CONTINUING EDUCATION
Have you ever thought to yourself how amazing it would be if you could actually
remember everything you have ever learned over your lifetime? The reality for
most of us is that if we don’t use it ... we tend to lose it. This is one of the main
reasons those of us in healthcare professions are required to take continuing
education courses.
In practice, we tend to get really good at the things we do every day. It may be the
way our front office operates when interacting with patients, their parents, or
third-party insurance carriers. Or it may involve a particular procedure or
technique that we do on a daily basis. We become so accustomed to our routine,
that, as the saying goes, “we could do it with our eyes closed.” This day-in and
day-out, “eyes-closed” repetition, although for the most part helpful, may prevent
us from mentally focusing on those areas of our practices which might potentially
benefit from further growth.
As you’re scanning the pages of this EZPEDO Magazine, take note of a variety of
topics that may help you “open your eyes” and improve your practice. Check out
our cover story on insurance coverage for pediatric Zirconia crowns (pg 26) or
Cathy Jameson’s article dealing with 10 essential strategies designed to create a
dynamic, successful practice (pg. 38). David Rothman reminds us all of the safety
our patients deserve and highlights strategies for handling common in-office
emergencies (pg 30). Jarod Johnson discusses common myths associated with
treating the pulp in primary teeth and the science that addresses these beliefs
(pg. 18). Finally, Levi Palmer shares some practical insight on dealing with
advanced cases of early childhood decay (pg. 54).
The goal of this publication is to bring topics of relevance and importance to
practicing dentists who treat pediatric patients. More than ever before, our
patients’ parents are educating themselves on techniques and current treatment
options available for their children. Continuing education is important to all of us,
forcing us to keep our eyes open—a crucial step in staying abreast of the latest
advances in science and clinical technique that will enable us to provide the very
best possible treatment for our patients.
If you have any comments about our current issue or suggestions for topics to
include in future issues, please send them to me at editor@ezpedo.com. I’d love
to hear from you.
CONTACT US
EZPEDO MAGAZINE
Vol. 2 No. 2 | September 2016
PUBLISHER
EZPEDO, Inc.
A: 6140 Horseshoe Bar Road, Suite L
Loomis, CA 95650
P: +1 (888) 539 7336
INT: +1 (916) 677 1447
E: info@ezpedo.com
W: www.ezpedo.com
MAGAZINE STAFF
JEFFREY FISHER, DDS
Editor-in-Chief
JAMES FISHER, MSPH, PhD
Senior Consulting Editor
ANN FISHER
Copy Editor
DANNY VAKARYUK
Art Director
TIMOTHY SHAMBRA
Senior Designer
CONTRIBUTORS
Aubrey Gooden, MS
Cathy Jameson, PhD
Daniel Vakaryuk
David Rothman, DDS
Jarod Johnson, DDS
Jeffrey Fisher, DDS
Karalee – Kari's Mom
Levi Palmer, DDS
Sarah Johnson
DIGITAL EDITION
www.ezpedo.com/publications
For new subscriptions, subscribe at ezpedo.com.
For all other reader services, including letters to
the editor, write to editor@ezpedo.com.
Jeffrey P. Fisher, DDS
Editor-in-Chief

S O C I A LNETWORK
P E O P L E , P L A C E S , A N D P A R T I E S
AAPD
GOOD
TIMES
This year’s AAPD and EAPD annual meetings
were held in San Antonio, Texas, and Belgrade,
Serbia. These events were a lot of fun and
a great opportunity to connect with friends.
Brenda Hansen Alfred Burns with his son,
and Vladimir Shcherbak
Jeffrey Fisher, Andrew Shannon,
Daniel Vakaryuk (right)
Lindsey Robinson,
Jeffrey Fisher
Cynthia Cacho,
Christel Haberland (right)
Katie Woehling, Jovas Booker
Parker White
A future member of AAPD with her mom
John Hansen conducting a mini-EZPU course

E V E N T S
2016
SPECIAL
MOMENTS
It was an absolute joy to spend quality time with a sizeable
number of pediatric dentists. You are a loving, caring group
of human beings, and we at EZPEDO highly value the care
you are providing for our next generation of pediatric patients.
EAPD
Mark Foster, Yakim Lahai, Oksana Oksenyuk, Natalia Popova, Alina Sitdikova
Serena Lopez Cazaux, Paloma Prieto and Gordana Brostovski
Brenda Hansen, Natalia Popova, Veronika Marie Vilimek A children's choir entertaining guests at the Belgrade City Hall
Arne Jacobsen and Brenda Hansen
Vladimir Shcherbak, Brenda Hansen, Carly Harrison

A dedicated husband and proud father
of four beautiful children, Dr. Cameron
Quayle is a pediatric dentist with private
practices in both Farmington and Pleasant
View, Utah, and a proud user of EZPEDO
pediatric Zirconia crowns.
DOCTOR TO DOCTOR

“When I began
using EZPEDO
crowns, I realized I
could look parents
in the eye and tell
them, These crowns
will look amazing.’”
Mountain View Pediatric Dentistry
CAMERON QUAYLE, DDS
2719 N. Highway 89, Suite 200
Pleasant View, Utah 84414
801.737.5437
991 Shepard Ln #100
Farmington, Utah 84414
801.447.5437
themoosedentist.com
’

KNOWN GLOBALLY.
LOVED LOCALLY.
Instruction and inspiration for pediatric dental professionals from the pioneers of
pediatric Zirconia crowns and the innovative leaders forging tomorrow's New
Generation Technology. Learn more about our proven innovation, and discover
how to use EZPEDO crowns to help grow your practice.
EZPU 2017 Destinations.
San Francisco
Las Vegas
Scottsdale
Philadelphia
Atlanta
Chicago
Dallas
Honolulu
Denver
EST. 2013
EZPUEZPEDO UNIVERSITY
Register online at ezpu.org
Join Us

WhatParentsAreLookingFor
K
ari is a girl featured recently in an EZPEDO Magazine ad, and Karalee is her mom. During a recent visit, we asked
Karalee a number of questions to get her perspective on what a parent looks for when searching for a dentist. Her
responses were so insightful we felt obligated to share her thoughts with you.
One Mom’s Experience Finding a Dentist for Her Kids.
BY KARALEE – KARI'S MOM
Karalee, with
her children.
Which dentist do you take your kids to?
This is the question every parent asks, or is asked, at some point. Providing a response should be so simple, but I have
learned after my experience with three kids, it most certainly is not. Searching for a dentist that is the right fit for your family
definitely takes some time and thought.
When I was little, we all just went to the family dentist that our parents went to. Now, it's a whole different story. One
change is that we now have so many pediatric dentist offices to choose from. Some offices have video games; others have
playrooms. Some have large rooms with multiple chairs for the hygienists; others provide movies, toys—you name it! In this
environment, making a choice can be quite the experience.
So how does a parent decide?
For me, I felt asking trusted friends and neighbors was a great way to start. Some may find consulting social media to be
a good source of suggestions and reviews. For the most part, the feedback is generally positive and helpful. But narrowing
down choices can still be difficult, because everybody's experience is unique and different, and there are plenty of opinions
out there. A third option is to just try out an office and see for yourself.

What was your own experience choosing a dentist?
What I discovered for myself personally is that there is
no one-size-fits-all with dentistry. I looked for an office and
atmosphere that matched my child’s personality. With my first
child, the videos and stimulation at the pediatric office were
really overwhelming for him, and it just made things more
difficult. We ended up going the small family practice route,
and it worked really well for him. My younger two are a differ-
ent story. The girls love the kid-friendly nature of the pediatric
office. They love having toys to play with while waiting, the
movies, and all the action! And now that my son is older, he's
fine with that as well.
Good relations with the front-office staff are absolutely
important. First impressions are so important. They may not
always be accurate, but sometimes that's all it takes to make
or break the experience. You start with them and you finish
with them. As a parent, I want to go in feeling comfortable and
walk out content!
The most important thing for me is having confidence in
the dentist. I have learned that trusting my gut is the best
answer. Using this tactic, something nearly universal in parent-
ing, is probably the most important factor, one I think we often
overlook. When it feels right, and it's a good fit, I have confi-
dence. My kids feel that, and have an overall sense of security.
That, for me, is key.
Your current dentist wasn’t the first one you went to.
How did you end up with your current dentist?
So, when my son Seth was around 18 months old, I took
him in for a cleaning. We went to the office I described earlier,
the one with all the video games, climby things, etc. It was
also where they had a room with 10 or 12 hygienist chairs.
The whole situation was really overwhelming for my son. They
attempted to do a cleaning (which wasn't even as thorough
as the teeth brushing that I was doing), and by the time they
were done with that, the dentist barely took a look in his
mouth. To add insult to injury, I had to write a $275 check for a
cleaning and check-up.
A year later, when I went back, I specifically asked if the den-
tist could look at his teeth first, because I felt like Seth never
even got a thorough check-up the first time. I didn't want to
spend my money again on something that didn't happen.
Then I asked if maybe we could perform the check-up in a
private room, because I felt like Seth was really overwhelmed
in the big room with all the other hygienists. I was given one
excuse after another why this wasn't usual. Finally, they sug-
gested maybe he would do better in their "teen room" where
there was less going on. Next, they suggested I go around
the corner and act like I'm just stepping away for a minute,
because he might do better if I wasn't there. I obliged. I wasn't
comfortable doing this, and I don't think Seth was either, but I
trusted them. As I was standing around the corner, I overheard

the hygienist, in a very harsh tone, tell him,“Your mom isn't
going to come back until you let us do what we need to do.”
It was at this point I came back, took his hand, and left, after
calmly taking the dentist aside and giving her a piece of
my mind.
To be honest, it was such a bad experience that I didn't go
back to any dentist for six years. When I did, we had two more
rather upsetting experiences with two other dentists. So I took
another two-year break until all the trouble with my daughter
Kari's teeth got too bad to ignore. That’s when I met Dr. Vicki.
Things went well, but then for financial reasons, we made
another change which led to another really bad experience.
So I finally concluded that, regardless of cost, I was going to
follow my gut. We went back to Dr. Vicki, and we’re staying
with her. I trust her, and her office is the only one where I
have felt at peace.
What are some of the things you like about Dr.Vicki’s office?
I think my favorite is the up-to-date, latest technology. I
can't tell you what a difference it made. For example, with
X-rays, Kari would have nothing to do with the sharp plastic
object being shoved between her teeth. She absolutely
flipped out. Magic Smiles used a tiny little camera that she
was not only intrigued by, but was also absolutely cooperative
with. The same thing with nitrous. Having a little colored and
scented disposable mask (not sure what they're called!) is far
less intimidating than a big gray one with tubes attached to a
huge machine. These things might not matter to all kids, but
they made all the difference in the world to mine.
Is there anything you don’t like about the visits?
I guess there were two things that put me off about my par-
ticular experience at Magic Smiles. First, I felt uncomfortable
when we talked about the wording on the anesthesia form.
Mostly because I was already struggling with the reality of the
situation, and I felt like the decision for her to have anesthesia
was based simply on the reasonable fear a 4-year-old would
be feeling. So when I read on the form, "Your child may need
anesthesia because they are not cooperative," it just put me
off a little.
The other difficult thing is accepting the board they strap
the little ones to. That always puts me off, but that's just a per-
sonal issue for me. I realize some parents don't want to spend
the money or take the risk of sedation, so using this device
may be their only answer.
But, as I mentioned before, the most important thing for
me is having confidence in the dentist. I trust Dr. Vicki and her
staff. I feel comfortable and valued there. My kids feel that
confidence, too, and have an overall sense of security. That, for
me, is key and explains why we won’t go anywhere else.

HELPFUL HINTS
THINGS
THAT
SHOW
ASSISTANTS
CAREby Sarah Johnson
1. THINK AHEAD
Anticipate your doctor’s next two moves.
2. LISTEN AND REMEMBER
Communication is key. If you're working as a new
assistant or working with a new doctor, ask questions to
find out what they prefer. You might find they have
different expectations from what you're used to.
3. PLAN FOR EFFICIENCY
Be prepared. The appointment starts with you. Make
sure your room is set up and know who your patient
is – their fears, and how their visit went before. Your
doctor is only as prepared as you are.
4. CONTROL THE APPOINTMENT
Especially in pediatrics, it's easy for parents to try and
take over the appointment, sometimes without you even
knowing it. Set your expectations with the parent in the
beginning, so they can be prepared. It sets the tone for
the visit.
5. MANAGE TIME WISELY
One of my essential tasks is to keep my doctor on time.
It also shows the parent/patient you respect their time.
Always know how much time you have for each
procedure.
6. RESEARCH NEW PRODUCTS
One of the things our office prides itself in is new
technology. I try to keep up with research about new
products to help our team be more efficient. It's
important to stay relevant.
Work
OFTEN IT IS TRUE IN
LIFE THAT THE
LITTLE THINGS TEND
TO GO UNNOTICED.
READ WHAT A FEW
RDA’S TRY AND DO
FOR THEIR DOCTOR
EACH DAY TO MAKE
THINGS GO JUST A
LITTLE SMOOTHER.

F A C E B O O K . C O M / E Z P E D O
T W I T T E R . C O M / E Z P E D O
Y O U T U B E . C O M / E Z P E D O
( 8 8 8 ) 5 3 9 . 7 3 3 6
EZPEDO
WE’D LOVE
TO CONNECT
WITH YOU.

In the ever-changing
world of dentistry, we
are constantly being
faced with the decision
to stay with the status
quo or try and navigate
the waters of innovation
and change. This article
discusses some of the
questions surrounding
pulpal treatment in the
pediatric dental patient.

Pulp
Fiction
Top Ten Myths of the
Primary Dental Pulp.
By Jarod Johnson, DDS
The primary dental pulp is challenged mostly by trauma or carious insult.
Historically, the vital primary pulp has been treated with a Formocresol pulpotomy,
and the vital permanent pulp with calcium hydroxide in the form of a direct pulp
cap to avoid root-canal therapy.1,2 Recently in the last two decades, developments
in materials, led by mineral trioxide aggregate, have forced providers to reconsider
materials used in vital pulp therapy.3 As pediatric dentists and general
practitioners, we continually seek to improve our clinical success by using new
materials and techniques as they are developed. To do this, we must constantly be
evaluating our treatment outcomes and stay up-to-date with the current best
evidence available in the pediatric dental ﬁeld. The purpose of this article is to
review common misconceptions about the primary dental pulp as it relates to
carious lesions and traumatic dental injuries.

Formocresol PulpotomyMTA Pulpotomy
IRM
MTA
Dentin Bridge
Vital Pulp
IRM
Coagulation Necrosis
Fixated Pulp
Vital Pulp
Ten Mythsabout the Pulp
Some of the most difficult pulpal challenges we face as dentists
treating children are the symptoms that patients experience while
bacterial infection progresses. This pulpal response occurs with
varying clinical manifestations. The American Academy of
Endodontists has two classifications of irreversible pulpitis4—
asymptomatic and symptomatic—making diagnosis of
asymptomatic pulps challenging. Diagnosing irreversible pulpitis
in children is further complicated by the fact that pulp testing in
primary teeth is unreliable, and children and parents may be
poor historians of symptoms.5 A recent study with permanent
teeth correlated clinical diagnosis with histological diagnosis.
For reversible pulpitis, histologic and clinical diagnosis matched
96 percent of the time; for irreversible pulpitis, the results
matched only 84 percent of the time.6 Pulpal necrosis can also
occur after symptoms have vanished, further leading to a
possibility of incorrect diagnosis. While our preoperative
diagnosis will match reality a majority of the time, even
asymptomatic pulps may still mask unhealthy conditions. Correct
clinical diagnosis may also change over time for primary teeth
due to the difficulties previously mentioned.
To further compound the task of making a correct diagnosis, a
recent study found that young permanent teeth diagnosed with
irreversible pulpitis were actually capable of healing.7 By
definition, irreversible pulpitis means a pulp that is incapable of
healing. So how can this be possible? To gain a better
understanding, we must evaluate the histological response of
the pulp to dental caries.
The understanding of caries progression and the
reaction of the dental pulp is a well-understood
phenomenon. As caries progress, the pulp begins to
undergo changes in response to bacterial infection. As
lesions appear in enamel, changes in the odontoblast
layer occur first, where it becomes less cellular and more
disorganized. As the carious lesion continues to grow
three-quarters of the way into dentin, reparative dentin
becomes evident. The odontoblast layer is reduced,
and vascularity increases in the pulp.
Finally, once bacteria have infected the pulp, coagulative
necrosis occurs, and the body elicits a response to the bacterial
infection. Lymphocytes, macrophages, and polymorphic
neutrophils proliferate adjacent to the necrosis. Deeper in the
pulp, the response is similar to that occurring in the dentin.
Interestingly, the radicular pulp remains normal in some
instances.8 The key evidence that allows for our pulp treatment
to be successful is the presence of healthy pulp tissue in the
radicular pulp; this is the basis for pulpotomies in the primary
and permanent dentition. If one is in doubt of the pulpal status
in a child, caries removal and evaluation of the pulp tissue
should be performed.
Formocresol is superior to
other medicaments for pulpal
therapy in primary teeth.
2.An asymptomatic pulp
is a healthy pulp.1.
*May be true
Formocresol
Formocresol has been considered the gold standard for primary
teeth pulpotomies for many years.9 Formocresol works by
mummifying the pulp stumps, causing pulp necrosis with hopes
of leaving a small amount of vital tissue in the root apex.10
Studies have associated teeth treated with Formocresol
pulpotomies with expedited exfoliation and internal resorption.11
Critics have also cited carcinogenicity and mutagenicity as
concerns associated with its use, while proponents have
maintained it is safe to use until viable alternatives exist.12,13
Multiple studies have shown other materials perform just as well
as Formocresol. The Handbook of the American Academy of
Pediatric Dentistry notes that ferric sulfate, mineral trioxide
aggregate (MTA), sodium hypochlorite, and laser treatment all
have equivalent results when compared to Formocresol.11 More
studies are needed to determine if some of these materials may
be superior to Formocresol. Mineral trioxide aggregate has been
shown to have promising results.14
ProRoot MTA
Within the last few years, many bioceramics have entered the
market led by the development of ProRoot MTA.3 ProRoot MTA
is by far one of the most studied materials in the class. MTA is
similar in composition to Portland Cement and contains
tricalcium silicate and dicalcium silicate. Its mechanism of action
is the release of calcium ions which combine with phosphate
ions in the blood stream to form hydroxyapatite. It is
biocompatible, has a high pH which provides a supportive
environment for dentin formation and a negative environment for
bacterial growth. The material sets with hydration from water
(four hours), and has been known to cause a grey discoloration
of teeth.14,15
MTA has demonstrated a high success rate in pulpotomies. A
recent study which compared groups treated with Formocresol
and MTA, reported clinical success and radiographic success
of 96.9 percent / 84.4 percent respectively for Formocresol
and 100 percent / 93.9 percent respectively for MTA at two
years. No statistical difference was found between all the
groups compared in the study.16 A second study found MTA
to perform better than Formocresol at two years (97 percent
clinical success verses 85 percent). In the same study, MTA
had even better radiographical results with 88.6 percent
success verses 54.5 percent for Formocresol.17 Numerous
other MTA products have entered the market; however, there
Carious Lesion
Tertiary Dentin
Infected Pulp
Affected Pulp

may be changes in composition, which may make them
perform differently than MTA.
Aside from pulpotomies in primary teeth, MTA can be used in
multiple dental applications. It can be used in teeth for direct
pulp caps, partial pulpotomies, pulpotomies, apexification,
perforation repair, obturation, retrograde endodontic fillings,
and regenerative endodontics. The diverse number of uses and
the clinical track record make it a valuable material to have in
the dental office.3,15
Biodentine
Biodentine is a tricalcium silicate with a calcium chloride
solution. It forms a putty-like substance which is considered
by some clinicians easier to place. The setting time is 10
minutes compared to four hours for MTA.18,14 It comes in a
form which is titrated to mix, which may provide a more
consistent mix than MTA. Biodentine has been studied
clinically in both animals and humans. It has been shown
in one study to form dentin bridges which are thicker than
those of MTA. A group of 28 premolars planned for
extraction underwent non-carious pulp exposures and pulp
capping with Biodentine and MTA. The teeth were
extracted and evaluated histologically. Both groups
showed clinical and histological success, and no statistical
difference was found between the two groups.19
In pulpotomies, Biodentine has recently shown similar results to
MTA at 18 months; clinical success was 95.24 percent and
100 percent respectively.20 A six-month study comparing
Formocresol and Biodentine showed no difference in 56 pairs
of teeth.21 One factor to consider is that cost may be
prohibitive in the primary dentition as the auto-mix capsules
cannot be dosed for multiple uses. Currently, Biodentine shows
promise given the limited clinical follow-up required and is a
viable alternative to Formocresol and MTA. However, more
research is warranted with pulpotomies in the primary dentition.
TheraCal LC
TheraCal LC is a resin-based product that contains calcium
silicates. It currently is not FDA approved for pulpotomies, but
has been used off-label.22 TheraCal DC is another calcium
silicate product that was recently discussed at the American
Academy of Pediatric Dentistry annual session.23 Both of these
materials lack long-term evaluation in a clinical setting.
Specifically, TheraCal LC’s depth of cure is 1.7 mm and
reaches a physiologic pH after seven days.24
It has
been shown to release calcium ions, and it exhibits
higher cytotoxicity to pulp cells in vitro, approximately
10 percent cell viability compared to 70 percent for MTA.25
TheraCal LC currently has not been studied in any long-term
clinical trials, but has been shown to create dentin bridges at
28 days in primates.26 Resin products have been shown to
have cytotoxicity that provides low-grade tissue irritation, but
they allow for pulpal healing in the absence of bacteria and
adequate coronal seal as discussed previously.27 The author’s
opinion is that, due to a number of concerns, TheraCal LC
should be limited to use in indirect and direct pulp therapy, as
other viable and cost-effective medicaments exist. The author’s
concerns are related to the following items: 1) cytotoxicity, 2)
ability of a resin product to create an adequate coronal seal,
3) the recommendations of the manufacturer, and 4) the lack of
clinical studies involving the primary dental pulp.
A tooth treated with a crown
requires a pulpotomy.3.
It is a misconception that primary teeth treated with Zirconia or
stainless steel crowns need to have pulpal therapy. Some
believe that the amount of reduction required to seat a Zirconia
crown would cause an iatrogenic pulp exposure. This belief is
not true. The amount of reduction required for an EZPEDO
crown is approximately 2 mm; this is the same ideal depth a
provider would prepare when restoring with an amalgam
restoration.28, 29
There are many reasons why a provider may select to treat a
tooth with a crown and not perform a pulpotomy: 1) decay on
the mesial surface of a primary first molar, 2) three or more
surfaces of decay, 3) decay on a hypoplastic molar, 4)
treatment of a high-caries-risk patient, and 5) treatment of
patients under sedation or in an operating room setting.11
Literature supports the conclusion that stainless steel crowns have
consistently outperformed Class II restorations in the primary
dentition.30 More evidence is needed to compare Zirconia
crowns to stainless steel crowns, but short-term studies have
shown equivocal results.31
One of the possible outcomes to any treatment in dentistry is
failure. Failures of Formocresol pulpotomies are estimated to
range from three to 38 percent.11 Failures can be asymptomatic
and may only be apparent radiographically. The proper
diagnosis for these situations with rarefying osteitis is previously
initiated therapy with asymptomatic apical periodontitis.4
An endodontist would not consider calling an asymptomatic
tooth with a radiolucency after root-canal therapy a success.
Nor should pediatric dentists consider an asymptomatic tooth
with a radiolucency after pulpal therapy a success. Those teeth
that exhibit apical or furcal radiolucencies should be treated by
pulpectomy or extraction with subsequent space maintenance if
necessary. Internal resorption should be monitored
radiographically, and if perforation occurs, extraction should be
the treatment of choice.
Teeth treated with pulpotomies
that exhibit rarefying osteitis
are a clinical success.
4.
Tooth #L has been previously treated with a pulpotomy. The
patient is asymptomatic and a furcal radiolucency is evident. The
diagnosis for #L is previously initiated therapy with asymptomatic
apical periodontitis, and extraction and space maintenance is
planned due to root resorption.

*May be true
The success of pulpal therapy is dependent on three
factors: 1) healthy tissue being present, 2) absence of
a microbial flora, and 3) an intact coronal seal.
Kakehashi, et al demonstrated in rats that teeth after
pulp exposures without restorations could exhibit
dentin bridging and healing if no bacteria were
present.32 Moreover, a study comparing surface-
sealed restorations (amalgam, zinc oxide eugenol,
composite) concluded that the major determinates of
healing were absence of microbial flora and an intact
coronal seal.27
The American Academy of Pediatric Dentistry guidelines
on pulpal therapy indicate that teeth treated with pulpal
therapy should receive coronal coverage unless the tooth
is expected to exfoliate in two years or less.33 Thus,
parents who desire a long-term esthetic solution for coronal
coverage should have their children treated with Zirconia
crowns. If the tooth is expected to exfoliate in less than
two years, a composite restoration may be placed.33
Pulpectomies are more
successful than pulpotomies
on anterior primary teeth.
6.Teeth treated with a
pulpotomy should be restored
with composite resin if parents
want a white tooth.*
5.
Three studies have been identified comparing pulpotomies to
pulpectomies in anterior primary teeth. The most recent study
was conducted at Baylor University, Texas A&M Health
Science Center, and published in 2012. The randomized
controlled clinical trial compared two groups, each composed
of 37 teeth. Patients in one group received a pulpectomy, and
patients in the other group received a Formocresol pulpotomy.
After 23 months, radiographic success was 89 percent for the
pulpotomy group, and 73 percent for the pulpectomy group.
No statistical difference was found between the two groups.
The other two studies that were identified by the author had a
low sample size (12 per group), and used a low
concentration of Formocresol (1.5 percent) with some teeth
restored with composite restorations which may not have
provided an adequate coronal seal.34
The most common age for dental trauma in the primary dentition
is 1 to 3 years of age when children are learning to walk.35
Treatment at this time can involve behavioral issues that
challenge practitioners as children may be pre-cooperative or
uncooperative for dental treatment. Common sequelae following
trauma involve discolored primary teeth. Discoloration can occur
as a dark-colored tooth, or a yellowing of the tooth. Yellowish
color is a result of calcific metamorphosis and the pulp laying
down more dentin as a response to trauma. Discoloration can
also be a greyish hue as the result of blood products staining
dentin. No treatment is indicated in either of these cases unless
pathology is present.
The darkening of teeth after trauma was evaluated at Hebrew
University and Hadassah School of Dental Medicine in
Jerusalem in a study based on a change in policy. Prior to the
policy change, primary teeth with discoloration were treated
with root-canal therapy. After the change, teeth without clinical
or radiographic pathology received only clinical and
radiographic re-evaluation. No statistical difference was found
between the two groups in relation to the eruption timing, path,
or calcification of the permanent tooth. The study concluded
that, “Root-canal treatment of primary incisors that had changed
their color into a dark-gray hue following trauma with no other
clinical or radiographic symptom is not necessary, as it does not
result in better outcomes in the primary teeth and their permanent
successors.” Teeth with darkening should be periodically re-
evaluated clinically and radiographically for pathologic
changes.36
Tooth #S was successfully treated with an MTA
pulpotomy and EZPEDO Zirconia crown.
A dark anterior primary tooth
requires pulpal therapy after
trauma.*
7.

Pulpectomies are less
successful in primary teeth
due to the complex anatomy
of the roots.*
8.
Primary teeth display variations in anatomy similar to those of
permanent teeth. These variations can appear as lateral or
accessory canals, variations in size and shape of the canals,
and anatomical variation of the apex. The root-canal system is
no more complex than in permanent teeth; however, the
response to bacteria make for more anatomical challenges.37
When the pulp forms more dentin in response to carious
insult, more calcifications occur, and cleaning and shaping
become more difficult.
It should also be noted that once root resorption occurs in
primary teeth, the number of accessory canals increases, and
elimination of the bacteria flora becomes more difficult.38
Pulpectomies have been reported to be highly successful with
proper cleaning and shaping in the absence of resorption.39
Pathologic changes due to caries or trauma may make
treatment of the root-canal system in primary teeth more
complex.
Prior trauma with root resorption evident on #E and #F, with large
carious lesions. EZPEDO crowns were placed on #D, #E, #F and,
#G, and they were treated with Biodentine pulpotomies due to
vital tissue remaining.
NOTE: Apical radiolucencies evident on #D and #E, and a widened
periodontal ligament on #F. Primary teeth with resorption should
be considered strong candidates for extraction.
Sodium hypochlorite has been used effectively in
endodontics to disinfect root canals. Its properties make it
useful to dissolve organic matter and kill microorganisms.
Low concentrations (less than 1 percent) will effectively
dissolve necrotic tissue and deactivate microorganisms
without dissolving vital tissue.5 Concentrations as high a
5.25 percent have been advocated for use in primary
teeth.38
Many clinicians are fearful of a sodium hypochlorite
incident or of causing damage to a permanent tooth due
to apical extrusion. Sodium hypochlorite has been used
safely in regenerative endodontic procedures with
permanent teeth where canals and the apical foramen
are much wider than in primary teeth.40 Use of a side-
vented needle, staying 2−3 mm short of working length
of teeth with wide apical foramens, and caution to never
allow the needle to bind, will allow for the irrigant to be
used safely with primary teeth.5
Teeth with apical pathology often present difficult
decisions for clinicians. The offending tooth and the child’s
stage in growth and development play key roles in
determining treatment during the decision-making process.
Primary canines and primary second molars may play a
more strategic role in the mouth than other teeth. Loss of a
primary canine would require extraction of the
contralateral canine to prevent a midline shift. Similarly,
loss of a primary second molar presents difficulties for
clinicians if it occurs prior to the eruption of the permanent
first molar, thus leading to difficulties with placement of a
distal shoe.41,42 Use of space maintainers may also create
clinical difficulties. A retrospective study evaluating 301
space maintainers between 1991 and 1995 showed a
failure rate of 63 percent.43 A pulpectomy can alleviate
the need to use a space maintainer if the tooth is
maintained and infection is eliminated.
The primary pulp dental infection can be treated similarly
to infection in the permanent tooth. Pulpal debridement
followed by obturation with a resorbable material can
successfully treat the localized dental infection. The
pulpectomy success rate can be correlated with the
amount of preoperative resorption. Those primary teeth
with no resorption had a success rate of 91.7 percent;
those with minimal resorption (< 1mm) had 82.8 percent,
and those with excessive resorption (greater than 1 mm)
had 23.1 percent. No statistical difference was detected
between incisors and molars treated with pulpectomies
during the study period.39
Sodium hypochlorite is
dangerous to use in pulpectomies
in primary teeth.
9.
Primary teeth with localized
swelling cannot be treated
successfully with a pulpectomy.
10.

Deep carious lesion on #K (irreversible pulpitis after caries removal) was treated with an MTA pulpectomy due to the lack of a
succedaneous tooth. The tooth is successfully maintained at six months and will be re-evaluated with radiographic follow up.
Note no furcal pathology.
Conclusion
My father, who is an endodontist and academic instructor, once stated, “Half of what we teach you in dental school will be
wrong.” While the statement may hyperbolize, it has instilled within me the belief that we should constantly evaluate our treatment
outcomes and adapt as a profession. This belief holds true with regards to vital and non-vital pulp therapy in the primary dentition.
As practitioners who treat children, we should all seek to be lifelong learners and stay up-to-date with the current best evidence
and practices within our profession.

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references

Why is understanding insurance important for dentists
and patients?
Cathy Jameson: Insurance has changed drastically over the last decade,
and knowing how to manage insurance is an essential business capability of
a dental practice. The American Dental Association (ADA) tells us that on
average more than 50 percent of revenues for practices come in the form
of insurance reimbursement checks, and for some practices that number is
closer to 70 percent.
Brenda Hansen: It’s clearly important for dental practices to understand
insurance, but it is equally important for parents and patients to understand
insurance. Typically, you see changes to insurance plans annually. It’s
important to familiarize yourself with any changes to your plan—it could
mean better coverage for better technology, something every family should
take advantage of.
When it comes to insurance, what are the biggest
challenges you see for practices?
Roger Levin: One challenge is that reimbursement from many insurance
companies is declining. We are seeing a trend going from classic indemnity
insurance to the PPO level which is often about 15 percent lower in
reimbursement to the doctor. Another challenge is the submission process.
Practices have to submit using the right codes. They are pretty good at this,
but, unfortunately, they don’t always get it right, so it takes more time, effort
and more overhead to support the overall process.
A Q&A with Industry Experts on Expanding Insurance Coverage for
Prefabricated Zirconia Crowns
YOU'RE COVERED
Though consumers would stand in line for an innovative new technology that solves a problem or promises to
improve their quality of life, insurance companies, on the other hand, move at a snail’s pace. Getting insurance
companies and state insurance programs to adopt a new dental technology can be much like plowing concrete–
frustrating, tedious and out right baffling. The process is usually convoluted as several experts can attest. But,
here’s the good news: it is not impossible.
Insurance coverage for Zirconia crowns like EZPEDO has come a long way, but it still has a way to go. We spoke
with experts across the dental industry about the challenges, process and landscape of the complex insurance
ecosystem surrounding this groundbreaking technology. Here is their advice for dentists and parents.
"Insurance coverage for Zirconia
crowns like EZPEDO has come a long
way, but it still has a way to go. "

What is the process to garner coverage for a new dental
procedure and material?
Charles Blair: The first step is to get an insurance code by meeting a
scientific bar. The American Dental Association and the code committee will
review information about the new dental procedure and verify that it’s not
experimental and that it has scientific success to back it up. Over a period
of two to three years, the code will become more commonplace as demand
increases. Every time a code can be used and put through the system, the
odds are the better it will be accepted by insurance companies.

Paul Reggiardo: The code really is the first step in establishing legitimacy.
Codes are important so that the dentist can record in the patient record
the exact service provided. Without a code, you can’t record the procedure
and the third party reimbursement is hindered. It has to be established that
there is a reasonable delivery of the service. By the time the code is issued,
that procedure has been done in significant numbers and by a significant
number of providers.
How are new codes established? And once established
does that mean insurance will cover it?

Roger Levin: Establishing a new code is extremely difficult. We have
seen new procedures receive codes, but typically it takes some level of
widespread use by the profession and time. You don’t just get a code
overnight.

Paul Reggiardo: Requests for coding can be made by any dentist, any
member of the public, a specialty organization, or the American Dental
Association’s own Council on Dental Benefit Programs. It’s a very open
process. Once a procedure code is adopted, then third-party benefit carriers
make a determination if it will be a covered benefit under a dental policy
and at what reimbursement level.

Charles Blair: A newer code, such as D2929 for Zirconia crowns, must
be covered in the plan document. Just because there is a code doesn’t
mean the insurance company will pay—it can take a year or two for it to
get embedded in the plan document where it is a covered benefit. In the
meantime, dentists can submit the code and if insurance companies reject
it, the dentist can go back and ask for an alternative benefit, say, or a
stainless steel crown.

Cathy Jameson: The truth of the matter is, there are still insurance
companies where it’s difficult to get Zirconia crowns covered. When a
majority of doctors in a particular area start filing a code for a procedure,
insurance companies will come along and start paying for it. The pressure
causes the insurance companies to cover. We encourage our clients to
always file the D2929 code even if they know it is not covered. This is still a
fairly new procedure in dentistry so we want doctors to use this service and
present it to the parents, allowing them to see the physical and emotional
benefits available to their children. Even though the fee may be higher, the
insurance company may reduce the fee to the equivalent of a stainless steel
crown. The more doctors in an area filing a certain procedure, the more
likely it will be a covered benefit.

Brenda Hansen: When the code for Zirconia crowns (D2929) was added,
it was a big deal for EZPEDO because it gave our product validity in the
industry and with more and more insurance companies and state medical
programs reimbursing it, it has become more affordable to parents, making
it even easier to make the right decision for their child. But just getting the
code does not mean that Zirconia crowns are automatically covered. The
level of reimbursement varies by state and plan.
Brenda Hansen, BS
Executive Director, EZPEDO, Inc.
& John P. Hansen DDS, Inc.
Paul Reggiardo, DDS
Pediatric Dentistry for Infants,
Children and Adolescents.
Roger Levin, DDS
Founder & CEO, Levin Group, Inc.
Charles Blair, DDS
Founder & CEO, Dr. Charles Blair
and Associates, Inc. & Founder,
Practice Booster
Cathy Jameson, PhD
Founder, Jameson
Management, Inc.
David Stanley, DDS
Wild About Smiles!
Pediatric Dentistry
Nolan Gerlach, DDS
Bellevue Pediatric Dentistry

Now that there is a code, are Zirconia crowns
reimbursed at the same level as other procedure options
such as composite crowns?
Roger Levin: For privately held insurance plans, a lot of this comes down to
the employer. The same insurance company might cover Zirconia crowns for
one set of patients and not another depending which plan the employer has
selected.
Nolan Gerlach: The Washington State Health Care Authority updated its
Medicaid reimbursement of Zirconia crowns to equal that of composite
crowns, but prior to this I noticed Medicaid was reimbursing the composite
crowns at a higher rate than the Zirconia crowns. In my mind, the Zirconia
crowns are at least an equal, if not better, alternative to restoring anterior
teeth. Covering it at a much lower rate disincentivizes providers from using
those type of crowns. On the other hand, equal coverage for the two types
has further opened up what I see as a superior product or superior solution.
David Stanley: In Tennessee, TennCare, Tennessee’s Medicaid program,
recently changed its policy to begin reimbursing patients for Zirconia
crowns. Though it is covered, we are walking a fine line right now because
the reimbursement for Zirconia crowns is about $7 less than it is for
stainless steel crowns and pre-veneered stainless steel crowns. The Zirconia
crown is a better crown and it will last longer. Multiple times we have to
replace pre-veneered crowns free of charge so, I am willing to take a hit on
the Zirconia crowns because we avoid the overhead charge of having to
replace them again.
Since every state and insurance plan is different, what
can be done to facilitate an increase in reimbursement
for Zirconia crowns in places where it is not currently
reimbursed or only reimbursed at a very low level?
Paul Reggiardo: If the purchaser of the insurance plan asks for the benefit,
then the insurance carrier can help determine the amount of premium that
would cover this additional benefit. The demand has to come from the
patients or, in pediatric cases, from parents. If the parents make it clear to
their employers that they want Zirconia crowns as a covered benefit, then
the employer will have a reason to explore adding them to the dental plan
coverage.
David Stanley: Having more dentists providing Zirconia crowns will grow the
demand for the technology, and ultimately the insurance industry will catch
up with reimbursing them. More dentists providing the procedure will help
educate parents on their options.
Cathy Jameson: One key for dentists to get a benefit reimbursed accurately
is a descriptive narrative. When filling out the narrative, step one is the
status of the tooth. Note the size and condition of prior restoration, if any.
Step two is to note the amount of remaining and/or lost tooth structure.
Step three is to note any pathology or symptoms. Step four is to note any
clinical observations not visible on the X-ray. Photos are beneficial. Dentists
should include the words that are more likely to get coverage approval such
as “decay” and “fracture” if they are applicable to the patient. The clearer
the narrative the better chance at coverage.

What advice do you have for dentists and parents
regarding insurance for Zirconia crowns?
Nolan Gerlach: I would encourage dentists and parents to simply ask
the question to their state medical group or employers. In my mind, I
felt like I simply asked the right question to the right people, “Why are
Zirconia crowns not being covered at the same rate?” I didn’t have any
expectations as to what my simple emailed question would lead to, but
with the incredibly supportive environment in Washington with The Access
to Baby and Child Dentistry program (ABCD), a simple question facilitated
a conversation and subsequent equal coverage of Zirconia crowns for
patients age 6 and younger, as long as the dentist has completed an
educational program.
Charles Blair: Dentists must always report the correct code. If it’s not paid,
appeal it and ask for an alternative benefit. The coverage should get better
over time.
Paul Reggiardo: It’s essential that all providers are familiar with the
procedural coding system. The ADA publishes procedure codes annually,
and there are a number of additions, deletions and modifications each year.
Cathy Jameson: If you are a dentist not familiar with Zirconia crowns, take
the time to research them. The Zirconia crown materials are healthier for a
child and also aesthetically superior. For us to not introduce Zirconia crowns
to our clients would be a mistake. We must bring to the table what is best
for the patient and best for the practice.
David Stanley: We are getting patients that are calling our office and asking
specifically for EZPEDO crowns. They want a strong, white crown. Providing
EZPEDO crowns to our patients has differentiated us from other practices
and I would recommend other dentists take a look at the technology and
attend courses (EZPEDO University for example) to familiarize themselves
with Zirconia crowns and their ever-changing insurance coverage.
Roger Levin: It’s really about creating a groundswell by dentists and parents.
When that groundswell takes place and parents are talking to employers
and dentists are talking to their societies, that’s really what it’s all about.
You are really after pressure by employers for insurance companies to look
at a certain procedure as one part of standard care to ensure families have
a specific option such as the Zirconia crown. It is not one person or one
committee, but it is a combined effort that leads to the best reimbursement
of new procedures.
Brenda Hansen: At EZPEDO we are proud of our product, and proud that
insurers have begun recognizing its billing code. We are here to aid dentists
and parents with reimbursement challenges and provide the educational
materials they need to approach legislators and employers so we can all
work together to facilitate the right conversation around the coverage
of Zirconia crowns and the need for the industry to work together for
coverage solutions that work. Insurance reimbursement for Zirconia crowns
is just another step in the right direction to help us fulfill our vision and
provide support to our customers through every phase of their
EZPEDO experience.
For a product with the potential to shift an industry, changing the way in-
surance understands the technology simply comes with the territory. At
EZPEDO, we believe the next generation of patients need next-generation
technology. We know that proactive dental practices, industry influencers,
dental educators and parents have the tools to bring the insurance industry
along with us. Keep in mind the famous words of the great orator and British
war leader, Sir Winston Churchill—“Never give up!” Working together, we can
improve insurance reimbursements across the board and continue making this
ground breaking technology more widely accessible and affordable than ever.
Billing
Health
Canada
22601 - Primary Anterior
22611 - Primary Posterior
Definition:
Restorations, Prefabricated,
Porcelain / Ceramic / Poly-
mer Glass, Primary Teeth.

Sedation and Medical Emergencies
in the Pediatric Patient
by David L. Rothman, DDS

Two categories of pediatric emergency
can occur during sedation. Anesthesia-
associated problems usually are airway
related and lead to hypoxia and cascade to
bradycardia and potentially death. Examples of
these include drug/dose problems, unintended
sedation-level changes, allergic reactions to the
agents used, laryngospasm and loss of
protective reflexes. Non-anesthesia emergencies
can occur at anytime and are not related to the
sedative or anesthetic agents. These may occur
concurrently or separately and can include
airway obstruction, allergic reactions, seizures
and hypoglycemia. It is important for the
practitioner to be able to identify and intervene
early in the event to be able to manage the
emergency and stabilize the patient before
further progression.
Though there are many reported numbers for the
incidence of emergencies during sedation and
anesthesia, they may be unreliable.
1, 2, 3
There is
no central agency in dentistry for reporting
incidences of morbidity or simple complications
which don’t affect the outcome of the sedation.
Other than insurance company closed-case
analyses, mortality numbers are difficult to obtain,
and only estimates exist regarding the number
of outpatient sedations given in a specific time
period. In addition, some practitioners do not
recognize problems or may choose to ignore
them because they believe they are too minor to
record such as temporary loss of protective
reflexes as the patient drifts between sedation
levels. Practices are inconsistent in their delivery
and monitoring, making data recovery difficult.
In general, the pediatric heart and lungs are
generally free of disease unless it is congenital.
The second most common disease affecting
children is asthma and is the most common
cause of admission for the pediatric patient. It
affects approximately 11–15 percent of children
and is now considered a lifelong disease. It is
important to understand the severity of the
asthma pre- and post-treatment and the
medications used because of the impact they
may have on the emergency treatment. Acquired
infections of the airway in children require a six-
week healing period before sedation or general
anesthesia should be done. Understanding
allergic versus infectious etiology is key to
treatment and prevention of medical
emergencies.
This article is by no means a complete discourse
on pediatric emergency management and will
only focus on respiratory, cardiovascular, and
sedative and local anesthetic drug overdose -
related emergencies. Other pediatric
emergencies will be covered in a future article.
The reader is well advised to do additional
research on pediatric diseases and emergency
management of patients and take appropriate
continuing education courses. Topics such as
foreign body obstruction and complications of
the routes of administration are covered in
courses such as Pediatric Advanced Life Support
by the American Heart Association and the
American Academy of Pediatrics.
T

Response to Emergencies
The concept of “rescue,” as proposed by Cote
2
states that the
purpose of all emergency treatment is to manage and stabilize the
patient until help arrives. Using local emergency services alone and
waiting for their response is not adequate rescue. Know and
understand if the emergency responders are EMTs or paramedics.
The office must have the resources and training necessary to perform
rescue from unintended sedation level changes, i.e. overdose, as
well as other categories of emergencies. The chances for a
successful outcome decrease as the distance from an emergency
facility increases and as time passes.
Learning to rescue alone is not adequate emergency preparation.
Prevention of the emergency through guidelines, understanding drug
dosages and pharmacology (with potential interactions), and
knowing your patient and his or her medical history will mediate the
risks involved. Documenting sedation incidents in the office and
reviewing those with staff and other practitioners allow us to learn
from experience and modify our delivery, monitoring and especially
our response, be it as simple as using a neck and shoulder roll or
a more involved response such as a drug dose change. It is recom-
mended that during sedations, children are maintained at the minimal
or moderate level
4
to maintain their protective reflexes and their
airways patent.
By following guidelines, we are able to minimize but not totally
eliminate risk. NPO guidelines may leave our patients
at risk for hypovolemia, especially if they perspire profusely while in
a medical immobilization device. The triad of hypovolemia,
hypoxia and hypercarbia lowers seizure threshold, increases
myocardial irritability and may hinder or prevent resuscitation efforts.
In addition, certain sedation medications such as chloral hydrate
may increase myocardial irritability and may negate the use of
epinephrine during emergency care.
Emergency Kit
The emergency kit for pediatric patients must be adequate to
maintain a patent airway and stabilize the child at the level of
sedation achieved as well as treat any concurrent emergencies until
either help arrives or the patient emerges and recovers. This implies
that if the patient drops to a level deeper than anticipated, the
doctor must be able to monitor and maintain the patient at the
unintended level and have the training, equipment and staff to do
so. The emergency kit must also contain equipment and supplies to
respond to other basic pediatric office emergencies and first aid. An
appropriate list is available in the AAP/AAPD Guidelines for
Monitoring and Management of Pediatric Patients During and After
Sedation for Diagnostic and Therapeutic Procedures
4
(chart 1). The
kit must contain specific equipment and sizes for pediatric
resuscitation, including face masks, advanced airway devices and
equipment for IV and IO access. The kit must be placed in an
identified and easily reached area and the components must be
clearly marked and labeled. Response must be organized and
practiced with individual roles assigned to each member of the
response team (chart 2).
Oxygen is always the first drug of choice. Room air has 21 percent
oxygen content. Oxygen, as a supplement in emergency situations,
should be delivered at 100 percent with the assistance of an
appropriately sized pediatric self-inflating, bag-valve mask system. A
mobile E-sized tank is capable of delivering 10 liters/minute of
oxygen for 60 minutes and may be used in areas not plumbed with
oxygen. Alternative oxygen delivery methods may be available but
must meet the requirements of access and transportability. Without
modification, the standard N2
O/O2
delivery unit is not capable of
delivering positive pressure oxygen because of an overload pop-off
valve in the system. The standard reservoir bag does not substitute
for a self-inflating, bag-valve mask though the unit may be used to
supply oxygen to the (BVM).
Masks used in resuscitation should be transparent with a form-fitting,
inflatable collar, which should also be checked on a regular basis. A
variety of different sizes should be available and should fit
comfortably between the nasal bridge and the chin. A 5cc syringe
without needle should be kept with the mask to deflate or inflate the
collar.
Advanced airway devices for managing airways during
emergencies include nasal and oral airways, endotracheal tubes
(ETT) and appropriate placement equipment. A valuable adjunct for
airway management is the laryngeal mask airway (LMA) which may
substitute for intubation in compromised airways. It is recommended
that experience be gained in this technique. The inflatable collar
may block regurgitated stomach contents from entering the airway.
Various sizes for pediatric patients must be available. Correct size
oral airways are measured externally from the tragus to the
commissure of the lips. Nasal airways are measured externally from
the tragus to the corner of the nares.
Automated Electronic Defibrillators (AED) are a conundrum in
pediatric emergency care, but states are increasingly mandating
their presence in dental offices. Short of aiding the staff in
resuscitating the doctor, they have little purpose in pediatric
practices as a first-line resuscitation device. Most cardiac problems
are not due to disease or congenital issues, but instead are due to
hypoxia leading to a transient tachycardia with the child succumbing
to a fatal bradycardia. Performing defibrillation on a hypoxic heart will
not revive it nor correct an arrhythmia.
2,5
Using local
emergency services
alone and waiting for
their response is not
adequate rescue.
SOBERING STATISTIC
In a study of predictors of out-of-hospital survival
rates, researchers found sobering results.
3–17%Long-term survival
SURVIVAL RATES POST CARDIAC ARREST
NOTE: Early detection and correction of an airway
emergency can dramatically reduce the chances of a
devastating event.

Routes for Administration
of Emergency Drugs
It is recognized that the optimum route of administration of all
emergency medications is intravascularly or intraosseously,
4,5
although alternate means are available. Submucosal delivery in the
area distal and superior to the maxillary molar in the region of the
pterygoid plexus or intramuscularly into the nearest exposed muscle
mass (gluteal or deltoid) may be used when there is optimum
circulation. Because the dental practitioner is most comfortable in
the oral cavity, the submucosal site mentioned is recommended for
drugs that may be given intramuscularly due to the high vascularity
of the area. This also avoids the possibility of swelling and airway
obstruction if administered in the floor of the mouth or the tongue.
Diazepam, because of its ethylene glycol base, is not appropriate
for intramuscular or submucosal administration except in extreme
cases.
Paradigm of Emergency Care
The paradigm of emergency care should involve a system or
method of treatment that guides our thoughts and actions. Prior to
the 2012 revision of the American Heart Association’s Pediatric
Advanced Life Support (PALS) course, the mnemonic of PABCD
where P is position, A is airway, B is breathing, C is circulation,
and D is drugs was used. As with the concept of rescue, the
absence of prevention in the thought process leads us to a situation
which may be preventable. Therefore, a paradigm of PPABCD,
where the first P is prevention, PABC are the same, and the D is
definitive treatment (realizing not all emergencies require drug
intervention) can be considered. The mnemonic has been recently
revised again to stress the increased focus on circulation. The key to
success is not to progress to the next letter if the prior letter is not
stabilized, i.e. do not attempt breathing if the airway is not
stabilized.
Emergencies of the Respiratory System
The most common emergency during pediatric sedations is hypoxia.
It may be caused by airway obstruction, drug overdose, local
anesthesia overdose or unintended sedation level, all of which may
lead to reduced respiratory rate and volume. When respiratory
and/or cardiac rates reach two-thirds of pretreatment rates, good
quality CPR should begin including bag-valve mask (BVM) intervention.
Survival rates after hypoxia and cardiac arrest are 3–17 percent;
6
therefore, early recognition and management are crucial. The early
signs of hypoxia are restlessness and agitation, transient increase in
heart rate then decrease, and irregular breathing patterns. The
various sounds of respiratory problems may be summarized as
follows:
Gurgling:
Snoring:
Crowing:
Wheezing:
fluid or foreign body in
the upper airway
tongue/soft palate/
tonsil obstruction
large tongue, vocal cord paralysis
or swelling, croup, epiglottitis,
foreign body, allergic reaction
with edema, laryngospasm
bronchospasm or partial
obstruction of the lower
airway on expiration
CHART #1
1.OXYGEN
2.AMMONIA SPIRITS
3.GLUCOSE (50%)
4.ATROPINE
5.DIAZEPAM
6.EPINEPHRINE
7.LIDOCAINE (CARDIAC)
8.DIPHENHYDRAMINE HYDROCHLORIDE
9.HYDROCORTISONE
10.PHARMACOLOGIC ANTAGONISTS (AS APPROPRIATE)
NALOXONE HYDROCHLORIDE FLUMAZENIL
EMERGENCY MEDICATIONS AND EQUIPMENT
1.NASAL AND ORAL AIRWAYS AND CLEAR MASKS OF ASSORTED
PEDIATRIC AND ADULT SIZES
2.PORTABLE OXYGEN DELIVERY SYSTEM CAPABLE OF DELIVERING
BAG AND MASK VENTILATION GREATER THAN 90% AT 10L/MIN
FLOW FOR AL LEAST 60 MINUTES (E.G. “E” CYLINDER)
3.SELF-INFLATING BREATHING BAGS AND RESERVOIR WITH MASKS
THAT WILL ACCOMMODATE CHILDREN AND ADULTS OF ALL SIZES
4.DEEP SEDATION AND GENERAL ANESTHESIA: ASSORTED PEDIATRIC
ENDOTRACHEAL TUBES, LARYNGOSCOPES WITH STRAIGHT AND
CURVED BLADES, MAGILL FORCEPS
AIRWAY MANAGEMENT EQUIPMENT
1.GLOVES
2.ALCOHOL WIPES
3.TOURNIQUETS
4.STERILE GAUZE PADS
5.TAPE
6.INTRAVENOUS SOLUTIONS AND EQUIPMENT FOR
ADMINISTRATION APPROPRIATE TO THE PATIENT POPULATION
BEING TREATED
• INTRAVENOUS CATHETERS (22, 24 GAUGE)
• INTRAVENOUS ADMINISTRATION SET (TUBING)
(MICRO-DRIP 60 DROPS/ML)
• INTRAVENOUS FLUIDS
• ASSORTED NEEDLES FOR DRUG ASPIRATION AND
ADMINISTRATION
• APPROPRIATELY SIZED SYRINGES
INTRAVENOUS EQUIPMENT FOR DEEP
SEDATION & GENERAL ANESTHESIA
CHART #2
1.INITIATES EMERGENCY CARE
• TREAT PATIENT/BASIC LIFE SUPPORT
• ACTIVATES OFFICE EMERGENCY PROTOCOL
2. REMAINS WITH PATIENT
TEAM MEMBER #1
1.BRINGS SUPPLIES/EMERGENCY KIT MEDICATIONS/O2
TANK
2.ASSISTS TEAM MEMBER #1
TEAM MEMBER #2
1.CROWD CONTROL
2.NOTIFIES EMERGENCY BACKUP SERVICE ON INSTRUCTIONS FROM
TEAM MEMBER #1
3.MEETS EMS AND ESCORTS THEM INTO THE OFFICE
4.MAINTAINS RECORDS
5.ASSISTS AS NEEDED
TEAM MEMBER #3

The treatment of hypoxia, regardless of cause, is as follows:
Asthma is the most common cause for admission to hospitals in the
pediatric population. Bronchospasm, the end result of asthma, may
also be caused by allergies, reactive airway disease following
infection or pneumonia, and mechanical or chemical irritation. The
most common signs are congestion, wheezing, dyspnea, confusion
or agitation and tachypnea and tachycardia. Because the pediatric
patient has limited oxygen reserves, intervention must be immediate.
The heart will tire quickly and hypoxia, hypovolemia and
hypercarbia will ensue quickly with lactic acidosis leading to an
irreversible condition.
The treatment of bronchospasm is as follows:
Laryngospasm may be caused by aspiration of a foreign body,
depth of sedation with partial loss of protective reﬂexes or post-viral
syndrome with reactive airway disease. With time, the situation
progresses and is harder to reverse without drug intervention.
The treatment of laryngospasm is as follows:
Abnormal Cardiac Rhythm and Pulses
Arrhythmias and dysrhythmias may have many causes but the most
common include an undiagnosed congenital defect, hypoxia,
effects of circulating catecholamines on a sensitized myocardium,
drug effects and vagal stimulation. The end result of the arrhythmia
is poor perfusion, lowered blood pressure, and the shunting of
blood from the peripheral circulation to maintain perfusion of the
blood-rich group. The Pediatric Advanced Life Support Course
(PALS) provides excellent training in the management of this
problem. Because arrhythmias have the potential to become fatal,
rapid identiﬁcation and treatment are imperative.
HYPOXIA
P(PREVENTION) • NECK ROLL
• LOOSE MEDICAL IMMOBILIZATION DEVICE
• KNOW SEDATION LEVEL AND DRUG
INTERACTIONS
• RUBBER DAM CAREFULLY PLACED ON SINGLE
SIDE–NOT CROSS ARCH
• SUCTION READILY AVAILABLE
P(POSITION) • SPINE WITH HEAD TILT
• MONITOR AND ASSESS AIRWAY & BREATHING
• ASSESS PATENCY
• POSITION TONGUE FORWARD/NO BLIND SWEEPS
• PLACE APPROPRIATELY SIZED NASAL AIRWAY
• OPA: TRAGUS TO CORNER OF THE MOUTH
• 100% O2
BY NASAL OR FULL FACE MASK
• LMA OR INTUBATE IF AIRWAY DOESNʼT OPEN
• MONITOR AND REASSESS
A(AIRWAY)
• ASSESS RESPIRATIONS
SELF VS ASSISTED / ADEQUATE VOL AND SPEED
• ASSIST AS NECESSARY WITH POSITIVE PRESSURE
100% O2
BY BAG-VALVE MASK (BVM)
B(BREATHING)
• ASSESS PERFUSION BY PERIPHERAL/CAROTID
PULSES
• BEGIN CPR
C(CIRCULATION)
• DETERMINE CAUSE AND TREAT WITH
APPROPRIATE DRUG
• ACTIVATE 911 AND TRANSPORT TO EMERGENCY
FACILITY
D(DEFINITIVE)
P(PREVENTION) • HISTORY
• CHROMALIN/ STEROID/ PUFFER HANDY
• DECREASE ANXIETY/ SUPPLEMENT WITH O2
• AVOID NARCOTICS (HISTAMINE RELEASERS)
P(POSITION) • PARTIALLY RECLINING
• 2–4 PUFFS OF ALBUTEROL INHALER
• Q 2 MINUTES FOR 2 DOSES
A(AIRWAY)
• ASSIST AS NECESSARY
BAG/ VALVE/ MASK IF NEEDED
• PREPARE TO INTUBATE
B(BREATHING)
• MONITOR AND CPR AS NEEDEDC(CIRCULATION)
• IF BRONCHOSPASM RESOLVES, CONTINUE
TREATMENT
• IF FAILS TO RESOLVE, NOTIFY EMS
D(DEFINITIVE)
BRONCHOSPASM
P(PREVENTION) • HISTORY OF INFETION
• USE OF RUBBER DAM AND HIGH-CAPACITY
SUCTION
P(POSITION) • SUPINE WITH HEAD TILT AND SHOULDER ROLL
• CHECK FOR FOREIGN BODY/ VOMITUS
• PLACE APPROPRIATE LENGTH ORAL AIRWAY
A(AIRWAY)
• 100% O2
THROUGH BVM
• CONSTANT MILD TO MODERATE PRESSURE /
NOT BURSTS
• DRUGS PRN
SUCCINYLCHOLINE 2–4 MG IM
WITH ATROPINE 0.4 MG
BE PREPARED TO VENTILATE FOR UP TO 30 MIN
B(BREATHING)
• MONITOR FOR PERIPHERAL PULSES
• CPR PRN
C(CIRCULATION)
• EMS ACTIVATION AND TRANSPORTD(DEFINITIVE)
LARYNGOSPASM
P(PREVENTION) • KNOW THE PATIENT
• KNOW THE DRUG, ITS INTERACTIONS AND ITS
EFFECTS
P(POSITION) • SUPINE WITH NECK AND SHOULDER ROLL
• MAINTAIN PATENCY
• NASAL OR ORAL AIRWAY AS NEEDED
• 100% O2
A(AIRWAY)
B(BREATHING)
• MONITOR AND ASSIST AS NEEDED
• BEGIN CPR IF NEEDED
C(CIRCULATION)
• NOTIFY EMS AND PRPARE FOR TRANSPORTD(DEFINITIVE)
ARRHYTHMIAS
• MONITOR AND ASSIST AS NEEDED WITH
BAG-VALVE MASK
• BEGIN CPR IF NEEDED
THE BEST WAY TO TREAT AN
EMERGENCY IS TO NOT HAVE ONE
Acquired infections of the airway in
children require a six-week healing
period before sedation or general
anesthesia should be done.

IMPORTANT:
Oxygen is always the
ﬁrst drug of choice.
WHY:
Because the pediatric
patient has limited
oxygen reserves,
intervention must be
immediate.

Sedation Drug Overdose
Despite the practitioner’s best efforts in predicting patient response
to a dose of sedative medication, there is always the chance of
hyper or hypo reactions to the drug such that the patient slips into a
deeper level of sedation than intended.
The practitioner must be prepared to respond appropriately and
maintain and protect the airway if loss of protective reflexes occurs.
The response to sedation drug overdose is as follows:
Local Anesthesia Overdose
The administration of local anesthesia concurrently with sedative
medications constitutes polypharmacy and requires additional
caution because of the risk of potentiation and fatal arrhythmias
secondary to lidocaine or epinephrine overdose. Because its
presence decreases the rate of anesthetic absorption, there is no
reason for not using local anesthetic with vasoconstrictor during
sedation of ASA 1 or 2 patients. In the case of overdose, increasing
CNS depression leads to the paradox of increasing CNS
stimulation, agitation and talkativeness. The patient exhibits seizures
until the blood level falls. Management of this emergency involves
stabilizing the patient and monitoring until blood levels fall.
Conclusion
The successful treatment outcome of an in-office emergency of a
pediatric patient during sedation is dependent upon rapid
identification of a problem and immediate intervention. The
emergency situation always takes precedence over the dental
procedure. Using recommended monitors and monitoring
techniques, early identification of critical events is possible. The
practitioner is advised to always be suspicious of changes in the
child’s responses. With a well-trained doctor and office staff,
experienced in emergency response, the likelihood of mortality or
severe disability decreases for the child. Continuous training for all
staff members is recommended.
References
1. Moore PA. Adverse drug reactions in dental practice: Interactions
associated with local anesthetics, sedatives, and anxiolytics. J Am
Dent Assoc 1999;130(4):541-544. Domino, D. Are pediatric
sedation deaths on the rise? 2010 May 18.
304662.drbicuspid.com.
2. Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C.
Adverse sedation events in pediatrics: a critical incident analysis of
contributing factors. Pediatrics 2000;105;805.
3. Guidelines for the use of sedation and general anesthesia by
dentists (2012). American Dental Association. www.ada.org/
sections/about/pdfs/anesthesia_guidelines.pdf.
4. Guidelines for monitoring and management of pediatric patients
during and after sedation for diagnostic and therapeutic procedures
(2006). AAPD Reference Manual 2015;37(6):211–227.
5. American Heart Association. Pediatric Advanced Life Support
(2010), course and manual. www.heart.org/PALS.
6. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of
survival from out-of-hospital cardiac arrest: a systematic review and
meta-analysis. Circulation 2010;3(1):63–81.
P(PREVENTION) • FOLLOW CURRENT LOCAL ANESTHESIA
GK/GM4GNIDEECXETONSESODDNASENILEDIUG
FOR COMMERCIALLY AVAILABLE DRUGS
• STOP PROCEDURE
P(POSITION) • SUPINE IN THE UNRESPONSIVE, SEDATED PATIENT
• NECK AND SHOULDER ROLL
• USUALLY ADEQUATELY MAINTAINED
• FOLLOW PRECAUTIONS FOR HYPOXIA
A(AIRWAY)
• USUALLY MAINTAINED
• 100% O2
TO PREVENT HYPOXIA, HYPERCARBIA/
AND ACIDOSIS
• MAY BE DEPRESSED OR ABSENT
• 100% O2
WITH BAG-VALVE MASK
B(BREATHING)
• USUALLY ADEQUATELY MAINTAINED
• HYPOTENSION AND TACHYCARDIA REQURE
BLS INTERVENTION
C(CIRCULATION)
• EMS ACTIVATION AND TRANSPORTD(DEFINITIVE)
LOCAL ANESTHESIA OVERDOSE
P(PREVENTION) • KNOW DRUG DOSE, INTERACTIONS AND EFFECT
• KNOW DRUG METABOLISM AND HALF LIFE
• IDENTIFY LEVELS OF SEDATION AND
RESPONSIVENESS
P(POSITION) • SUPINE WITH NECK AND SHOULDER ROLL
• 100% O2
• ORAL AIRWAY OR INTUBATE IF NEEDED TO
GUARANTEE PATENCY
A(AIRWAY)
• ASSIST WITH BVM AS NEEDED
B(BREATHING)
• MONITOR AND ASSIST WITH CPR IF NEEDEDC(CIRCULATION)
• STOP DENTAL PROCEDURE
• START IV (REQUIRED FOR DEEP SEDATION / GA)
• MONITOR APPROPRIATE VITAL SIGNS
• REVERSAL AGENTS IF APPROPRIATE
NALOXONE 0.01 MG/KG IM Q5M TO MAX 1MG
FLUMAZENIL 0.2 MG IV Q1M TO MAX 1 MG
• MONITOR AND ASSESS LEVEL OF SEDATION
D(DEFINITIVE)
SEDATION DRUG OVERDOSE
A Special Thanks to the ADSA
This article was originally published in the winter 2016 (Vol. 48 No. 3)
edition of , the official publication of the American Dental
Society of Anesthesiology. We are grateful for the opportunity to
share this valuable information with our readers.
Pulse

BE A HERO
KNOW WHAT TO DO!

There is a special place in heaven for pediatric dentists and their teams.
Children are not small adults. They are human beings going through
normal stages of growth and life.
The pediatric practice becomes and remains healthy when excellent
clinical and management principles, specific to your specialty, are
closely tied to the “human” principles of children or young people.
Therein lies the key to success: combining people skills with management
skills.
At Jameson Management, we have a specific division that focuses on
pediatric practices. Let’s look at 10 essentials for a dynamic, successful
pediatric practice based on the experience of our pediatric consultants.
ESSENTIALS
FOR A DYNAMIC,
SUCCESSFUL
PEDIATRIC
PRACTICE
By Cathy Jameson, PhD
10

Photography courtesy of Joelle Speed, DDS
The Smile Gallery—Roseville, California

In each and every encounter,
settle for nothing but the best.

1. Develop a practice that
epitomizes excellent care of both
the business and children. One
goes hand in hand with the other.
In a pediatric practice, you have certain requirements and issues.
Your management systems must be established, administered, and
monitored appropriately. The success of your practice will be in
direct proportion to the success of your systems. Each system is
vital. And—each system is tied to every other system. The efficiency
and effectiveness of your systems allow you to focus on the business
at hand—taking care of the children and their parents. In each and
every encounter, settle for nothing but the best. Focus on both the
physical and emotional needs of each child. One is tied to
the other.
2. Create and deliver a new patient
“experience” that is fun for the
kids and informative and
motivational for the parents.
The new patient experience is both the child’s and the parent’s
introduction to your practice—and (hopefully) to a long-term
relationship with you. From the parent’s initial meeting with you
(perhaps through a referral or through your marketing) and
throughout each successive encounter, the relationship moves in
one direction or another. Every person on the team can make or
break the relationship.
Kids are kids. They want and need to have fun. Keep their interest
and meet them where they are coming from, and you will go a
long way together.
When learning is informational and motivational for both parents
and children, they gain insights, and your mutual relationship is
nurtured. This type of reciprocal relationship fosters successful
treatment, encourages cooperation, and builds long-term
commitment.
3. Plan, prepare, and present your
recommendations excellently
using visual aids—particularly
photography.
Approximately 83 percent of learning takes place visually—for all
people no matter what their age. Therefore, use visual aids to
educate both children and parents. Remember that kids today (and
most of their parents) have grown up with something digital in their
hands. So again, meet them where they are coming from. Use
photography, visual education programs, video and digital formats.
They could probably run the programs for you. Use visual aids, and
you will have a much more cooperative child.
4. Develop the role of a patient or
surgical coordinator.
The responsibilities of a patient or surgical coordinator are
adaptable according to the needs of your individual practice.
However, in today’s sophisticated world of dentistry, finding a
qualified and dependable person to fill this role is essential. This
person will provide third-party back-up support for the doctor’s
treatment recommendations, make financial arrangements, and
schedule appointments—both in the office and in the hospital,
when appropriate.
Coordinating schedules and making sure that patients/parents are
well-informed is critical for assuring patient compliance and
cooperation. This coordinator can be your liaison with the offices of
your referring colleagues. The referring doctors need and want to
be “in the loop” regarding patients whom they have referred to
you.
Follow-up and follow-through are vital elements of your office
success.
5. Stay in contact with your
referring doctors and their teams
by scheduling special events and/
or offering informative courses.
Make sure that your referral
sources understand the following
about your practice: 1) you can see
all children, not just children with
special needs or behavioral
challenges, and 2) you will send
referred patients back to their
original doctor, if that is their
request.
Develop and refine your system of nurturing referrals—the lifeblood
of your practice. While your external marketing protocols will
certainly help your new-patient flow and your existing patient
retention, your internal marketing, including nurturing referrals from
other healthcare professionals, remains a stronghold for your
practice development.
Consider hosting social events for these referring practices. Include
the entire team. You want to have a solid, trusting relationship with
the referring doctor. However, patients (parents) will often prefer to
converse with a team member who they particularly like or trust. So
include team members when you invite referring doctors to your
office. Let them see who you are, what you do, and why coming to
you is a good idea. Host CE programs that benefit the entire team.
Serve a nice lunch at the CE event. Give door prizes, etc. Make it
fun, informative, and motivational. Invest money in order to make
this a memorable, high-quality event.
Make sure your entire team is there—hosting and interacting. Pass
out material about your practice. Have the doctor or a team
member welcome the guest group and briefly introduce what you
emphasize in your practice. Make sure that you clearly identify the
type of children you see and outline how you welcome patients to
your practice. Also, acknowledge certain situations in which a
patient may be referred to you for a particular treatment while
emphasizing your willingness to return the patient to the general
practice, if so desired.
Make a point of thanking the attendees. The purpose of this event
is to show appreciation to the referring practice.

6. Scheduling is the heartbeat of your
practice. Be prepared. Know the
school holidays. Identify your home-
schooled children so that they may be
called on short notice. Determine
how many children from the same
family can be seen at one visit. Learn
proven ways to reduce broken
appointments and no-shows.
Your parents will be very grateful that you know when their children will
be in or out of school. Your efforts to schedule appointments during those
times provides excellent customer service and is also a good marketing
strategy. Of course, your kids who are home schooled will be available
at times when children in public or private schools are unavailable. Keep
track of those kids.
Jameson Management consultant, Dru Halverson, RDH, recommends that
you try the “every other” appointment scenario. For example you can say,
“Mrs. Jones, I’m sure you can appreciate that all of our parents would like
the after-school appointments. And so, in order to accommodate
everyone to the best of our ability, we schedule one appointment after
school and the next one during school hours. Then we switch back. In this
manner, everyone has a chance to schedule those after-school, popular
times.”
If you allow more than one child to come at a scheduled appointment
time, make sure the parents understand that you are making an
exception, and that you must be able to count on them showing up on
time. If they cancel at the last minute, of course, you will not be able to
reserve that much time in the future.
Send a welcome packet and ask the parents to fill out the information
sheets and health history forms. Ask them to send these documents back
to you prior to the appointment. This will reduce your broken
appointments and no-shows at those first visits. Data has shown that when
someone completes the forms and sends them back—either physically or
digitally—they will be more likely to show up.

Getting to know your
patients on a personal
level can be very
rewarding, both
personally and
professionally.

The better you listen to the
child (or parent), the better
they will listen to you when it
comes time for you to speak,
teach, or recommend.

7. Communicate with your kids:
know that your children hear
everything, see everything, and
are frightened of everything. Use
your visual aids, digital teaching
tools, and comforting words. Be
interested in them personally.
Make their day—know their sports
teams, pets, and special interests.
Communication is the bottom line to your success. Relationships
depend on accurate and empathetic communication. All our senses
are involved in effective communication. Tour your own office and
see what it says. Is it comforting? Child friendly? Fun? Use visual
aids throughout every encounter. Focus on the senses—
constructively. Use music, fragrance, colors, activities, tasty oral
products, visual educational materials, and hands-on teaching tools
—things your patients and their parents can hear, smell, see, taste,
and touch.
Speaking of hearing and music, it’s been said that the sound of a
person’s name is music to their ears. Personalize every encounter
with the child and/or the parent. Know their names. Call them by
name. Know something about them. This is another reason why it
is so valuable to send the welcome packet prior to the
appointment.
Brenda McNulty, Jameson Management consultant and pedo
specialist, says that when anyone—but specifically a child—
realizes that you know something about them and care about
them, they respond by opening up, connecting, and listening.
And, by the way, the better you listen to the child (or parent), the
better they will listen to you when it comes time for you to speak,
teach, or recommend.
8. Communicate with the parents:
know that they feel badly if their
child has a cavity or any other
issue. Empathize while you
educate.
McNulty points out that oftentimes when a parent is shown a
disturbing condition in their child’s mouth, they feel guilty and
distressed. This drives home the point that education is valuable,
not only to the child but also to the parents. Show parents the
photos of their child’s mouth. Don’t sugarcoat the situation. Focus
on how to restore the child’s health and how to prevent further
deterioration. Focus on what can be. Give them the
instruction and motivation to handle home care in a more proactive
and effective manner.
If things have improved when they return for their next visit, be sure
to note that and give the parent positive reinforcement for work well
done. Even though things may not be perfect, provide that
constructive reinforcement. Michael LeBoeuf says, “That which is
rewarded is repeated.” Appreciation and acknowledgement are
the most powerful of all rewards and motivators.
9. School visits and community
outreach are vital. Know your
school nurses and teachers. They
care about their students and will
value your support of them and
their students.
You are a part of a compassionate healthcare team. School nurses,
teachers, principals, and lay persons are all interested in the health
and well-being of the children in their school—or they wouldn’t be
there. When you take an interest in the children at their school, they
will wrap their arms around you. Provide educational events,
celebrate Children’s Dental Health Month, or provide toothbrushes
and toothpaste along with training sessions. Be there. Be a
significant, participating member of the school’s educational team.
Show you care.
10. Turn to the AAPD for
marketing support and practice-
development tools.
The American Academy of Pediatric Dentistry provides courses on
all aspects of clinical, management and marketing for your practice.
In addition, they provide materials to support your practice and
educate your parents and kids. When you are planning CE events
for your referring doctors or scheduling educational events for your
schools, you can access AAPD materials that are applicable to
your event.
The academy introduces new materials, technology, and products
at their annual sessions and at state and local venues. Be a part of
your supportive organization. Access the marketing and practice-
development tools that they provide.
IN SUMMARY
Your pediatric practice provides unique, essential care for a
healthy, growing child. You are definitely “on purpose” with the
service and care you deliver. Excellent management systems
combined with effective people skills support your ability to provide
outstanding clinical treatment. This combination leads to a
dynamic, successful pediatric practice.
Study the 10 essentials described in this article. Ask yourself,
“What am I doing well?” Acknowledge those things. Reinforce
them. Keep doing them. Then ask yourself the more productive
question, “How can I do these things even better?” Therein lies the
key element for growth. Follow this path of continual improvement
—a path designed to ensure your success.
For information regarding Cathy’s lectures or the
services of Jameson Management, see their website:
www.jamesonmanagement.com or contact their
email: info@jamesonmanagement.com.

91% of unhappy
customers will not
willingly do business
with you again.
BUSINESS
On average, loyal
customers are worth
up to 10 times as
much as their ﬁrst
purchase.
CUSTOMERS
It is 6-7 times more
expensive to acquire
a new customer than
it is to keep a current
one.
ACQUISITION
70% of buying
experiences are based
on how the customer
feels they are being
treated.
EXPERIENCE
STATISTICS PROVIDED BY:
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