MyView: Back to the Future
January 08, 2018
By Leonard J. Carapezza, D.M.D.
Leonard J. Carapezza, D.M.D.
I am in my fourth quarter of a specialty in dentistry where I truly have had the privilege of practicing and being an influence in the lives of many of my patients.
It is heart-wrenching to read or be informed that a very young pediatric patient has lost his/her life while undergoing a dental procedure under in-office sedation.
To my way of thinking, this type of tragedy should never happen in a private practice setting. A proper medical history and dental diagnosis with a well-defined and thought-out treatment plan should allow one to categorize the young patients’ immediate dental needs in that framework.
The specialty in the past and present defines itself as being more psychological rather than procedural based. What situations are bringing about new paradigms in the delivery of restorative care to the young pediatric patient? Is it the change in the permissiveness of child rearing, the availability of insurance coverage or the economic pressures of being a dentist, opening a practice, supporting a practice and paying down one’s accumulated debt? I believe it is all these factors combined.
Fifty years ago, the child’s dentist was in charge. The Tell, Show, Do and the Hand Over Mouth technique were in play and properly performed as taught in our specialty programs worked very well and was successful with a high percentage rate. Today, with the media and legal attention to child abuse, Hand Over Mouth has been eliminated from pediatric specialty programs for fear of legal action and internet defamation. The treatment of the child in a dental environment is now done with the parent or care keeper as an active participant of Tell, Show and Do.
This shift in communication participation takes time while the economic clock is ticking; without question it costs money and is not conducive to today’s cost-driven practices. The psychological format of pediatric practices of the past should not be lost, but instead should be valued and may be defined by some as social visits. This approach by the practitioner will show the benefit of trust-building relationships that have been endangered in the present day office tragedies.
Immediate restorative dental needs of the young patient can be temporized with pain control until the child is more willing to accept definitive treatment. A recent approach to the prevalent and severe caries disease in children is the use of silver diamine fluoride as part of an ongoing caries management plan. The purpose of the use of silver diamine fluoride is the action of its antimicrobial and remineralization potential to arrest active carious dental lesions. Slow the process down. Common sense today, unfortunately, is not so common.
The pediatric continuing education programs are placing too much emphasis on sedation and over-treatment procedures — which risks pulpotomies and encourages preventative quadrant dentistry — enticing the increase of the practice income. The current pediatric dental culture is not spending enough time and effort to teach the young pediatric dental patient how to accept all forms of dentistry which is our main job as defined by the specialty.
All routine types of pediatric dentistry can be done with the safest pain control anesthetic ever developed — local anesthesia — plus caring and empathetic practitioners.
Back to the future and resurrect the ghosts of the pediatric past — our Founding Fathers.
This editorial, reprinted with permission, originally appeared in the May/June 2017 issue of Pediatric Dentistry. Dr. Carapezza is an associate clinical professor in the department of pediatric dentistry at Tufts University School of Dental Medicine and has a private practice in Wayland, Massachusetts.