Kingdom and the United States to investigate the use of intraoral fluoride-releasing
devices. These are small diameter glass beads that are attached by composite resin, to
the buccal surface of a tooth (1130HChapter 6). The device dissolves slowly in saliva,
releasing fluoride as it does so. Those currently on trial have continued to elevate
salivary fluoride levels for up to 2 years. Whether the released fluoride is equitably
distributed around the mouth is not yet known. The placement, and retention in situ,
of the glass beads in such children may be a challenge.
Duraphat fluoride varnish (5% sodium fluoride = 22,600 p.p.m. fluoride, Colgate) is
an almost ideal preventive agent for children with poor tolerance of dental
procedures. The amber-coloured polyurethane-based material is applied to the tooth
surfaces, preferably dry, although the varnish is water tolerant, and the resulting
adherent film slowly releases fluoride (1131HFig. 17.7). The exercise should be repeated up
to four times a year depending on caries risk. A reduction of caries in permanent teeth
of between 30% and 62% has been reported using Duraphat TM varnish.
Recourse to one or other forms of conscious sedation may be indicated for a child
with impairments who finds it difficult to co-operate for dental care. However, a
degree of compliance is necessary in order to retain the nasal hood for the delivery of
nitrous oxide/oxygen for inhalation sedation(1132HFig. 17.8) as it is for the insertion of a
cannula for intravenous sedation. However, IV sedation is not usually indicated for
children although the drug used most commonly in the United Kingdom, Midazolam,
can be given orally although again, the outcome may not be predictable.
For some patients general anaesthesia will be necessary to provide adequate dental
care (1133HFig. 17.9). This facility is not widely available and often means considerable
disruption for the family because of the distance involved in travelling to specialist
centres. Additionally, the child may be unsettled by the whole process of being
starved, looked after by strange personnel, being anaesthetized, and then waking up
with a sore throat and perhaps a mouth full of blood. There is evidence that this
experience is only in the short-term memory as many parents comment on how much
better their child is in terms of behaviour, sleeping patterns, and eating after the
immediate postoperative period.
Treatment planning for dental care under general anaesthesia has to be more radical.
The opportunity to reduce a 'high' restoration or to review a doubtful tooth is not
necessarily available without recourse to another general anaesthetic. Radiography is
an important aid in theatre, especially for the patient who is totally unco-operative in
the dental chair. It is particularly important for detecting otherwise hidden pathology
and for early enamel lesions. The latter cannot normally be left in the hope that they
will remineralize by preventive means. Similarly, the chances of restoration failure
can be reduced by the use of pulpotomy techniques and preformed metal crowns.
Most forms of treatment can be carried out under general anaesthesia provided there
is sufficient operating time and the patient's general condition permits it.
Success is dependent upon careful pre-anaesthetic assessment by dentist and
anaesthetist. Appropriate perioperative care in theatre, for example, steroid or
antibiotic cover, and the back-up of in-patient facilities where medically or socially
indicated, are vital to a successful outcome. Patients with Down syndrome may have
altlanto-axial joint instability and will need extra care in moving from trolley to