Chapter 3 Pediatric dentistry Principal sources: J. R. Pinkham 2005 Pediatric Dentistry: Infancy Through Adolescence 4th ed.

, Elsevier Saunders. R. Andlaw 1996 A Manual of Paedodontics, Churchill Livingstone. J. O. Andreasen 1981 Traumatic Injuries of the Teeth, Munksgaard. J. O. Andreasen 1992 Atlas of Replantation and Transplantation of Teeth, Mediglobe. G. J. Roberts and P. Longhurst 1996 Oral and Dental Trauma in Children and Adolescents, OUP. R. R. Welbury 2001 Paediatric Dentistry, 2nd ed., OUP. M. E. J. Curzon 1999 Handbook of Dental Trauma, Wright. M. S. Duggal et al. 2002 Restorative Techniques in Paediatric Dentistry, Dunitz. P.56 The child patient

Treat the patient, not the tooth.

Principal aims of treatment

Freedom from pain and infection A happy and cooperative patient Prevention Development and maintenance of healthy and attractive primary and permanent dentitions Points to remember

Praise good behavior (reinforcement, p. 60), discourage bad. Involve parents (they determine whether the child will return). Do not offer choice where there is none. Avoid rhetorical questions (Would you like to get into my chair?). Children have short attention spans (with age). Children have decreased sensory acuity (they may confuse pressure with pain, sensitivity tests are less reliable). Children have decreased manual dexterity, therefore they need help with tooth brushing <7 years. Formulate a comprehensive treatment plan, which should address both operative and preventive care, at an early stage. Start with easy procedures (e.g., OHI) and progress, at the child's pace, to more complicated treatment. Set attainable targets for each visit and attain them.

The first visit

Children should first visit a dentist as soon as they have teeth (i.e., about 6 months of age). For young children, watching other members of the family receive treatment prior to their turn may be preferable. Let parent accompany child: check medical history and reason for dental visit. Talk to the child: communication is the key to success! Show patient the chair, mirror, and light, and explain purpose (tell, show, do, p. 60). Count the patient's teeth. If there is good progress, polish a few teeth, but don't tire child by attempting too much.

Show parent the child's teeth and what has been done that visit. If child is in pain, the source of this needs to be determined and dealt with as quickly as possible. Younger children can be more successfully examined if parent sits with the child facing dentist and then lowers child back onto his or her arm or the dentist's lap (kneeto-knee technique).

Treatment planning for children Diagnosis Dental caries is often a rapidly progressing condition in children. It is essential to accurately diagnosis disease prior to development of a treatment plan. This is achieved by taking a history, doing an examination, and, where possible, taking bitewing radiographs. Bitewings are essential for an accurate diagnosis unless all surfaces of the primary molars can be visualized (i.e., the dentition is spaced). Treatment plan The ultimate aim in dentistry for children is for the child to reach adulthood with good dental status and a positive attitude toward dental health and dental care. The final treatment plan will take into account the following considerations:

Behavior management (p. 60) Prevention (Chapter 2) Restorative treatment (p. 80) Developing occlusion

Remember to consider the developing occlusion:

Long-term prognosis for first permanent molars (p. 140) Palpate for maxillary permanent canines at age 9-10 years (p. 144) Be aware of disturbances in eruption sequence (p. 65) and asymmetry Early referral to specialist for skeletal discrepancies and for any abnormal findings

The treatment plan is drawn up visit by visit. Each visit has both a preventive and operative component (delivering one preventive message per visit). Since it is considered easier to administer LA for maxillary teeth, these teeth are usually treated before mandibular teeth. Restorative care (i.e., repair) without prevention is of limited value. Dental caries is treated by preventive measures; restoration purely repairs the damage caused by the carious process. Children with caries in primary molars treated by prevention alone are likely to experience toothache or infection, especially if the child is young when the caries is first diagnosed. A combination of prevention and restoration and extraction is indicated for most children with caries in the primary dentition. Other considerations Pain or evidence of infection may alter the order of the treatment plan. Temporization of open cavities at the start of treatment

gives a good introduction to dentistry; helps to minimize the risk of pain before treatment is completed; improves comfort (e.g., during brushing and eating); reduces salivary Streptococcus mutans count;

produces a preliminary coronal seal, enhancing the chances of pulpal recovery and survival; and may provide slow release of fluoride in the short term if a GI cement is used.

Delivery of care Once the treatment plan has been decided upon, discuss appropriate delivery of care with the parent and child:

Council parent and patient about the treatment options. LA/sedation/GAconsider and discuss risks vs. benefits of each (p. 61). Plan operative care at a pace appropriate to the child's ability to cope. Be prepared to reconsider method of delivery of care (e.g., sedation or GA) if patient proves unable to accept treatment using original delivery strategy.

Look out for any signs of underlying medical or social problems that may modify the treatment plan:

Small stature Failure to thrive Systemic disease Non-accidental injury (NAI; p. 100).

The anxious child Techniques for behavior management Most of these are fancy terms to describe techniques that come with experience of treating children over a period of time. However, for the student they may prove useful for answering essay questions as well as for handling their first few child patients. General principles

Show interest in the child as a person. Touch > facial expression > tone of the voice > what is said. Don't deny the patient's fear. Explainwhy, how, when. Reward good behavior, discourage bad. Get the child involved in treatment, e.g., holding saliva ejector. Giving the child some control over the situation will also help them to relax, e.g., raising their hand if they want you to stop for any reason.

Tell, show, do This is self-explanatory, but use language the child will understand. Desensitization Used for children with preexisting fears or phobias, this involves helping the patient to relax in the dental environment, then constructing a hierarchy of fearful stimuli for that patient. These are introduced to the child gradually, with progression to the next stimulus only when the child is able to cope with the previous situation. Modeling is useful for children with little previous dental experience who are apprehensive. Encourage the child to watch other children of similar age or siblings receiving dental treatment happily. Behavior shaping The aim of this is to guide and modify the child's responses, selectively reinforcing appropriate behavior, while discouraging/ignoring inappropriate behavior.

Reinforcement is the strengthening of patterns of behavior, usually by rewarding good behavior with approval and praise. If a child protests and is uncooperative during treatment, do not immediately abandon the session and return them to the consolation of their parent, as this could inadvertently reinforce the undesirable behavior. It is better to try and ensure that some phase of the treatment is completed, e.g., placing a dressing. Should parent accompany child into the operatory? This is essential on first visit, thereafter it depends on child's age. If in doubt, ask for the child's preference. However, if the parent is dental phobic, their anxiety in the dental environment may adversely affect child, so in these cases it is probably wiser to have the parent remain in the waiting room. Some children will play up to an overprotective parent to gain sympathy or rewards, and may prove more cooperative by themselves. However, many parents wish to be involved in and informed about their child's treatment. Ideally parents should be motivated positively and instructed implicitly to act in the role of the silent helper. Any device used to restrain the child such as Papoose boards requires prior parental consent. P.61 Sedation Indicated for the genuinely anxious child who wishes to cooperate with treatment. Oral Drugs such as midazolam and chloral hydrate can be used, although specialized knowledge and skills are required. Intramuscular Rarely used in children. Intravenous Rarely used in children. Per rectum Popular in some Scandinavian countries. Inhalation A nitrous oxide/oxygen mixture is used to produce relative analgesia (RA) and is the most popular technique for use with children. It is effective for reducing anxiety and increasing tolerance of invasive procedures in children who wish to cooperate but are too anxious to do so without help. For technique, see p. 578. It is a good idea not to carry out any treatment during the visit when the child is introduced to happy air. Let the child position the nosepiece him- or herself. Hypnosis Hypnosis produces a state of altered consciousness and relaxation, though it cannot be used to make subjects do anything they do not wish to do. Although many good books1 and articles are available on the subject, attendance of a course is necessary to gain experience with susceptible subjects, so the operator has confidence in their ability. It can be described as either a way of helping the child to relax or as a special kind of sleep. General anesthesia GA allows dental rehabilitation and/or dental extractions to be achieved at one visit. It should only be used for dental treatment when absolutely necessary (i.e., when other methods of management, e.g., LA or sedation, are deemed unsuitable). Alternative strategies and the risks of GA must be discussed to enable parents to make an informed decision. Legally, GA should be provided in a hospital setting. Risks The risk of unexpected death of a healthy person

under GA has been estimated to be about 3 in 1 million; under sedation has been estimated to be about 1 in 2 million.

Other behavior problems and their management

The questioner attempts to delay treatment by a barrage of questions. Firm but gentle handling is needed. Tell the patient that you understand their anxieties and that you will explain as you go along. The temper tantrum: try to establish communication. Praise good and discourage bad behavior. Set an easily achievable goal, e.g., brushing teeth, and make sure it is achievedcomment on the positive outcome, not what was not achieved.

The child with toothache When faced with a child with toothache the dentist should use clinical judgment to try and determine the pulpal state of the affected tooth or teeth, as this will determine the treatment required. To that end, the following information should be obtained: History Take a pain history (see p. 228) from the child and parent. Beware of variations in accuracy; anxious children may deny being in pain when faced with the prospect of undergoing dental treatment, whereas parents who feel guilty for delaying seeking dental care may exaggerate pain. Remember some pathology is painless, e.g., chronic periradicular periodontitis. Examination Swelling, temperature, lymphadenopathy. Intraorally look for caries, abscesses, chronic buccal sinuses, mobile teeth (due to exfoliation or apical infection) and erupting teeth. Percussion Can be unreliable in children. Care is needed to establish a consistent response. Sensitivity testing Again, this is unreliable in primary teeth, but for permanent teeth a cotton roll, ethyl chloride, and considerable ingenuity may provide some useful information. In older children electric pulp testing may be helpful. Radiographs Bitewing radiographs are most useful because they not only are less uncomfortable for small mouths than periapicals but also show the bifurcation area where most primary molar abscesses begin. Remember, the only 100% accurate method is histological! Diagnosis Sharp, short pain on hot/cold/sweet stimuli = reversible pulpitis. Longer-lasting pain on hot/cold/sweet stimuli = irreversible pulpitis. Spontaneous pain with no initiating factor (no mobility, not tender to percussion [TTP]) = irreversible pulpitis. Pain on biting and pressure and/or swelling and tenderness of adjacent tissues, mobility = acute periradicular periodontitis. With an irritable child keep examination and operative intervention to a minimum, doing only what is necessary to alleviate pain and win the child's trust. If extractions under GA in the hospital setting are required, consider carefully the long-term prognosis of remaining teeth to try and avoid a second trip to the operating room in the near future. Other common potential causes of toothache:

Dentoalveolar trauma (p. 98) Mucosal ulceration (p. 434) Teething (p. 65)

Abnormalities of tooth eruption and exfoliation Natal teeth are usually members of the primary dentition, not supernumerary teeth, and so should be retained if possible. They most frequently affect the mandibular incisor region and, because of limited root development at that age, are mobile. If in danger of being inhaled or causing problems with breastfeeding, they can be removed under LA.

Teething As eruption of the primary dentition coincides with a reduction in circulating maternal antibodies, teething is often blamed for systemic symptoms. However, local discomfort, and so disturbed sleep, may accompany the actual process of eruption. A number of proprietary teething preparations are available, which usually contain a combination of an analgesic, an antiseptic, and anti-inflammatory agents for topical use. Having something hard to chew may help, e.g., teething ring. Eruption cyst is caused by an accumulation of fluid or blood in the follicular space overlying an erupting tooth. The presence of blood gives a bluish hue. Most rupture spontaneously, allowing eruption to proceed. Rarely, it may be necessary to marsupialize the cyst. Failure of/delayed eruption It must be remembered that there is a wide range of individual variation in eruption times. Developmental age is of more importance in assessing delayed eruption than chronological age.

Disruption of normal eruption sequence and asymmetry in eruption times of contralateral teeth >6 months warrants further investigation.

General causes Hereditary gingival fibromatosis, Down syndrome, Gardner syndrome, hypothyroidism, cleidocranial dysostosis, rickets. Local causes

Congenital absence. This is the most likely cause for failure of appearance of maxillary lateral incisor (p. 66). Crowding. Treatment: extractions. Retention of primary tooth. Treatment: extraction of primary tooth. Supernumerary tooth. This is the most likely reason for failure of eruption of maxillary permanent central incisor (p. 66). Dilaceration (p. 68) Dentigerous cyst Trauma to primary tooth leading to apical displacement of permanent incisor Abnormal position of crypt. Treatment: extraction or orthodontic alignment. See options for palatally displaced maxillary permanent canine (p. 144). Primary failure of eruption usually affects molar teeth. The etiology is not understood. Although bone resorption proceeds above the unerupted tooth, they appear to lack any eruptive potential. Treatment: keep under observation, but ultimately extraction may be necessary.

P.65 Infraoccluded (ankylosed) primary molars occur where the primary molar has failed to maintain its position relevant to the adjacent teeth in the developing dentition and is below the occlusal level of adjacent teeth. This is caused by preponderance of repair in the normal resorptive/repair cycle of exfoliation. This is usually self-correcting (if the permanent successor is present and not ectopic) and the affected tooth is exfoliated at the normal time.1 However, where the premolar is missing or where the infraoccluded molar appears in danger of disappearing below the gingival level, extraction may be indicated. Ectopic eruption of the upper first permanent molars resulting in impaction of the tooth against the second primary molar occurs in 2-5% of children. It is an indication of crowding. In younger patients (<8 years) it may prove self-correcting (jump). If still present after 4-6 months (hold) or in older children, insertion of an orthodontic separator may allow the first permanent molar to erupt normally. More severe impactions should be kept under

observation. If the second primary molar becomes abscessed or the first permanent molar is in danger of becoming carious, then the primary tooth should be extracted. The resulting space loss can be dealt with as part of the overall orthodontic treatment plan later. Premature exfoliation The most common reason for early tooth loss is extraction for caries. Traumatic avulsion is less common. More rarely, systemic disease such as leukemia, congenital or cyclic neutropenia, diabetes, hypophosphatasia, Langerhans cell histiocytosis, Papillon-Lefevre syndrome, Chediak-Higashi syndrome, or Down syndrome may result in an abnormal periodontal attachment and thus premature tooth loss (p. 192). Alveolar bone loss in a young child is a serious finding and warrants referral. Normal sequence of eruption (permanent dentition). P.66 Abnormalities of tooth number Anodontia Complete absence of all teeth. Rare. Partial anodontia is a misnomer. Hypodontia Absence of less than six teeth. Oligodontia Absence of six or more teeth. Prevalence Primary dentition 0.1-0.9%, permanent dentition 3.5-6.5%.1 In Caucasians the most commonly affected teeth are third molars (25-35%), maxillary lateral incisor (2%), and maxillary and mandibular second premolars (3%). Affects F>M and is often associated with smaller than average tooth size in the remainder of dentition. Peg-shaped maxillary lateral incisor often occurs in conjunction with absence of contralateral maxillary lateral incisor NB canine migrates down guided by the distal aspect of maxillary lateral incisor. When maxillary lateral incisor is absent, peg shaped, or small rooted, it is important to monitor the upper canine for signs of ectopic eruption. Etiology Often familialpolygenic inheritance. Also associated with ectodermal dysplasia and Down syndrome. Treatment Primary dentitionnone. Permanent dentitiondepends on crowding and maloccusion. Third molarnone. Maxillary lateral incisorsee p. 114. Mandibular second premolarlate development of mandibular second premolar is not unknown. If patient crowded, extraction of mandibular second primary molar, either at around 8 yrs for spontaneous space closure or later if space is to be closed as a part of orthodontic treatment. If lower arch well-aligned or spaced, consider preservation of mandibular second primary molar, and bridgework later. Hyperdontia Better known as supernumerary teeth. Prevalence Primary dentition 0.8%, permanent dentition 2%.1 Occurs most frequently in premaxillary region. Affects M>F. Associated with cleidocranial dysostosis and cleft lip/palate (CLP). In about 50% cases supernumerary in primary dentition followed by supernumerary in permanent dentition, so inform parents. Etiology Theories include offshoot of dental lamina, third dentition. Effects on dentition and treatment

No effect. If unerupted, keep watching; if erupts, extract. Crowding. Treatment: extract; if supplemental, extract tooth with most displaced apex. Displacement. Can cause rotation and/or displacement. Treatment: extraction of supernumerary tooth and fixed appliance, but tendency to relapse. Failure of eruption. Most likely cause of maxillary incisor to fail to erupt. Treatment: extract supernumerary tooth and ensure sufficient space for unerupted tooth to erupt. May require extraction of primary teeth and/or permanent teeth and appliances. Then wait. Average time to eruption in these cases is 18 months.1 If after 2 years unerupted tooth fails to erupt despite sufficient space may require conservative exposure and orthodontic traction.

Abnormalities of tooth structure Disturbances in structure of enamel Enamel usually develops in two phases, first as an organic matrix and second, mineralization. Disruption of enamel formation can manifest as the following conditions. Hypoplasia Caused by disturbance in matrix formation and characterized by pitted, grooved, or thinned enamel. Hypomineralization Hypocalcification is a disturbance of calcification. Affected enamel appears white and opaque, but post-eruptively may become discolored. Affected enamel may be weak and prone to breakdown. Most disturbances of enamel formation will produce both hypoplasia and hypomineralization, but clinically one type usually predominates. Etiological factors (not an exhaustive list) Localized causes Infection, trauma, irradiation, idiopathic (see enamel opacities, p. 72). Generalized causes 1 Environmental (chronological hypoplasia) Prenatal, e.g., rubella, syphilis Neonatal, e.g., prolonged labor, premature birth Postnatal, e.g., measles, congenital heart disease, fluoride, nutritional 2 Hereditary Affecting teeth onlyamelogenesis imperfecta Accompanied by systemic disorder, e.g., Down syndrome Chronological hypoplasia So called because the hypoplastic enamel occurs in a distribution related to the extent of tooth formation at the time of the insult. Characteristically, because of its later formation, maxillary lateral incisor is affected nearer to its their incisal edge than maxillary central incisor or maxillary canine. Fluorosis See p. 28. Treatment of hypomineralization/hypoplasia Treatment depends on extent and severity: Posterior teeth Small areas of hypoplasia can be sealed or restored conventionally, but more severely affected teeth will require crowning. Stainless steel crowns (p. 86) can be used in children as a semipermanent measure. Anterior teeth Small areas of hypoplasia can be restored using composites, but larger areas may require veneers (p. 258) or crowns. For treatment of fluorosis.