Pediatric Dentistry

Pediatric Dentistry encompasses all aspects of oral health care for children and adolescents. Oral health: a state of sound and well functioning dental and oral structures. Child: every human being below the age of 18 years Robert Bunon- 1743 (Father of Pediatric Dentistry) The first dental care program for children was put forward by Dr Talma, dentist to King Leopold of Belgium.

Cognitive development

Child management
Dental caries and prevention
Dental Trauma Oral conditions that can be first seen by medical doctors Use of antibiotics in paediatric dentistry

Why do we learn the normal psychology?

To meet the specific need of the child o Interpretation of child behavior o Understanding your own reaction

Psychology of the child

Phases and stadia of development

No universal line for development Piaget's cognitive theory:

Cognitive

cognito = thinking

Sensorimotors (0-2)

Preoperation al phase(2-6)

Concrete Formal phase(7- operation 12) 12+

Piaget's cognitive theory

Sensorimotor phase (0-2)

contact

senses. Complete dependency Reacts through : Crying, arching his back Object permanence does not exist until the 6th month Imitate actions of adults. Understand simple commands Social contact: 2 m smiles at every one 3-4 m familiar faces 7-12 m dislike strangers(Medical care provider)

with the environment by using his

Preoperational phase(2-7)

2-3(early stage) Ritualistic Up to 3 egocentric Imitate animals Still dependant 3 age of treatment maturity

late stage 3+:

Seeking independency Understands symbols: word. Aware of gender. Role playing. Less egocentric Imitation of animals: brave like a bear.. Fear of separations(3). Visual fear (3), Auditory fear (4) bodily harm fear(5)

Concrete operational stage(712)

Understand symbols (health) but still bonded thinking here and now. They can compare things and integrate their own experiences with others Attention: Dont rely on health benefits when motivating the child( tied thinking).

Formal Operational stage 12+

Return to egocentrism Think about future and consequences They can discuss the management. Perception of treatment can be idealized and influenced by the media

Fear of the dentist is one of the top five causes of fear!!

Dental fear: reaction to threatening stimuli. Dental anxiety: Non specific feeling of apprehension.

Principles of child management techniques

A-Non pharmacological: Distraction Modeling

Dentist

Rewarding

B-Pharmacological management and pain control

1- Local anesthesia

Dentist Reversal temporary cessation of painful impulses from a particular region of the body.

Components: Anesthetic agent: Lidocaine, mepivacaine + Vasoconstrictor +buffer+ conservatives

Method of application of local analgesia

Topical

(ointment, spray) Infiltration: application of local anesthesia around the nerve endings. Blocks: placement of anesthetic near a main nerve trunk. Intraosseous anesthesia: involves achieving access to the bone and injecting the anesthetic solution.

2-Sedation: depressed level of consciousness that may vary from light to deep. Indications : Psychological indications Phobia Fainting during the procedure Gagging reflex Medical indications: Controlled ischemic heart diseases Hypertension Epilepsy Spasticity disorders (cerebral palsy)

A.

Oral sedation: Midazolam, diazepam

B.

Intravenous sedation Anaesthetist Drugs: propofol, ketamine, midazolam

Sedation

C.

Inhalation sedation Trained Dentist or

Anaesthetist Drug : nitrous oxide (laughing gas)

Sedation

Contraindications of laughing gas: Unaccompanied patient Psychiatric patients Thyroid dysfunction Pregnancy Common cold (nitrous oxide sedation) Contraindications to sedation with benzodiazepines: hepatic insufficiency Porphyry Myasthenia gravis Allergy to benzodiazepine group of drugs.

3- General anesthesia: a controlled status of unconsciousness accompanied by partial or total loss of protective reflexes Anaesthetist

Dental caries

The most common chronic disease in childhood Definition : local loss of dental hard tissues mediated by dental plaque.

Dental plaque: is a biofilm formed when the to tooth consist of microrganisms 75% of plaque volume , organic components (extracellular polysaccharides , glycoprotein, desquamated cells) and inorganic components

The main bacteria responsible for initiation of dental caries are streptococci mutans. Others : Lactobacillus acidophilus, actinomyces viscosus. Streptococci mutans bacteria have the ability to adhere to the tooth surface and metabolize dietary sugars.

Dental caries

Origin of the bacteria:

Colonization of streptococci mutans must first take place before caries develops. Transmission of bacteria from the mother or the care giver. Presence of a tooth (needed for bacterial attachment!!).

The acidic products of the bacteria decrease the ph (> 5.5) and dissolve the dental hard tissues.

Prevention of dental caries

Diet

modification: decrease intake of snakes, soft drinks, bottle feeding with carbohydrate sticky food. Frequency of intake is more important than quantity. Avoid sucrose containing food. Use sucrose substitutes like sorbitol and xylitol.

Tooth brushing and fluoride: Tooth brushing should be initiated from the eruption of the first tooth. Fluoride (tooth paste, water, food) leads to decrease in dental caries. Attention: Fluoride concentration should be optimized for young children. 6months-2years 500ppm starting 1.5 years 2-6 years 1000 ppm 6+ 1450 ppm

Fissure sealants: is a thin plastic like coating applied to the chewing surfaces of the molar teeth(posterior teeth).

Should we treat caries in primary teeth

Pain. Abscess Facial cellulites Ludwigs angina: cellulites involving the facial spaces at the floor of the mouth (life threatening) Cavernous sinus thrombosis. Premature loss of primary teeth

malposition of the permanent the teeth

Severe dental caries that affect the children in young age( 71 months). Cause : interaction of factors Bacteria + nursing bottle at bed time. Unrestricted breast feeding (controversial)

Early childhood caries

Role of the medical doctors

The mouth is part of the body!!!

The physician should contribute to the oral health by educating the parents about the importance of oral health and advising them to: Initiate tooth brushing at least two times/day.
Use a fluoridated tooth paste when it is applicable. Decreases the frequency of snacks intake.

1.
2.

3.

Behavior management: To prevent behavior management problems create a safe and trustable environment: Every one in the clinic (Dentist, Nurse,..) should transmit a positive behavior. Use distracting objects in the surgery as well as in the reception( posters , TV, toys.).

Principles of child management techniques

4. 5.

The parents to start regular dental check up Patients with congenital heart defects should be referred for dental check up not later than 6 months after eruption of the first tooth. Recognition of cases of Early childhood caries (ECC )and refer them to his dental colleague.

6.

Dental caries

Dental trauma
One of the common presentations of young children to emergency clinics. 30% of children suffer trauma to primary teeth Boys: girls, 2:1. Upper anterior teeth are the most common site. Etiology of trauma: falls, traffic accidents, sport, violence, child abuse.

 Classification : 1. Injuries to the dental A. Crown fracture. B. Root fracture. C. Crown-root fracture

hard tissues:

2- injuries to the periodontal ligament: A. Concussion : tooth is sensitive but not displaced. B. Subluxation: tooth is loose but not displaced C. Luxation: tooth is displaced D. Avulsion: Complete displacement of the tooth from the mouth

Injuries to the supporting bone: fracture of maxilla or mandible. Injuries to the soft tissue: Gingiva, oral mucosa and tongue.

Management: ABCs History taking. Examination: A. General assessment( head injuries , assessment of cranial nerves, etc). B. Dental assessment. Attention: Dont forget to check tetanus immunization Investigations: radiographs: depends on the injury, intraoral radiographs, lateral oblique, occipitomental, c-t scan etc..

Management of dental trauma

1-Crown fracture: Reattachment of the fractured part or restoring the tooth with dental filling material Attention: Fractured part of the tooth should be kept wet (stored in water)awaiting for reattachment.

Root fracture, concussion subluxation and luxation: the treatment varies from having soft diet to splinting the tooth Soft tissue injuries: any debris should be removed and cleaned with antiseptic (chlorhexidine acetate 0.5%). suturing should be considered. Fracture of the mandible and maxilla: fixation

Management of avulsion(tooth is displaced out of the mouth): A. First aid :timing is essential for survival of the tooth. Replant the tooth immediately if the tooth is clean If the tooth is dirty , rinse the tooth in milk and then replant. Or restore the teeth in the Childs mouth between anterior teeth and the lip. Or put the tooth in glass of milk, normal saline. Seek dental aid immediately. Attention: dont use water as storage medium for avulsed tooth dont replant primary teeth!!

 Greet

the child without a mask. Presence or absence of family members. Physical proximity: the intimate zone of the child is 45 cm. Timing of the visit Communication with the parents and the child.

Principles of child management techniques

B-The dentist will then splint the tooth with wire and a dental composite material. Antibiotics should be prescribed.

Role of the physician in dental trauma

A.

All physician should receive education regarding dental traumas

They must be trained to provide first aid (tetanus vaccination, avulsed teeth, etc..)
B. C.

They must refer the child immediately to the dental colleague, as in many cases the early treatment by the dentist can help to improve the prognosis.

D.

They can collaborate with their dental colleagues to identify cases of NAI (non accidental injuries) and report them

A child is considered to be abused if he /she be treated in a way that is unacceptable in a given culture at a given time

Dental trauma

NAI

Lecture by R.Welbury

How to identify cases of child abuse 50% of abused children suffer injuries to the head and neck. Signs: Injuries of various stage of healing. Repeated injuries Injuries in babies and pre-mobile children.

Bruises is on of the most common injuries( in shape of implement used). Injuries whose clinical presentation is not in consistent with the story of the patient

Attention: children normally lie to protect the parents.

NAI

Lecture by R.Welbury

Oral conditions that could be recognized by the physician

Teething: a normal process of eruption of a tooth but sometimes the infant shows signs of systemic distress by systemic distress: slight fever, diarrhea, local irritation, redness of the gum and drooling. Management: Teething remedy (teething gel) Rehydration

Natal teeth: is one that erupt within 30 days of birth. 1 case per 2000-3000. My cause trauma to the breast. If extremely mobile ,then should be extracted.

Bacterial infection: Facial cellulites.

Signs

and symptoms: patient is febrile, sick , upset and dehydrated. Parents are distressed and anxious.

Management: This is an emergency and can be a life threatening condition . Antibiotics Pain control Fluids maintinance Removal of the causative tooth (primary tooth)or root canal therapy(permanent tooth) Warm saline mouth rinse

Viral infection
Primary herpetic gingivostomatitis: Most common cause of severe oral ulceration. Self limiting Caused by herpes simplex type-1 virus Incubation time is 3-5 days. Signs and symptoms: irritability, pyrexia and malaise red and edematous gingiva. rupture Vesicles painful ulcers healing Management: oral fluids, mouthwashes, topical anesthetic and analgesics.

Fungal infection
Candidosis The most common form in children is oral thrush. removal White plaque hemorrhagic base. Causative fungi: Candida albicans Predisposing factors: low immunity(HIV, diabetes), broad spectrum antibiotics, chemotherapy and radiotherapy. Diagnosis: clinical Management: Antifungal medication for 8 days Local: Nystatin ointment, systemic: Amphotericin B.

Recurrent aphthous ulcer 20% of the population Three types: minor, major and herpitiform Heal within 10 days cause?? Nutritional deficiency, stress Diagnosis: clinical+ blood tests for full blood , vitamin b12, serum ferritin. Symptomatic care, mouthwashes, topical steroids.

Use of antibiotics in pediatric dentistry

Conservative use of antibiotics resistance

1- contaminated intra oral wounds: minimum 5-7 days. 2-Acute facial swelling of dental origin. Intravenous antibiotics may be indicated. Attention : painful tooth without systemic involvement (fever, malaise) or extra-oral swelling is not an indication of antibiotics. 3-Dental trauma(Avulsion) 4-Pediatric periodontal disease 5-Prophylaxis .