Pediatric Dentistry **With Recall** Chapter 57 Pediatric Dentistry **With Recall**
The Pediatric Dentist A pediatric dentist will continue his or her education for an additional 2 to 3 years after dental school The program of study and hands-on experience prepares the specialist to meet the needs of infants, children, adolescents, and persons with special healthcare needs What population is served by the pediatric dentist? (Infants, children, adolescents, and persons with special healthcare needs)
The Pediatric Patient Chronologic age Mental age Emotional age The child’s actual age in terms of years and months Mental age The child’s level of intellectual capacity and development most important Emotional age The child’s level of emotional maturity Recall #1: Would it be possible to see a 21 y/o patient in a pedo office? A child’s mental age may vary by a year or two from the chronologic age. The dental assistant may encounter physical, mental, emotional, and behavioral differences between boys and girls and between children of different cultures and socioeconomic backgrounds. A guideline (norm) for the average child’s development can be used as a simple index to the child’s anticipated behavior level at a certain age.
The Pediatric Dental Office Treats patients from infants through adolescents as well as special needs Display cheerfulness in a pleasant environment with a nonthreatening décor Treatment areas are designed with an open-bay concept in mind Dental personnel dress in bright coordinating colors Recall # 2: What is unique about the treatment setting of a pediatric office? Recall # 3: What types of patients are seen in a pediatric dental office? Recall # 4: Is it possible for a child to be 10 years old but act 7? If so, what are you describing about this patient? What is an open-bay concept? (Many practices are designed with the open bay concept, in which several dental chairs are arranged in one large area. The advantage of this design is that it provides reassurance by allowing pediatric patients to see other children who are receiving care.) How can a general dental practice adapt its facilities to appeal to pediatric patients and still consider the needs of adult patients? (The office may offer different books and magazines, as well as educational brochures.)
Age & Behavior Management The initial examination is important for both the child and the dental team Children begin to want control and structure ages 3-5 (“play age”) The rapport developed during the initial examination can establish an attitude toward dental health that will last for a child’s lifetime Many dentists will follow a behavior scale early in the treatment of a pediatric patient ** pg 980** Recall # 5: What developmental stage to children first want control and structure of their environment? Recall # 6: How would Dr. Frankl describe a “positive” child? (pg 980) Dr. Spencer Frankl developed one of the most widely used systems, the Frankl scale, to measure a pediatric patient’s behavior.
Guidelines for Child Behavior Be honest with the child Consider the child’s point of view Use “tell, show, do” Give positive reinforcement Words that unnecessarily evoke fear in the child should be avoided. The dental team should not assume that a procedure or instrument is so harmless that it will not concern a child. “Tell, show, do” is very important at this age in preparing the child and eliciting the appropriate cooperation. Do not reward undesirable behavior.
The Challenging Patient Sedation This is prescribed to calm the patient and put him or her at ease before treatment Nitrous oxide–oxygen This method of mild sedation can help calm a patient for treatment Physical restraint Restraints are used to prevent injury to the child and dental team Recall # 7: When would a “papoose” board be used? (bottom right pg 980) Voice control (speaking calmly but firmly) will usually prevent the need for additional steps. For young toddlers and preschool-age children, a parent may be asked to help keep the child calm and under control. Under what conditions would physical restraints, ranging from hand-holding to a papoose board, be required? (This device is excellent for the younger child who has been sedated, or for the patient with special needs who may have limited control of his or her movement.)
Patients with Special Needs Severely to profoundly mentally challenged children and adults typically undergo dental treatment under general anesthesia in the operating room of a hospital. Patients have limited IQ and adaptive skills. Moderately mentally challenged patients may require sedation or treatment under general anesthesia. Recall #8: What types of skills are limited in a mentally challenged patient? Severely to profoundly mentally challenged children and adults typically undergo dental treatment under general anesthesia in the operating room of a hospital. Moderately mentally challenged patients may require sedation or treatment under general anesthesia. What is the role of the dental assistant in treating patients with special needs? (See the bulleted list on the right side of page 981.)
Down Syndrome (Trisomy 21) Eruption of teeth may be delayed, with the primary incisors not erupting until after 1 year of age. Teeth may be small and peg-shaped, often with malocclusion. Periodontal problems are common because of malaligned teeth, mouth breathing, or poor dental care at home. The forward position of the mandible and underdeveloped nasal and maxillary bones do not provide sufficient space for the tongue. The resulting open-mouth, forward-tongue position gives the appearance of an enlarged tongue. Recall # 9: What is another term for Down Syndrome? What dental and periodontal issues are commonly seen in patients who have Down syndrome? What special procedures may be required for treatment? (Eruption of teeth may be delayed, with the primary incisors not erupting until after 1 year of age. Teeth may be small and peg-shaped, often with malocclusion. Periodontal problems are common because of malaligned teeth, mouth breathing, or poor dental care at home. The forward position of the mandible and underdeveloped nasal and maxillary bones do not provide sufficient space for the tongue. The resulting open-mouth, forward-tongue position gives the appearance of an enlarged tongue. Dental treatment will depend on psychological development and physical problems.) The patient should be approached in terms of mental age and abilities, not in terms of chronologic age.
Autism A developmental disorder that affects how information is processed in the brain by altering how nerve cells and their synapses connect and organize The patient may exhibit behavioral problems with management difficulties Patients who have autism have a known desire for sweet foods and generally have poor oral hygiene which puts them at an increased risk for decay and periodontal disease The disorder is characterized by an inability to get along with people, poor social skills, lack of interpersonal relationships, and an abnormal speech and language. These patients are at increased risk for increased dental caries and periodontal disease.
Cerebral Palsy This nonprogressive neural disorder is caused by brain damage that occurred prenatally, during birth, or postnatally before the central nervous system reaches maturityhe two most Oral hygiene in most patients with cerebral palsy is poor, in part because of the nature of their disease and the resultant physical limitations. The patient and the caregiver should receive a thorough orientation to a home care program, with modifications as necessary to meet the patient’s special needs. Frequently an electric toothbrush can be used effectively. Special adaptations of toothbrush handles and other aids to hygiene also may be helpful Recall # 10: Would it be common to treat a patient with cerebral palsy in a wheelchair? If so, why? Cerebral palsy most often is classified according to type of motor disturbance. The two most common types are spasticity and athetosis. Why might oral hygiene be a problem at home for patients who have cerebral palsy? What home care aids are available? (Oral hygiene in most patients with cerebral palsy is poor, in part because of the nature of their disease and the resultant physical limitations. The patient and the caregiver should receive a thorough orientation to a home care program, with modifications as necessary to meet the patient’s special needs. Frequently an electric toothbrush can be used effectively. Special adaptations of toothbrush handles and other aids to hygiene also may be helpful.)
Diagnosis and Treatment Planning First appointment should take place around first birthday Regular exams begin at age 2 Parental consent must be given before any dental care is provided for persons under 18 Recall # 11: When should a child first see the dentist? The first appointment is scheduled to collect information, introduce the child to the dentist and staff, and help the child feel comfortable in the office surroundings. It also gives the dental team an opportunity to educate the parents on preventive techniques and pediatric care.
Medical and Dental History Past hospitalizations and surgeries Date of the child’s last visit to a physician Medications, daily medications Unfavorable reactions to any medicine; allergies Weight at birth and any problems at birth Level of learning Main concern about the child’s dental health Finger, thumb, and pacifier habits Fluoride and toothbrush habits Inherited family dental characteristics Ask about and record regular or as-needed medications, such as asthma inhalers, vitamins, and antibiotics. Parents may forget to mention all medications.
Initial Clinical Examination Radiographic imaging (to be taken every 6 months for patients at high risk for caries) Extraoral examination Intraoral soft tissue examination Examination and charting of teeth Recall #12: If a patient is at a high risk for decay, how often should radiographs be taken? The radiographic examination may include a combination of radiographs, a single radiograph, or none, if radiographs are not indicated or the child does not cooperate. What might the extraoral examination include? (The extraoral examination is used to evaluate the patient’s profile to determine skeletal characteristics.) What soft tissues are evaluated and documented? (The tissues of the gingiva and periodontum)
Preventive Dentistry for Children Oral hygiene Efforts are geared to improving a child’s brushing and flossing technique Fluorides Children between the ages of 6 months and 16 years should take in fluoride daily Fluoride varnish is being used for caries prevention on a routine basis Diet Review the specific nutrients a child needs to grow Recall # 13: Would fluoride varnish be used on a child? What are some components of a balanced diet? (Nutritious snacks should be eaten instead of sugary snacks, chips, or soda.) Demonstrate proper flossing and brushing techniques during the office visit. Provide constructive feedback. Depending on the type of water consumed by the patient, fluoride supplements or fluoride toothpaste should be recommended.
Orofacial development Sealants These are applied to pits and fissures to help keep them cavity-free Orofacial development Malocclusions, crowded or crooked teeth, and bite problems must be identified, and the dental staff must intervene (Ex. Appliance to stop thumb sucking as preventative orthodontics) Sports safety Protective equipment should be worn during any recreational sport that might injure the mouth area Recall #14: What procedure is recommended for children to protect the pits and fissures of posterior teeth? Recall #15: Is an appliance that is used to stop a patient from sucking the thumb considered interceptive or preventative orthodontics? Recall # 16: As a swimmer, should you wear a mouth guard? Why is early evaluation of oral and facial development important? (Early preventive and interceptive orthodontic treatment can prevent the need for more extensive treatment later.) Preventive orthodontics allows the dentist to prevent or eliminate irregularities and malpositions in the developing dentofacial region. Interceptive orthodontics allows the dentist to intercede or correct problems as they develop.
Pediatric Procedures Restorative procedures Endodontic procedures Instrument size Matrix system (T-band and spot-welded) Endodontic procedures Pulpotomy Prosthodontic procedures Stainless steel crown Recall # 17: What types of matrices are commonly used on primary teeth? Recall #18: What endodontic procedure would most likely be done on a primary tooth? Recall #19: Would a child be referred to a prosthodontist for placement of a stainless steel crown? What is the difference between a pulpotomy and a root canal? (Pulpotomy is the complete removal of the coronal portion of the dental pulp. A root canal is a treatment used to repair and save a tooth that is badly decayed or becomes infected. During a root canal procedure, the nerve and pulp are removed and the inside of the tooth is cleaned and sealed.) Because of the importance of maintaining primary teeth throughout adolescent years, the dentist requires a crown system to cover severely decayed and endodontically treated teeth without the cost and time investment of a fixed prosthesis.
Dental Trauma Fractured anterior teeth Traumatic intrusion Extrusion and lateral luxation injuries Avulsed teeth Recall #20: Which teeth are injured most frequently? Why would surrounding and supporting hard and soft tissues require different treatments? (It would depend on the type and extent of the damage.) In addition to this list of the most common causes of dental trauma, what else do you think can cause dental and facial trauma? (Answers will vary.) Refer students to Figure 57-16 on page 989 for a flyer describing actions to take in a dental emergency.
Fractured Anterior Teeth Documentation of the accident includes: Clinical examination Radiographs Vitality testing Anterior teeth are the most commonly fractured teeth in children. Why do you think is proper documentation of dental injuries important? (Answers will vary.) What factors determine how fractured anterior teeth are treated? (The extent of the damage to the pulp)
Fractured Anterior Tooth If this tooth is salvageable, it will require root canal therapy (if the pulp is involved), followed by a post-and-core buildup, and finally a crown. What is an example of a fracture in which the tooth cannot be saved? What is the treatment? (Answers will vary.) Why is it important to evaluate the teeth adjacent to and opposing the fractured tooth? (To see if the damage extended to more than one tooth) Courtesy Dr. Frank Hodges, Santa Rosa, CA.
Avulsed Teeth A tooth is torn away or dislodged completely by force Recover the tooth immediately Wrap the tooth in a moistened gauze Go immediately to the dentist's office Recall #21: What happens when a tooth is avulsed? Primary teeth are not usually replanted. Sound permanent teeth that are avulsed without root fracture are often replanted. Why is immediate replantation advisable? (The success rate for replantation of permanent teeth is highest when the tooth is replanted within 30 minutes of the accident.)
Avulsion of Maxillary Central Incisors This is an intraoral view of a child’s mouth missing permanent teeth 8 and 9, most likely as a result of traumatic avulsion. If the teeth and the situation are suitable for replantation, the teeth will be held in place with a splint and will require root canal therapy in the future. Antibiotics will most likely also be prescribed. Courtesy Dr. Frank Hodges, Santa Rosa, CA.
Extrusion and Lateral Luxation Teeth are displaced from their position, causing damage to the periodontal ligament Displaced teeth are repositioned Often time a splint is used to stabilize teeth while the heal Recall # 22: How would a dentist stabilize a tooth after an injury? What is the difference between extrusion and lateral luxation? (Extrusion is displacement of a tooth, and luxation is dislocation.) How are displaced teeth typically treated? (The dentist repositions displaced teeth as soon as possible. A temporary splint of resin material or ligature wire is used to stabilize the repositioned permanent teeth.)
Child Abuse Child abuse must be suspected when: Injuries are in various stages of healing Teeth are chipped or injured The child has scars inside the lips or on the tongue and tears of the labial frena The child exhibits battering or other injuries around the head and neck Facial bruises, swelling of the facial structures, or black eyes are evident The child has bite marks Injuries are not consistent with the explanation presented by the parent Unless a state has a mandated-reporter requirement for healthcare professionals, the dental assistant has no legal obligation to report suspected child abuse (this would be the responsibility of the dentist or dental hygienist). However, the assistant may serve as an important witness. What should the dental assistant do if he or she suspects abuse? (Report it to the dentist)
Child Abuse Recall # 23: Are you as a DA legally required to report child abuse? Recall # 24: Could a fractured or broken nose be a result of child abuse? Recall # 25: Who in the dental office should report child abuse (and is legally required to do so)?