Pediatric Dentistry Chapter 57 A child’s first teeth normally erupt at about age 6 months. The dentist is one of the primary healthcare professionals monitoring the growth and treatment of soft and hard tissues in the head and neck, extraorally and intraorally. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

Chapter 57 Lesson 57.1 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

Learning Objectives Pronounce, define, and spell the Key Terms. Describe the appearance and setting of a pediatric dental office. Give the stages of childhood from birth through adolescence. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

Learning Objectives (Cont’d) Discuss the specific behavior techniques that work as positive reinforcement when treating children. Describe why children and adults with special needs are treated in a pediatric practice. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

Introduction Pediatric Dentistry is the specialized area of dentistry limited to the care of children from birth through adolescence, with additional focus in providing oral health care to patients with special needs Children are treated in pediatric dental settings and in general dental offices. What are the pros and cons of treating pediatric and special needs patients at a specialized practice versus treating them within a general dental practice? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

The Pediatric Dental Office 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. What is an open-bay concept? How can a general dental practice adapt its facilities to appeal to pediatric patients and still consider the needs of adult patients? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

Fig. 57-2 Example of a pleasing, patient-friendly reception area in a pediatric dental office. What features of this pediatric dental office welcome children and put them at ease? What features appeal to parents and staff? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

The Pediatric Patient Chronological 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 Emotional age The child’s level of emotional maturity A child’s dental age may vary by a year or two from the chronological 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. With so many variables in pediatric patients, what skills should the dental assistant develop? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

Stages of Childhood Birth to 2 years Children learn to sit, stand, walk, and run. Vocally they progress from babbling to using simple sentences. Children identify familiar faces, then progress through periods of being friendly and then fearful of strangers. At this age, children are too young to be expected to cooperate in dental treatment. (Cont’d) What fairly common dental or oral conditions require dental care at this age? A child’s entire primary dentition, consisting of 20 teeth, erupts by about age 3. What other conditions may require initial evaluation by a pediatric dentist? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

Stages of Childhood Ages 3 to 5 years (Cont’d) Ages 3 to 5 years The child needs to be allowed to develop autonomy and initiative. The child requires control and structure in his or her environment. The child is able to follow simple instructions. The child welcomes an active role in the treatment experience. Child-friendly names for instruments and procedures also help reduce anxiety. A children may need a parent during all or part of the treatment. Why do dental-office policies vary with regard to the presence of a parent? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

Stages of Childhood Ages 6 to 12 years (Cont’d) Ages 6 to 12 years This is a period of socialization. The child is learning to get along with people. The child is learning the rules and regulations of society. The child is learned to overcome fears of objects and situations. Treatment is usually performed without a parent or guardian present. Children may present with memories, positive or negative, of past dental treatment and also may have misconceptions about i. How should the dental assistant respond? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

Behavior Management Be honest with the child. Consider the child’s point of view. Use “tell, show, do.” Give positive reinforcement. Dental offices differ in the amount of interaction a dental assistant has with pediatric patients. Often it is the assistant’s role to provide a welcoming environment and to orient the patient to instruments, materials, and procedures. It is important to listen to the child and to provide him or her with ways of communicating any anxieties or discomfort. Why? “Tell, show, do” is very important at this age in preparing the child and eliciting the appropriate cooperation. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

The Challenging Patient Premedication This isrescribed to calm the patient and put him or her at ease before treatment. Nitrous oxide–oxygen This method of mild sedation that can help calm a patient for treatment. Physical restraint Restraints are used to prevent injury to the child and dental team. It is important that children who are treated pharmcologically for conditions such as attention-deficit disorder or attention deficit–hyperactivity disorder take their medication as usual before dental treatment. Nitrous oxide is an inhaled sedative that helps calm the patient during treatment and wears off quickly. Local anesthesia also may be used. Under what conditions would physical restraints, ranging from hand-holding to a papoose board, be required? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

Patients with Special Needs Mentally challenged Mild: IQs ranging from between 50 and 55 to 70 Moderate: IQs ranging from between 35 and 40 to 50 or 55 Severe: IQs ranging from between 20 and 25 to 35 or 40 Profound: IQs below 20 to 25 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? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

Down Syndrome This disorder is also called trisomy 21 Down syndrome is a chromosomal aberration resulting in certain abnormal physical characteristics and mental impairment. Mental impairment may range from mild to moderate retardation. A person with Down syndrome is affected by low of muscle strength and weak muscle tone. Heart conditions are possible. An affected child may exhibit abnormalities in dental development. Periodontal problems are possible. These patients are usually pleasant, warm, and friendly but will likely require undivided attention, patience, and encouragement. What dental and periodontal issues are commonly seen in patients who have Down syndrome? What special procedures may be required for treatment? How can the dental assistant help make the dental office experience a positive one? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

Cerebral Palsy This nonprogressive neural disorder is caused by brain damage that occurred prenatally, during birth, or postnatally before the central nervous system reaches maturity. Characterized by: Paralysis Muscle weakness Lack of coordination Other disorders of motor function Poor oral hygiene When cerebral palsy is not combined with other disorders, children with cerebral palsy are of normal intelligence. It is imperative to remember this during treatment. Why might oral hygiene be problem at home for patients who have cerebral palsy? What home-care aids are available? How can the dental assistant help in patient education? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

Chapter 57 Lesson 57.2 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

Learning Objectives Describe what is involved in diagnosis and treatment planning in a pediatric patient. Discuss the importance of preventive dentistry in pediatrics. Give the types of procedures for the pediatric patient compared with the treatment of patients with permanent teeth. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

Learning Objectives Assist in pulpotomy of a primary tooth. (Cont’d) Assist in pulpotomy of a primary tooth. Assist in the placement of a stainless-steel crown. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

Diagnosis and Treatment Planning 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 (Cont’d) Ask about and record regular or as-needed medications, such as asthma inhalers, vitamins, and antibiotics. Parents may forget to mention all medications. What are the implications for dental care if a child has an allergic reactions to a medication? Why should the type of water the child has been raised on and consumes now be documented? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

Diagnosis and Treatment Planning (Cont’d) Clinical examination Radiographic examination Extraoral examination Intraoral soft-tissue examination 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? What soft tissues are evaluated and documented? What will the intraoral examination of hard tissues include? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

Fig. 57-5 Example of dental report card used for recall appointments Fig. 57-5 Example of dental report card used for recall appointments. (Courtesy of Dr. John Christensen.) This is an example of a form that may be used at a periodic oral examination as a report card. What information is included on the dental report card? Why is the report card useful? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

Preventive Dentistry Oral hygiene Fluoride Diet Efforts are geared to improving a child’s brushing and flossing technique. Fluoride Children between the ages of 6 months and 16 years should take in fluoride daily. Diet Review the specific nutrients a child needs to grow. (Cont’d) 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. How does insufficient nutrition contribute to caries, staining, halitosis, and chemical erosion? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

Preventive Dentistry Sealants Oral/facial development Sports safety (Cont’d) Sealants These are applied to pits and fissures to help keep them cavity-free. Oral/facial development Malocclusions, crowded or crooked teeth, and bite problems must be identified, and the dental staff must intervene. Sports safety Protective equipment should be worn during any recreational sport that might injure the mouth area. Sealants are often applied to prevent occlusal caries resulting from food debris and bacterial entrapment in newly erupted permanent posterior teeth (most often molars). Why is early evaluation of oral and facial development important? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24

Pediatric Procedures Restorative Endodontic procedures Amalgam Composite Endodontic procedures Pulp capping Pulpotomy Prosthodontic procedures Stainless-steel crowns Why is an alternative matrix band, instead of the standard adult matrix band, used in restorative dentistry for children? What is the difference between a pulpotomy and a root canal? How do pediatric and adult crowns differ after pulpotomy or root canal of a primary molar? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25

Dental Trauma Causes of dental injuries to children Automobile accidents Bicycle accidents Sports injuries Child abuse Why would surrounding and supporting hard and soft tissues require different treatments? In addition to this list of the most common causes of dental trauma, what else can cause dental and facial trauma? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

Fig. 57-13 Educating school personnel about dental emergencies Fig. 57-13 Educating school personnel about dental emergencies. (Courtesy of Dr. John Christensen.) What should supervising adults be familiar with on this poster? In what ways can appropriate immediate care result in a more favorable outcome? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27

Types of Injuries Fractured anterior teeth Documentation of the accident includes: Clinical examination Radiographs Vitality testing (Cont’d) Anterior teeth are the most commonly fractured teeth in children. Why is proper documentation of dental injuries important? What factors determine how fractured anterior teeth are treated? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28

Fig. 57-14 Fractured anterior tooth. (Courtesy of Dr. Frank Hodges.) 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? Why is it important to evaluate the teeth adjacent to and opposing the fractured tooth? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29

Types of Injuries Traumatic intrusion (Cont’d) Traumatic intrusion The tooth is forcibly driven into the alveolus so that only a portion of the crown is visible. For a primary tooth, the dentist treats the symptoms, and a tooth may be allowed to re-erupt. The tooth is treated in accordance with the clinical and radiographic findings. Why do these teeth often need root canal therapy? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30

Types of Injuries Extrusion and lateral luxation (Cont’d) Extrusion and lateral luxation Teeth are displaced from their position, causing damage to the periodontal ligament. Displaced teeth are repositioned A temporary splint is placed. What is the difference between extrusion and lateral luxation? How are displaced teeth typically treated? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31

Types of Injuries Avulsed teeth (Cont’d) 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. Primary teeth are not usually replanted. Sound permanent teeth that are avulsed without root fracture are often replanted. What treatment will most likely take place in the dental office? Why is immediate replantation advisable? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32

Fig. 57-15 Avulsion of maxillary central incisors. (Courtesy of Dr Fig. 57-15 Avulsion of maxillary central incisors. (Courtesy of Dr. Frank Hodges.) 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. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33

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. Suspicion may also be warranted if intraoral palatal bruising, lacerations, or petechiae, or various extraoral bruises in the same area in different stages of healing, are noted. What should the dental assistant do if he or she suspects abuse? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34

Reporting Child Abuse Required information: Name, address, sex, age, height, and weight of the child Name and address of the adult with custody of the child Description of the current physical and emotional abuse or neglect of the child Evidence of previous injuries or negligence Any information that may assist in establishing the cause of the injuries Sketches or photographs documenting the nature and location of the injuries Proper documentation, including photographs, is crucial in documenting physical evidence. This information should be kept confidential and reported in a professional manner. Why is it also important to address and report child neglect? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35