Pediatric Dentistry PDF

Diagnosis and treatment planning Examination of the Mouth and Other Relevant Structures Successful dental treatment for children can be achieved by recording:  a detailed history.  a complete clinical examination.  an appropriate investigations.  a diagnosis.  treatment plan.  Obtain all rel...

Diagnosis and treatment planning Examination of the Mouth and Other Relevant Structures Successful dental treatment for children can be achieved by recording:  a detailed history.  a complete clinical examination.  an appropriate investigations.  a diagnosis.  treatment plan.  Obtain all relevant information along with an informed consent before treatment.  First examination for the child be done at the time of the eruption of the first tooth and no later than 12 months of age.  is the sequentially arrangement of the various treatment needs to provide maximum benefit to the patient. It is designed to correct existing oral problems and to prevent anticipated future problems. Advantages of treatment planning: 1. Avoiding the re-diagnosis. MODIFICATION 2. Give serial appointments. 1) cooperation from the patient and parents. 3. Instruments can be prepared before patient’s arrival. 2) condition of teeth and oral hygiene. 4. Estimation of the time, no. of appointments, total fee. 3) extraction is needed or not. 4) Nature of tooth movement and type of appliance required. Obtaining accurate data from a child is very difficult.  Most of the times, data about child is provided by the guardian and not the child and may be inaccurate and dependable on their emotional maturity.  Children do not behave in clinic the same way as they do at home or with friends or teachers.  is the sequentially arrangement of the various treatment needs to provide maximum benefit to the patient. It is designed to correct existing oral problems and to prevent anticipated future problems. Advantages of treatment planning: 1. Avoiding the re-diagnosis. MODIFICATION 2. Give serial appointments. 1) cooperation from the patient and parents. 3. Instruments can be prepared before patient’s arrival. 2) condition of teeth and oral hygiene. 4. Estimation of the time, no. of appointments, total fee. 3) extraction is needed or not. 4) Nature of tooth movement and type of appliance required.  2) Medical/referral phase: patients with positive medical history should referred to pediatrician for evaluation and consent. It may also be required to modify the dosage or change a particular drug according to the underlying systemic condition. 3) Systemic phase: Any medication given to modify dental treatment, such as premedication for behavior management or antibiotic prophylaxis to a child with congenital cardiac defect. 4) Preventive phase: to prevent or minimize dental disease. A plaque control program, diet counseling, orthodontic consultation, topical fluoride application, pit and fissure sealant application and child parent education on home care oral hygiene practice should be done. 5) Corrective phase: Extractions. restoration (short and simple procedure to allow the development of trust and confidence). minor surgical procedures. space maintainers. minor orthodontic corrections. prosthetic rehabilitation. A major difference between the treatment of children and the treatment of adults is the relationship.  Treating adults generally involves a one- to -one relationship, a dentist patient.  Treating a child relies on a one-to-two relationship among dentist, patient, and parents or caregivers. pediatric dentistry treatment triangle Child is at the apex of the triangle and he is the focus of attention of both the family and the dental team. It’s a dynamic process involves dialogue, voice tone, facial expressions, body language, and touch.  Intellectual development (mental development): quantified mental abilities in relation to chronologic age. intelligence quotient (IQ) Binet IQ formula used is: IQ= (mental age/ chronological age) × 100. Child whose mental age and chronological age were identical had an IQ of 100. Individuals with intellectual disability may require special behavior guidance.  Behavior management Nonpharmacological methods Pharmacological methods Pre-appointment behavior modification anything said or done to have a positive influence on the child’s behavior before the child enters a dental operatory. Video clipping may include other children undergoing dental treatment, live patient as models such as siblings or parents. Behavior modification techniques: A)Communicative management includes: voice control, non-verbal communication, desensitization, Tell-Show-Do Modelling, distraction. B) Hand-Over-Mouth (HOM). C)Patient immobilization.  Fears 1. Objective fears: acquired by direct physical stimulation (seen, felt, smelt, or contacted) but not of parental origin. 2. Subjective fears: suggested to the child by Fears from previous unpleasant contact with others without the child experiencing them. dentistry.  imitative (transmitted while displayed by parent Repeated hospitalization leading to fear of and acquired by the child without being aware of uniforms, smell of hospital, drugs or chemicals. it).  suggestive or imaginative fears ( acquired by imaginative capacity).  Anxiety and Fear  Fear (Apprehension based on history): It is a primal emotion which stems from a recognized source developed to protect the individual from harm. e.g. fear of needle.  Anxiety (Fear of the unknown): It is one of the primary emotions acquired soon after birth. It stems from anticipation of danger, the source of which is unknown. Fear and anxiety can intensify pain  III) According to Frankl’s Behavior Rating Scale Rating 1: Definitely negative. Refuse treatment. Rating 2: Negative. Reluctance to accept treatment. Rating 3: Positive. Accept treatment. Rating 4: Definitely positive. Good rapport with the dentist, laughter and enjoyment.  II) According to Wright’s clinical classification Cooperative: relaxed, minimal apprehension, can be treated by straightforward. Lacking cooperative ability: very young children with whom communication cannot be established due to age also those with specific disabling conditions. Potentially cooperative: have the ability to cooperate but choose not to (the most challenging pts.), they are the most common pts you are going to meet, they are further categorized as follows: Some factors that might contribute to the child’s behavior (related to the dentist) 1. Scheduling: Most children are fresher in the morning, so they will be comfortable, also waiting too much leads to tiredness and restlessness. 2. Appointment length: treat each (Quadrant) in appointment, the patient loses his concentration if the appointment is more than 30-45 minutes. 3. Dental Attire: Some Pediatrics have a negative experience toward the white coat and mask, so some dentists tend to wear colorful clothes, but some of them refuse (personal choice).  Voice Control  Voice and the facial expression of dentist are important.  Voice control must be used carefully because parents may find it to be an aversive technique so discussing this technique with parents prior to its use may decrease risk for misunderstanding.  It is indicated for uncooperative and inattentive patients, while contraindicated due to age, disability, mental or emotional immaturity, who are unable to understand.  Behavior shaping: it is a procedure which very slowly develops behavior by reinforcing successive approximations of the desired behavior until it occurs. Most behavior is learned and learning is the establishment of a connection between a stimulus and a response. For this reason, it is sometimes called stimulus-response (S-R) theory.  4. Contingency: term used for presentation or withdrawal of reinforcers. Reinforcers can be: I. Positive reinforcers- its presentation increases the frequency of desired behavior. II. Negative reinforcers- withdrawal of which increases the frequency of desired behavior (Exclusion of the parents once the child shows an inappropriate reaction). Types of Reinforcers: 1. Materials reinforcers: gifts like toothbrush kits, drawing kits, favorite cartoon stickers or toys. 2. Social reinforcers: a pat on the back of shoulder, shaking hands, hugging or verbal praise in the presence of their parent. 3. Activity reinforcers: allowing child to perform his/her choice of activity (watching a favorite TV show or movie or playing his games of interest (first you work, then you may play).  Pharmacologic management The use of drugs to manage the behavior of pediatric patients undergoing dental procedures. It includes inhaled gases, oral medications, drugs administered via IV infusion, IM injection, and other routes of administration. Degree of sedation 1. Minimal sedation (anxiolysis): a minimally depressed level of consciousness, retains the patient’s ability to respond normally to tactile stimulation and verbal commands. Cognitive function and coordination may be modestly impaired, ventilation and cardiovascular functions are unaffected. IM route: it relies upon the high vascularity of muscle tissue. Indicated when other routes are unavailable or have proved ineffective. Complications are nerve injury, intra- vascular injection, air embolism, periostitis, hematoma, abscess, cyst or necrosis. IV Route: most effective method. Effective blood levels of drugs are achieved quite rapidly. The use of IV sedation is somewhat restricted to certain types and ages of patients. Venipuncture is difficult to accomplish in very young due to smaller vein size and availability together with the need to restrain the patient, so it is often more suitable for the apprehensive preteen and adolescent patient.  Nitrous oxide N2O: most frequently inhalation agent used in pediatric sedation. It is a slightly sweet- smelling, colorless, heavier than air and inert gas. Very potent analgesic but weak anesthetic. It is absorbed quickly from the alveoli and physically dissolved in blood with no chemical combination, excreted through the lungs without any biotransformation. The objectives of its use:  Reducing anxiety and untoward movement.  Enhancing communication and cooperation.  Raising pain threshold and tolerance for longer appointments.  Aiding in treatment of a patient with mental and/or physical disabilities.  Reducing gagging. 4. Diffusion Hypoxia: Since it has a lower blood solubility, it rapidly diffuse into alveoli and dilutes the alveoli air causing fall in partial pressure of the oxygen in the alveoli, to avoid this 100% O2 for 10 min. is given. 5. Hallucinations: can occur when we give high concentration of N2O. The goals of sedation for the pediatric patient are: 1. Guard the patient’s safety and minimize physical discomfort and pain. 2. Control anxiety, minimize psychological trauma, and maximize the potential for amnesia. 3. Control behavior or movement. 4. Return the patient to a physiologic state in which safe discharge is possible.  Therapy to stimulate root growth and apical repair in immature permanent teeth with pulpal necrosis Apexification a procedure that precede root canal therapy in management of irreversibly diseased pulps and open apices to stimulate the process of root end development. When the closure occurs, or when the calcific “plug” is observed, endodontic procedures may be completed. 1. Tooth is isolated with rubber dam and an access opening is made. 2. Radiograph to establish root length (avoid placing file through apex, which might injure the epithelial diaphragm). 3. After remnants of the pulp have been removed, canal is irrigated. 4. Canal is dried with large paper points. 5. Thick paste of Ca(OH)2 is inserted in canal. An endodontic plugger may be used to push the material to the apical end, but should not be forced beyond the apex. 6. A cotton pledget is placed over Ca(OH)2, and seal is completed with a layer of reinforced cement.  REPs rely on the chemical debridement of the root canal, as there is minimal or no mechanical instrumentation.  Root canal irrigation with sodium hypochlorite to disinfect the canal and eliminate necrotic organic materials.  1.5% sodium hypochlorite is used as higher concentrations have harmful effects on differentiation and survival of dental pulp stem cells.  17% ethylene diamine tetra acetic acid (EDTA) used as a final irrigation step to condition the superficial root canal walls, expose the dentin protein matrix, and improve dental pulp stem cell proliferation.  Ankylosis: It is caused by injury to the periodontal membrane, subsequent inflammation and invasion by osteoclastic cells resulting in irregularly resorbed areas on the peripheral root surface. Repair may cause a mechanical lock or fusion between alveolar bone and root surface. Radiograph shows an interruption in the periodontal membrane and dentin may appear to be continuous with alveolar bone and clinically appears submerged. Ankylosed anterior primary tooth must be removed if there is evidence of delayed or ectopic eruption of the permanent successor. If ankylosis of a permanent tooth occurs during active eruption, a discrepancy between its position and adjacent will be obvious. Uninjured teeth will continue to erupt and may drift mesially, with a loss of arch length so surgical repositioning or removal of the ankylosed tooth is necessary. NOTE: Permanent filling in young children should not be done from the beginning, because:  Dentinal tubules are widely open. So any cut in crown or cementation might produces irritation to pulp.  Full length of the clinical crown is not yet established.  Pulp chamber of newly erupted tooth is wide and any cutting might get pulp exposure.  Root of the tooth continue to develop 3-4 years after eruption.  Partial displacement of tooth out of its socket (it appears longer), and results in pulpal necrosis. Immediate treatment involves Extrusion careful repositioning of tooth and stabilization. If not respond to pulp vitality tests within 2 to 3 weeks, endodontic treatment should be undertaken. Lateral Luxation Displacement of tooth in any direction other than axial. Tooth is mobile, displaced and tender to percussion and masticatory forces, bleeding from gingival crevice. Radiographically, there is widening of PDL space on one side and crushing of lamina dura on other side. Treatment: 1. local anesthesia if forceful positioning is anticipated, reposition the tooth in normal position using digital pressure. 2. Splint tooth for 2 weeks and if there is a marginal bone breakdown then splint for 6-8 weeks. 3. Advice soft diet. Follow up period of 1 year.  Types of storage media: 1. Hank's balanced salt solution (HBSS): Considered as best transport medium due to presence of essential metabolites for vitality of PDL cells. 2. Milk: acceptable medium has a favorable pH. Maintains vitality of periodontal cells for about (2-6) hours. 3. Saliva: natural storage medium. 4. Saline: physiologic pH. 5. Tap water: Considered as bad as dry storage, its hypotonicity causes cell lysis. It should be used only if any of the above is not readily available. Intrusion of permanent teeth: have a poorer prognosis than primary. Tendency for injury to be followed by rapid root resorption, pulpal necrosis, or ankylosis is greater. Treatment: 1. For a tooth with a closed root end:  less than 3 mm, allow to erupt. If no movement is evident after 2 to 4 weeks, the tooth may be repositioned either orthodontically or surgically before ankylosis can take place.  7 mm or more, tooth is repositioned surgically and stabilized for 4 to 8 weeks. Pulp will become necrotic, so do endodontic treatment. 2. For a tooth with incomplete root formation:  Allow it to erupt spontaneously. If no movement is seen within a few weeks, orthodontic repositioning should begin.  7 mm or more, repositioned surgically and stabilized. Spontaneous eruption results in fewest complications in immature teeth, regardless of the degree of intrusion. Root fracture is that fracture involving dentin, cementum and pulp, relatively uncommon. The mechanism is usually a frontal impact, which creates compression zones labially and lingually. The resulting shearing stress zone dictates the plane of fracture.  Root fracture of primary teeth is relatively uncommon (more pliable alveolar bone allows for displacement of the tooth).  When root fracture does occur, it should be treated in the same manner as recommended for permanent teeth; however, the prognosis is less favorable.  The pulp in a permanent tooth with a fractured root has a better chance to recover, since the fracture allows immediate decompression and circulation is more likely to be maintained.  prognosis is poor if fracture extends below the gingival margin.  Root fractures occur in the apical third are more likely to undergo repair (many are undetected until evidence of a calcified repair is seen radiographically). Treatment of Root fracture Coronel third (cervical fracture): 1) If the remaining root is long enough, coronal portion can be removed, endodontic treatment with post and core. 2) If the remaining root is short, do extraction. If the fracture line located subgingivally, removal of the coronal fragment supplemented by gingivectomy and/or osteotomy, in order to convert subgingival fracture to supragingival. Middle third fracture: 1) If there is slight mobility: root canal in which obturation with silver cone (acts as a splint). Sometime the apical part stay vital so inject Ca (OH)2 to interrupt the fracture line. New calcific body will be formed in fracture line. 2) If there is high mobility: extraction. Fracture of apical third: no treatment. Just observe the child in future and do pulp test. Vertical Root Fracture also called cracked tooth syndrome, mostly in posterior teeth and its etiology is mostly iatrogenic like insertion of screws, after pulp therapy or due to traumatic occlusion. Persistent dull pain of long-standing origin, it is elicited by applying and releasing the pressure. Radiographically: If central beam lies in the line of fracture, so it is visible as radiolucent line. When asked to bite/chew on a cotton applicator or a rubber polishing wheel patient gets sharp pain. Single rooted teeth –extraction, multi rooted teeth hemisection and the remaining tooth is endodontically treated.  2.Ugly duckling stage It is a transient or self -correcting malocclusion seen in maxillary incisor region between 8-9 years of age. As the developing permanent canines erupt, they displace roots of the lateral incisors mesially so transmitting the force onto roots of central incisors which get displaced mesially. A resultant distal divergence of crowns of the incisors occurs leading to creation of diastema in the incisor region. Children tend to look ugly and parents are apprehensive. This condition usually corrects by itself when canines erupt as the pressure is transferred from the roots to the crown of the incisors. b) Eruption of the second permanent molar: it begins to erupt and the arch circumference may become shorter than that of primary arch by utilization of the Leeway space. Early loss of primary teeth may: 1. Affect the alignment of the permanent teeth. 2. Supra eruption of opposing. 3. More distal teeth can drift and tip mesially. 4. More forward teeth can drift and tip distally. 5. Altered tooth positions may include:  "Symptomatic" space deficiency with loss of arch length and circumference.  Blocked or deflected eruption of permanent teeth.  Unattractive appearance.  Food impaction areas and increased caries and periodontal disease.  Partial displacement of tooth out of its socket (it appears longer), and results in pulpal necrosis. Immediate treatment involves Extrusion careful repositioning of tooth and stabilization. If not respond to pulp vitality tests within 2 to 3 weeks, endodontic treatment should be undertaken. Lateral Luxation Displacement of tooth in any direction other than axial. Tooth is mobile, displaced and tender to percussion and masticatory forces, bleeding from gingival crevice. Radiographically, there is widening of PDL space on one side and crushing of lamina dura on other side. Treatment: 1. local anesthesia if forceful positioning is anticipated, reposition the tooth in normal position using digital pressure. 2. Splint tooth for 2 weeks and if there is a marginal bone breakdown then splint for 6-8 weeks. 3. Advice soft diet. Follow up period of 1 year. Factors affecting planning for space maintainers: 1. Time elapsed since tooth loss: space closure take place within 6 months so appliance must be placed as soon as possible. 2. Amount of space loss:  Maxillary 2nd primary molars results in greatest amount of closure, up to 8 mm of space loss in a quadrant, while Mandibular shows loss of up to 4 mm in a quadrant.  Loss of upper or lower 1st primary molars shows almost equal amounts of space closure.  Space loss potential is high if the primary molar loss occurs in approximation to 1st permanent molar eruption.  After 1st permanent molars have erupted, loss of 2nd primary molars may still result in space closure.  Loss of a 1st primary molar with retention of the 2nd primary molar shows minimal amounts of space closure.  Various antibiotic mixtures and Ca(OH)2, have also been suggested, the most widely used is triple antibiotic paste which is a mixture of water and equal parts of metronidazole, ciprofloxacin, and minocycline. (0.1 mg/mL) 1. Sealing the pulp chamber with flowable composite to However, discoloration may maintain the paste below the CEJ. occur due to minocycline 2. eliminating the minocycline and keeping only present in the paste. metronidazole and ciprofloxacin in the paste. 3. substituting minocycline with another antibiotic, such as clindamycin, or amoxicillin. Pulpal necrosis: Any type of injury especially the displacement type may cause severance of the apical vessels, and loss of vascular supply to the pulp leading to autolysis and necrosis (commonly asymptomatic and radiograph is essentially normal).  The acute symptoms and clinical evidence of infection will inevitably develop at a later date.  Anaerobic microorganisms enter through gingival sulcus or blood stream or both.  In a less severe type of injury, hyperemia and slowing of blood flow through the pulpal tissue may cause necrosis of the pulp, Such teeth should be extracted or treated endodontically. A tooth receiving an injury that causes coronal fracture may have a better pulpal prognosis than a tooth without fracturing the crown. Part of the energy of the blow dissipates as the crown fractures, rather than all of the energy’s being absorbed by the tooth’s supporting tissues.  Arch length analysis To estimate the space adequacy for the succedaneous teeth and to predict how much space will be required for eruption and proper alignment in the arch. Analysis used for estimating space adequacy: Nance analysis: 1. The length of dental arch from the mesial surface of one mandibular first permanent molar to the mesial surface of the corresponding tooth on the opposite side is always shortened during the transition from the mixed to the permanent dentition. 2. In the mandibular arch leeway of 1.7 mm per side exists, in the maxillary arch leeway space is o.9 mm per side. Limitations: it is seldom used as it requires a complete set of periapical radiographs. Deciduous Dentition Period:  Spacing: It is very common to find physiological spaces, with the most prevalent spaces mesial to the primary canine in maxilla and distal to the primary canine in mandible "primate spaces" or "anthropoid spaces". The other spaces are called the developmental spaces which play an important role in the development of permanent dentition. Closed space or non-spaced, so children are highly prone to malocclusion during the development of permanent dentition.  Shape of dental arch: are wider and U shape with spaces visible between teeth.  Terminal plane relation of the deciduous molars: deep bite, f1at curve of Spee, shallow cuspal interdigitation.  2. Non-Pharmacological Local Pain Management: 1. Laser analgesia: Laser pulses alter the behavior of a neuronal cell membrane causing a temporary disruption of the NaK pump. This leads to loss of impulse conduction thus an analgesic effect is achieved. The analgesic effect, together with the lack of contact and vibration in the manipulations, are prerequisites for accepting laser treatment as effective in reducing anxiety in children and adolescents. 2. Reversal Of Local Anesthesia: prolonged duration of soft-tissue anesthesia is often an undesirable effect of local anesthesia. Self-induced soft tissue trauma, a sensation of altered face appearance, impaired speech and eating are some of the post-operative side effects of local analgesia. These effects are more disturbing in pediatric patients. Various means for reversal of the local anesthetic action have been developed for a faster recovery. Phentolamine mesylate (OraVerse) is a short-acting alpha-adrenergic antagonist, leading to an increased clearance of local anesthetic solution from the injection site, reducing the duration of action. Since it is an antagonist to the vasoconstrictor and not to the anesthetic agent compound, it is mainly recommended for use in non-surgical treatment. Silver diamine fluoride (SDFs): used to halt the cariogenic process and prevent new caries with silver salt stimulated sclerotic or calcified dentin formation, silver nitrate’s potent germicidal effect, and fluoride’s ability to reduce decay. The antimicrobial action of silver compounds is proportional to the bioactive silver ion released to interact with bacterial or fungal cell membranes. SDF has specific interest because of ease and simplicity of use (paint on), affordability of material, minimal requirement for personnel time and training, and noninvasiveness. Side effects teeth staining and unpleasant poor taste. Calcium phosphate fluoride: such as casein phosphopeptide–amorphous calcium phosphate, formulated as professionally applied pastes. These remineralizing agents may complement and increase the established clinical effectiveness of topical fluorides. IV-Quantitative Light-induced Fluorescence: is a light box containing a xenon bulb and a handpiece, similar in appearance to an intraoral camera. Live images are displayed via a computer and accompanying software enables patient’s details to be entered and individual images of the teeth of interest to be captured and stored. Once an image of a tooth has been captured, the next stage is to analyze any lesions and produce a quantitative assessment of the demineralization status of the tooth. Advantages:  high reproducibility.  detection of small incipient lesions.  image storage and transmission.  motivational tool for patient.  Disadvantage: isolation sensitive procedure.