IAPD Recommendations: Pediatric Dentistry PDF

IAPD Recommendations 1. High viscosity glass ionomer cements may be Consensus-based statement > Global agreement 70% used in atraumatic restorative treatment (ART) or 4. Because of the greater longevity of preformed interim thera...

IAPD Recommendations 1. High viscosity glass ionomer cements may be Consensus-based statement > Global agreement 70% used in atraumatic restorative treatment (ART) or 4. Because of the greater longevity of preformed interim therapeutic restorations (ITR), as an option for conventional treatment in primary teeth. ART/ITR metal crowns, their use may be recommended on may be used for controlling caries in children that are high-risk children having multi-surface or large not cooperative for definitive treatment or treating cavitated lesions on primary molars, especially when multiple open carious lesions before rendering children undergo full mouth rehabilitation under definitive restoration. general anaesthesia. Consensus-based statement > Global agreement 100% Consensus-based statement > Global agreement 95% 2. Glass ionomer and resin-modified glass ionomer restorative materials may be used as restorative 5. In cases of permanent teeth with large carious materials for single surface restorations in primary lesions or severe enamel defects, preformed metal and permanent posterior teeth. crowns may be used as semi-permanent restorations. Consensus-based recommendation > Global agreement 87% Consensus-based statement > Global agreement 95% 3. Where local regulations permit and without any 6. Zirconia crowns are an aesthetic alternative to other contraindications to the use of amalgam preformed metal crowns and may be used for teeth providers may use dental amalgam for restoration based on clinical judgement and shared decision with similar indications. making. Consensus-based statement > Global agreement 79% How to cite: IAPD Foundational Articles and Consensus Recommendations: Restorative Dentistry in Children, 2022. http://www.iapdworld.org/2022_01_restorative-dentistry-in-children. Background Minimal invasive dentistry focuses on caries arrest remineralization of demineralized enamel and dentin, procedures rather than surgical intervention. The optimal caries preventive measures, minimally strategies for minimal invasive dentistry include: invasive surgical interventions, and repair rather than early caries detection and caries risk assessment, replacement of restorations. IAPD Recommendations 1. Minimal invasive dentistry should be complemented methods are effective in the management of non- by preventive measures for caries arrest that include cavitated approximal dentinal lesions. topical fluoride exposure, and placement of pit and Consensus-based recommendation > Global agreement 82% fissure sealants. 4. When necessary, surgical interventions should Evidence-based recommendation > Global agreement N/A emphasize minimal cavity designs, conservative 2. The use of silver diamine fluoride (SDF) is effective removal of carious dentin approximating the pulp, in arresting cavitated caries lesions. and adhesive restorative materials to restore form Evidence-based recommendation > Global agreement N/A and function. 3. Minimally invasive approaches such as infiltration Consensus-based recommendation > Global agreement 78% How to cite: IAPD Foundational Articles and Consensus Recommendations: Minimal Invasive Dentistry, 2022. http:// www.iapdworld.org/2022_02_minimal-invasive-dentistry. Background Amelogenesis Imperfecta (AI) refers to a group of may include conical teeth, microdontia, delayed genetic disorders affecting dental enamel. Diagnosis eruption, ectopic eruption, ankylosis, and submerged of AI is commonly based on phenotype, medical and primary teeth, tooth wear of primary teeth and family histories. Clinical features associated with reduced alveolar development. Issues often include AI may include: sensitivity, calculus, post-eruptive aesthetics, compromised chewing function, and breakdown, aesthetic concerns, reduction of vertical negative psychosocial impact. dimension, difficulties eating, increased caries risk, reduced bond strength, delayed eruption or failure Supernumerary teeth are teeth or tooth-like structures of eruption, pre-eruptive coronal resorption and in addition to the normal number of primary and anterior open bite. permanent teeth. Associated features may include: Dentinogenesis Imperfecta (DI) is a group of delayed or failed eruption of permanent teeth, autosomal dominant conditions characterized crowding, rotation or ectopic position of permanent by defective formation of dentine, affecting the teeth, root malformations, cyst formation of primary and permanent dentitions. Shield’s classic unerupted supernumerary teeth. classification defined this group of disorders into: Type 1: DI associated with osteogenesis imperfecta Dens evaginatus are cusp-like formations that (OI); Type 2: DI not associated with OI; Type 3: contain enamel, dentine and occasionally pulp. Dens rare DI with thin coronal and radicular dentine and invaginatus is defined by the growing of enamel, severe attrition leading to pulpal abscess. Dentin dentine and pulp complex into the pulpal space. dysplasia is an autosomal-dominant trait, affecting both primary and secondary dentitions. The affected Natal teeth are present at birth and neonatal teeth teeth are characterized by short or total absence erupt within the first 30 days of life. The majority of of roots, obliterated pulp chambers, and peri-apical natal and neonatal teeth represent the early eruption radiolucencies. of primary teeth. Complications include irritation or Hypodontia is defined by the absence of one or more trauma to infants’ tongues, sublingual ulceration, teeth, with exception of the third permanent molars. laceration of the mother's nipples, and aspiration of Clinical conditions associated with hypodontia the teeth. IAPD Recommendations 1. Management of amelogenesis imperfecta in 2. Management of dentinogenesis imperfecta in permanent teeth may include: permanent teeth may include: Early intervention with a. Management of tooth sensitivity. composite restorations; stainless steel, cast metal or Consensus-based statement > Global agreement 89% ceramic crowns, and overdentures to prevent loss of vertical dimension. b. Use of aesthetic procedures such as whitening, Consensus-based statement > Global agreement 89% composite, or ceramic veneers. Consensus-based statement > Global agreement 72% 3. Management of dentin dysplasia in permanent c. Early interventions with composite restorations, teeth may include: veneers, and stainless steel, cast metal or ceramic a. Conventional endodontic is often challenging crowns. or not possible in teeth with total obliteration of Consensus-based statement > Global agreement 74% root canals and pulp chambers.  Consensus-based statement > Global agreement 78% Consensus-based statement > Global agreement 83% b. Oral rehabilitation with removable prosthetics b. Selective progressive reduction of the dens after extractions, or bone grafting and a sinus evaginatus to prevent complications. Pulp lift may be required for implant placement at the exposure and pulp protection must be considered. appropriate age. Consensus-based statement > Global agreement 87% Consensus-based statement > Global agreement 89% c. Excision of dens evaginatus if complications are 4. Management of the clinical conditions associated present. The possibility of pulp exposure must be with hypodontia in permanent teeth may include: considered. a. Placement of composite restorations; stainless Consensus-based statement > Global agreement 72% steel, cast metal or ceramic crowns and veneers to 7. Management of dens invaginatus may include: manage conical, microdont teeth and tooth wear. Consensus-based statement > Global agreement 83% a. Placement of fissure sealants and monitoring if the tooth is vital. b. Removable prosthetics, resin retained bridges, Consensus-based statement > Global agreement 89% over-dentures, tooth autotransplantation and/or dental implants for replacement of missing teeth. b. Caries removal and adequate restoration if Consensus-based statement > Global agreement 77% carious. Consensus-based statement > Global agreement 95% 5. Management of supernumerary teeth may include: c. Depending on patient cooperation, root canal a. Monitoring with periodic radiographic exams treatment if the pulp becomes necrotic. if there are no associated complications and if Consensus-based statement > Global agreement 85% orthodontic treatment is not planned. Consensus-based statement > Global agreement 82% 8. Management of natal and neonatal teeth may b. Removal of the supernumerary tooth (teeth) include: with or without surgical exposure if not aligned in a. Extraction if the tooth is supernumerary, exces- the arch or needs orthodontic intervention. sively mobile, or interfering with breastfeeding. Consensus-based recommendation > Global agreement Consensus-based statement > Global agreement 83% 78% b. If possible, covering the incisal portion of the 6. Management of dens evaginatus may include: tooth with composite resin or smoothing the incisal a. Monitoring and placement of fissure sealant, if edge if the tooth interferes with breastfeeding. there are no associated complications. Consensus-based statement > Global agreement 70% How to cite: IAPD Foundational Articles and Consensus Recommendations: Dental Anomalies, 2022. http://www. iapdworld.org/2022_03_dental-anomalies. Background Tongue-tie or ankyloglossia refers to an abnormally the justification for frenotomy (simple incision of short, thickened or tight lingual frenulum that shows lingual frenum) has shifted from improving speech an alteration on its insertion and fixation, usually problems to improving breastfeeding. Frenotomy is near the tip of the tongue. Diagnosis depends on a simple incision of the lingual frenum; frenectomy the assessment of the structure and function of is the removal of the lingual frenum. The anatomical the lingual frenulum, varying from simple visual location and topography of the lingual tissue inspection and/or palpation of the frenulum to a make lingual frenectomy vulnerable to various more complex multi-scale classification system. Children with ankyloglossia may have restricted postoperative and intraoperative complications. tongue mobility resulting in speech or feeding Rare complications of lingual frenotomy may include difficulties. The evidence for frenectomy (removal excessive bleeding/hemorrhage, airway obstruction, of lingual frenum) is weak for improving speech injury to salivary structures, oral aversion, and disorders, malocclusion, difficulty licking, difficulty scarring. Some complications due to lingual keeping teeth clean, increased risk of dental caries, lower central incisor diastema, tethered gingival frenectomy may include reattachment or recurrence tissues lingual to the lower incisor, sleep apnea, and of frenulum attachment, scar tissue formation and social embarrassment. restriction in tongue movement; development of new speech disorder or worsening of existing speech Ankyloglossia is present in 0.1% to 11% of disorder; excessive bleeding/hemorrhage during or newborns. Risk factors include being male (3:1) and immediately after the surgery; formation of mucus positive family history. It can be associated with breastfeeding problems due to difficulty to attach or retention cyst or ranula; sublingual hematoma stay latched onto the breast, and to maternal nipple formation; numbness and paresthesia of the tongue pain. In recent years, with the encouragement of and neighboring soft tissues; development of space breastfeeding as the primary mode of infant feeding, infection. IAPD Recommendations 1. Frenectomy (complete removal of lingual frenum) Consensus-based statement > Global agreement 89% improves speech disorders. For both frenectomy 3. Speech therapy and postoperative exercises and frenotomy (cutting the frenum) the evidence is weak for improving malocclusion, difficulty licking, are suggested following lingual frenotomy or difficulty keeping teeth clean, increased risk of dental frenectomy. caries, lower central incisor diastema, tethered Consensus-based statement > Global agreement 78% gingival tissues lingual to the lower incisor, sleep apnea, and social embarrassment. 4. Prior to frenotomy or frenectomy for breast- Consensus-based statement > Global agreement 82% feeding difficulties, consultation with the infant’s medical provider or lactation consultant may help 2. Prior to frenectomy for speech concerns, consultation with a speech pathologist may help case selection. case selection. Consensus-based statement > Global agreement 83% How to cite: IAPD Foundational Articles and Consensus Recommendations: Management of Ankyloglossia, 2022. http://www.iapdworld.org/2022_04_management-of-ankyloglossia. IAPD Recommendations 1. Optimal fluoride levels in water supplies for the Consensus-based recommendation > Global agreement 89% prevention of dental caries and reduction of dental 5. Brushing children’s teeth twice daily with caries incidence is both safe and effective. fluoridated toothpaste, between 1,000 – 1,500 Consensus-based statement > Global agreement 89% ppm fluoride is effective in reducing dental caries 2. Dietary fluoride supplements may be effective in in children. Using an age appropriate amount of reducing dental caries in permanent teeth for children toothpaste on the brush (“smear” for children under at increased caries risk who drink fluoride-deficient age 3; “pea-size” for children 3-6). water. Consensus-based recommendation > Global agreement 95% Consensus-based statement > Global agreement 72% 6. Prescription-strength 1.1% NaF (0.5% F) gels and 3. Professionally applied topical fluoride treatments pastes are effective in reducing dental caries in high as 5 percent NaF (2.26% F) varnish are efficacious caries risk children over the age of 6. in reducing caries in the primary and permanent dentition of children at caries risk. Consensus-based recommendation > Global agreement 78% Evidence-based recommendation > Global agreement N/A 7. Use of 38% silver diamine fluoride (5% F) is 4. 1.23% percent fluoride gel preparations are effective for the arrest of dentine caries lesions in efficacious in reducing caries in the permanent primary teeth. dentition of children at increased caries risk. Evidence-based recommendation > Global agreement N/A How to cite: IAPD Foundational Articles and Consensus Recommendations: Use of Fluoride for Caries Prevention, 2022. http://www.iapdworld.org/2022_05_use-of-fluoride-for-caries-prevention. IAPD Recommendations 1. When choosing the behaviour guidance techniques, 6. The most acceptable behaviour management the medical, dental and social history and cognitive techniques for parents include: tell-show-do, positive level need to be considered. reinforcement, distraction, and nitrous oxide/oxygen Consensus-based statement > Global agreement 100% inhalation. 2. To monitor and document child behaviour or Consensus-based statement > Global agreement 84% anxiety over time, it is advisable to use a scale (e.g., 7. Patient protective stabilization may be indicated the Frankl, Houpt or Venham behaviour scales) for a patient who: requires immediate diagnosis/ Consensus-based statement > Global agreement 91% urgent care; requires limited treatment and cannot 3. Additional informed consent may be necessary cooperate; has uncontrolled movements due to age, for behaviour management techniques that may be has emotional or cognitive-developmental issues; considered aversive. or is necessary for the safety of the patient, staff, Consensus-based statement > Global agreement 88% dentist, or parent. 4. Behaviour management must be performed by Consensus-based statement > Global agreement 79% adequately qualified dental providers with each country’s or state’s regulations followed. 8. Indications for sedation or general anaesthesia Consensus-based statement > Global agreement 88% include: pre-cooperative and fearful patients for whom non-pharmacological behaviour guidance 5. In some cases, and if the dental needs allow, techniques are likely to be unsuccessful; patients who delaying the treatment or minimally invasive approaches can be an alternative to immediate cannot cooperate due to physical, medical or special treatment requiring aversive techniques, sedation and/ needs; and patients with extensive dental treatment or general anaesthesia. needs or treatment of dental trauma. Consensus-based statement > Global agreement 92% Consensus-based statement > Global agreement 96% How to cite: IAPD Foundational Articles and Consensus Recommendations: Behaviour Guidance in Paediatric Dental Patients, 2022. http://www.iapdworld.org/2022_06_behaviour-guidance-in-paediatric-dental-patients. IAPD Recommendations 1. Once dental erosion is observed, the location and Consensus-based statement > Global agreement 96% level of erosion should be documented by utilizing 6. If bulimia is suspected as the cause of erosion, an appropriate scale. At each subsequent dental visit, referral to the patient’s medical provider is indicated. dental erosion should be monitored, documented, Consensus-based statement > Global agreement 96% and managed. Consensus-based statement > Global agreement 87% 7. Patients with erosive tooth wear should use an 2. The etiology of dental erosion should be additional fluoride source like toothpaste or rinse explored. Acidic dietary exposures, history of preferably containing stannous fluoride. gastroesophageal reflux disease (GERD) and bulimia Consensus-based statement > Global agreement 87% should be considered. 8. If the dental erosion is progressing, then the Consensus-based statement > Global agreement 100% etiology needs to be re-addressed and appropriate 3. If dietary acidic exposure is the cause of dental management offered. erosion, then the patient should be counseled to Consensus-based statement > Global agreement 100% reduce acidic food and beverages. Consensus-based statement > Global agreement 97% 9. Restorative intervention of non-carious teeth with erosion should be delayed, if possible, to allow for 4. One should avoid swishing any acidic beverages monitoring. to avoid erosion of the facial surfaces of all teeth. Consensus-based statement > Global agreement 96% Consensus-based statement > Global agreement 71% 5. If the child reports symptoms of GERD (e.g. 10. Erosive lesions causing pain should be treated with stomach aches, hot burps, heart or throat burning) the appropriate restorative material to eliminate pain. referral to their medical provider should be made. Consensus-based statement > Global agreement 87% How to cite: IAPD Foundational Articles and Consensus Recommendations: Management of Dental Erosion, 2022. http://www.iapdworld.org/2022_07_management-of-dental-erosion. IAPD Recommendations 1. Antibiotic treatment may not be indicated with children below the age of 12 years, pregnant women dental infections that are contained within the tooth and lactating mothers due to the risk of discoloration or immediate surrounding tissues with no signs of in the developing permanent dentition. systemic infection or facial swelling. Consensus-based statement > Global agreement 95% Consensus-based statement > Global agreement 91% 5. The International Association of Paediatric 2. In healthy children, most dental infections may Dentistry (IAPD) endorses the American Heart resolve without antibiotics by removal of the source Association’s (AHA) guideline on the prevention of of infection either by extraction or root canal treatment of the infected tooth. infective endocarditis. Consensus-based statement > Global agreement 91% Consensus-based statement > Global agreement N/A 3. Dental providers should consider altering or 6. The International Association of Paediatric discontinuing antibiotics before completion of a full Dentistry (IAPD) endorses the International course of therapy, as a result of ineffectiveness to Association of Dental Traumatology guidelines minimize the risk of antibiotic resistance. regarding the use of antibiotics as part of the Consensus-based statement > Global agreement 86% treatment of avulsed permanent teeth. 4. Tetracyclines should be avoided, if possible, in Consensus-based statement > Global agreement N/A How to cite: IAPD Foundational Articles and Consensus Recommendations: Antibiotic Therapy in Paediatric Dentistry, 2022. http://www.iapdworld.org/2022_08_antibiotic-therapy-in-paediatric-dentistry. Ethical Considerations in Paediatric Dentistry: Foundational Articles and Recommendations American Academy of Pediatric Dentistry. Policy on the Ethical Responsibilities in the Oral Health Care Management of Infants, Children, Adolescents, and Individuals with Special Health Care Needs, 2018. Available at: https://www.aapd.org/globalassets/media/policies_guidelines/p_ethical.pdf. Accessed May 1, 2020. American Academy of Pediatric Dentistry. Best Practices: Informed consent, 2019. Available at: https:// www.aapd.org/research/oral-health-policies--recommendations/informed-consent/. Accessed May 1, 2020. Mouradian WE. Ethics and leadership in children's oral health. Pediatric Dent. 2007;29:64-72. Adewumi A, Hector MP, King JM. Paediatric dentistry: Children and informed consent: A study of children's perceptions and involvement in consent to dental treatment. Br Dent J 2001;191:256-9. Background Ethics, defined as the moral principles governing our non-maleficence and justice should therefore be decisions and actions, should guide us in how we the foundation of our decision-making processes behave and relate to each other as human beings. and be applied in all aspects of the management of The four principles of ethics: autonomy, beneficence, paediatric patients. IAPD Recommendations 1. Each patient should be treated fairly, without bias, 3. Informed consent should always precede dental judgement or discrimination based on their culture, treatment. A parent or legal guardian should consent religion, beliefs, behaviour, race, gender, special on behalf of minors and patients with intellectual needs or health status. disabilities. Informed consent should include the Consensus-based statement > Global agreement 100% following information: diagnosis, treatment options (including no treatment), the risks and benefits, costs 2. Dental professionals ethical obligation is to and burdens (social and other) associated with each provide necessary treatment. Patients should be option, as well as the opportunity for questions. referred to other health professionals who can Consensus-based statement > Global agreement 91% provide proper treatment if the needs of the patient are beyond the practitioner’s scope or skills. 4. Except for child abuse or a child of the age of Consensus-based statement > Global agreement 100% emancipation, a practitioner must obtain consent for treatment from the parent/legal guardian. 6. The benefit of the treatment should outweigh the Consensus-based statement > Global agreement 91% risks the child is subjected to, including radiation and behaviour management techniques. 5. If possible, assent for treatment should be Consensus-based statement > Global agreement 96% obtained from the patient. At a level appropriate for 7. Dentists are responsible for their clinical and a child’s understanding, the child should be involved ethical decisions regardless of opinions or influence in the treatment planning and treatment processes. of parents/legal guardians or business owners. Consensus-based statement > Global agreement 82% Consensus-based statement > Global agreement 100% How to cite: IAPD Foundational Articles and Consensus Recommendations: Ethical Considerations in Paediatric Dentistry, 2022. http://www.iapdworld.org/2022_09_ethical-considerations-in-paediatric-dentistry. IAPD Recommendations 1. Primary prevention for ECC includes: g. Applying pit and fissure sealants to susceptible a. Limiting sugar intake in foods and drink for molars. children under two years. Evidence-based recommendation > Global agreement Consensus-based statement > Global agreement 100% N/A b. Avoiding night-time bottle feeding with milk 2. Secondary prevention for ECC includes: or drinks containing free sugars; and baby bottle and breastfeeding beyond 12 months, especially if a. More frequent fluoride varnish applications, frequent and/or nocturnal. such as four times per year for children with white Consensus-based statement > Global agreement 84% spot lesions. c. Optimal exposure to dietary fluoride that can be Consensus-based statement > Global agreement 84% delivered by fluoridated water, but with less evidence b. Applying pit and fissure sealants to non- for fluoridated salt, and fluoridated milk. cavitated carious lesions molars. Consensus-based statement > Global agreement 78% Evidence-based recommendation > Global agreement N/A d. Brushing child’s teeth with the age-appropriate amount of fluoridated toothpaste, ideally should 3. Tertiary prevention for ECC includes: contain 1,000–1,500 ppm fluoride. a. Silver diamine fluoride used to arrest cavitated Consensus-based statement > Global agreement 90% lesions. e. Establishing a dental home and having a dental Evidence-based recommendation > Global agreement N/A visit for comprehensive care in the first year of life. Consensus-based statement > Global agreement 100% b. Conservative caries removal and tooth restoration to prevent further tooth breakdown, f. Regular 5% fluoride varnish applications for any child at increased caries risk. pain and prevent unnecessary pulp exposures. Evidence-based recommendation > Global agreement Consensus-based recommendation > Global agreement N/A 84% How to cite: IAPD Foundational Articles and Consensus Recommendations: Management of Early Childhood Caries, 2022. http://www.iapdworld.org/2022_10_management-of-early-childhood-caries. IAPD Recommendations 1. According to the WHO Committee for Nutrition Consensus-based statement > Global agreement 89% Guideline, to reduce dental caries risk, sugar intake 4. According to the American Academy of Pediatrics, should be less than 5 percent of energy intake (less fruit juices have few nutritional benefits and are not than 16 grams of sugar ( 4 teaspoons) per day for recommended for children under age 1. For children children, aged 4-8. Consensus-based recommendation > Global agreement 89% 1-3 years of age, the intake of juice should be limited to no more than 120 ml per day; for children 4-6 2. Breast-feeding in infancy may protect against years of age, no more than 180 ml per day. dental caries, but if it continues after 12 months it Consensus-based recommendation > Global agreement 83% may increase the risk of caries. Consensus-based recommendation > Global agreement 89% 5. Dental professionals need to become engaged 3. Baby bottles or closed containers should not be in advocacy efforts to reduce the amount and used to feed children beverages with added (free) high frequency of intake of foods and beverages sugar. To avoid feeding throughout the night, bottles containing sugar. should not be left in the crib. Consensus-based statement > Global agreement 100% How to cite: IAPD Foundational Articles and Consensus Recommendations: Diet and Dental Caries, 2022. http://www. iapdworld.org/2022_11_diet-and-dental-caries. Schwendicke F, Dorfer C, Paris S. Incomplete caries removal: A systemic review and meta-analysis. J Dent Res 2013;92:306-14. Smaïl-Faugeron V, Glenny AM, Courson F, Durieux P, Muller-Bolla M, Fron Chabouis H. Pulp treatment for extensive decay in primary teeth. Cochrane Database Syst Rev. 2018 May 31;5:CD003220. Trairatvorakul C, Koothiratrakarn A. Calcium hydroxide partial pulpotomy is an alternative to formocresol pulpotomy based on a 3-year randomized trial. Int J Paediatr Dent. 2010;22:382-9. Chen Y, Chen, X, Zhang Y, Zhou J, et al. Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis. BMC Oral Health 2019;19:227. Background Pulp therapy in the primary dentition aims to preserve duration, aggravating and relieving factors); clinical the teeth until they exfoliate naturally. In the signs (extra- and intra oral); radiographic examination young permanent dentition, pulp therapy aims to (crown, furcation, periapical areas, and the adjacent preserve pulp vitality and allow root development bone); and in permanent teeth with closed apices to continue, helping to achieve a favorable crown- testing the sensibility of the pulp (electric pulp root ratio. It also aims to achieve wider dentinal testing, cold test and heat test). The correct walls for long-term retention and function of the diagnosis affects the treatment and prognosis. The teeth. Indications and type of pulp therapy depends vital pulp therapy includes indirect pulp therapy (IPT), on the status of the pulp: healthy, reversible pulpitis, irreversible pulpitis, or necrosis. Clinical diagnosis can direct pulp capping (DPC) and pulpotomy. The non- be achieved from the medical and dental history; pain vital pulp therapy includes pulpectomy and lesion history (location, intensity, whether spontaneous, sterilization and tissue repair (LSTR). IAPD Recommendations 1. Teeth with pain of a short duration that is not affected tooth should always be considered when spontaneous are likely to have a vital pulp that may determining the type of pulp therapy. have reversible pulpitis, and therefore should be Consensus-based statement > Global agreement 94% treated with vital pulp therapy. 4. If pulp therapy is not recommended, then Evidence-based recommendation > Global agreement N/A alternative treatment options such as extraction 2. Teeth with spontaneous pain or pain that lasts should be considered. after the removal of an aggravating factor, a sinus Consensus-based statement > Global agreement 94% tract, soft tissue pathology or gingival swelling 5. Regarding pulp therapy for primary teeth: and inflammation (not associated with periodontal a. Clinicians may choose to use materials for disease), excessive mobility (not from exfoliation), indirect pulp treatment such as calcium hydroxide, and radiographic signs (apical/furcation radiolucency, glass ionomer cements, and dentin bonding internal/external root resorption) suggests agents. irreversible pulpitis and/or necrosis, and therefore Evidence-based recommendation > Global agreement should be treated with non-vital pulp therapy. 88% Evidence-based recommendation > Global agreement N/A b. Indirect pulp treatment should be used to 3. Patients’ medical history and restorability of an treat vital primary teeth with deep caries to avoid  pulpal injury or exposure. Indirect pulp treatment treat necrotic primary teeth. consists of excavating to hard dentine on the Evidence-based recommendation > Global agreement peripheral walls of deep lesions while leaving the N/A firm caries-affected dentine on the pulpal floor. Caries removal to soft dentine on the pulpal floor 6. Regarding pulp therapy for young permanent may be appropriate with deep lesions impinging on teeth: the pulp. a. Clinicians may use protective liners such as Evidence-based recommendation > Global agreement calcium hydroxide, zinc oxide and eugenol, dentine N/A bonding agents, and glass ionomer cements. c. Materials such as glass ionomer cement, Consensus-based statement > Global agreement 76% resin-modified glass ionomer cement, calcium hydroxide, zinc oxide/eugenol, or MTA may be b. Indirect pulp treatment should be used to treat used for indirect pulp treatment and placed over vital permanent teeth with deep caries to support the remaining dentine to enhance pulp healing and the pulp recovery and reduce the risk of pulp repair. exposure. Evidence-based recommendation > Global agreement Consensus-based recommendation > Global agreement N/A 88% d. Calcium hydroxide or MTA may be used as pulp c. In direct pulp capping, the exposed pulp should capping agents in primary teeth with traumatic or be capped with either calcium hydroxide or MTA iatrogenic pulp exposures. Consensus-based recommendation > Global agreement and sealed from the rest of the oral environment 82% by placement of a suitable restoration. e. Pulpotomies in primary teeth should be done Consensus-based recommendation > Global agreement preferably with MTA. 88% Evidence-based recommendation > Global agreement d. With pulpotomy (Cvek pulpotomy), the exposed N/A pulp tissue should be covered with calcium f. Formocresol pulpotomies show high success; hydroxide or MTA; and then restored. however, other materials such as Biodentine Consensus-based recommendation > Global agreement and MTA are as effective and may have greater 100% parental acceptance. Consensus-based recommendation > Global agreement e. Pulpectomy, apexification, or MTA apical barrier 84% may be used for immature permanent teeth with g. Pulpectomies in primary teeth should be non-vital pulp. completed with resorbable materials such as Consensus-based recommendation > Global agreement iodoform and calcium hydroxide (Endoflas®), zinc 88% oxide, non-reinforced zinc oxide eugenol, and f. Pulp revascularization may be used for immature iodoform and calcium hydroxide paste (Vitapex®, permanent teeth with non-vital pulp tissue. Metapex®). Consensus-based statement > Global agreement 82% Evidence-based recommendation > Global agreement N/A g. Coronal pulpotomy may be used for the management of mature carious permanent teeth with reversible h. Lesion Sterilization Tissue Repair (LSTR) which includes disinfection of root canals pulpitis. with an antibiotic mixture (e.g., ciprofloxacin, Consensus-based recommendation > Global agreement metronidazole, and clindamycin) may be used to 74% How to cite: IAPD Foundational Articles and Consensus Recommendations: Pulp Therapy for Primary and Young Permanent Teeth, 2022. http://www.iapdworld.org/2022_12_pulp-therapy-for-primary-and-young-permanent-teeth. IAPD Recommendations 1. Important caries risk factors are the presence management. of enamel defects, previous caries experience and Consensus-based recommendation > Global agreement 100% the longitudinal evaluation of lesion progression (increased dimension/ cavitation of white spot lesions 4. The term “active surveillance” is used to denote or presence of new lesions) at recall visits. instituting caries preventive measures and careful Consensus-based recommendation > Global agreement 100% monitoring of caries arrestment or progression. 2. Other useful caries risk factors in children are: whether the mother/caregiver has active caries, the Consensus-based statement > Global agreement 94% socioeconomic status of the family, and whether the child consumes fermentable carbohydrates at high 5. Along with other information, the likelihood of a frequency (see Table for caries risk indicators). patient returning for periodic recalls and compliance Consensus-based recommendation > Global agreement 94% with preventive therapy, is important for considering 3. Besides determining caries risk at initiation of active surveillance strategies. therapy, and ongoing assessment of a changes in risk factors over time allows for refinement of caries Consensus-based statement > Global agreement 100% Dental Caries Care Pathways Based on a Child’s Caries Risk Assessment. Low Risk Moderate Risk High Risk Caries Risk Child has no caries Child has/had 1 or more lesions Child has/had 1 or more proximal lesions Indicators No new lesions in 1 year 1 or more lesions/year More than 2 new lesions/year No white spot lesions Infrequent white spot lesions Numerous white spot lesions High SES Middle SES Mother/caregiver has active caries Low SES Diagnostic Exam interval 12 months Exam interval 6 months Exam interval 3 months Procedures Radiograph interval Radiograph interval 6-12 months Radiograph interval 6 months Diet analysis Preventive Brushing with F Brushing with F toothpaste twice Brushing with F toothpaste twice daily Therapy toothpaste twice daily daily Systemic fluoride supplements** Sealants Professional topical fluorides tx Professional topical fluoride tx every 3 months every 6 months Sealants Sealants Brushing with high potency F gel (over age 6) Dietary counseling Restorative None Active surveillance of white spot Active surveillance white spot lesions Therapy and enamel proximal lesions Restoration of enamel proximal lesions enamel proximal lesions Restoration or SDF tx. of progressing lesions Restoration or SDF*** tx. of Restoration or SDF tx. of cavitated lesions progressing lesions Restoration or SDF tx. of cavitated lesions * SES = socioeconomic setting ** Age and water supply considerations *** SDF = silver diamine fluoride topical treatment How to cite: IAPD Foundational Articles and Consensus Recommendations: Caries Risk Assessment and Care Pathways, 2022. http://www.iapdworld.org/2022_13_caries-risk-assessment-and-care-pathways. IAPD Recommendations 1. Hall crown technique may be indicated for: (a) 3. Retrospective studies show that the longevity of fearful or anxious children; (b) primary teeth with deep primary teeth restored using the Hall crown technique or multi-surface caries without pulp involvement; is comparable to the conventional techniques. (c) treatment where equipment for conventional procedures is not available. Consensus-based recommendation > Global agreement 76% Consensus-based statement > Global agreement 71% 4. Conventional preparation for preformed metal 2. Disadvantages of the Hall crown technique may crowns may be the preferred method to treat primary include the necessities for a prior visit to place teeth with multi-surface lesions to ensure proper fit, separators, temporary open bite after placement, poorer adaption of the crown to tooth surface. better occlusion, and crown alignment. Consensus-based statement > Global agreement 82% Consensus-based statement > Global agreement 70% How to cite: IAPD Foundational Articles and Consensus Recommendations: Hall Technique for Crown Placement in Primary Molars, 2022. http://www.iapdworld.org/2022_14_hall-technique-for-crown-placement-in-primary-molars. IAPD Recommendations 1. Administration of local anaesthetics should be 6. Needle gauges between 23-27 mm should be used based on the weight/body mass index (BMI) of the for intraoral injections when aspiration is necessary. patient, not to exceed the established maximum Consensus-based statement > Global agreement 94% dosage. The lowest total dose to provide effective 7. Short needles should be used for infiltration. A anesthesia should be used. long needle should be used for a deeper injection Consensus-based statement > Global agreement 100% into soft tissue. 2. A bisulphite preservative is used in local Consensus-based statement > Global agreement 88% anaesthetics containing epinephrine. For patients having an allergy to bisulphite, use a local anesthetic 8. To minimize needle breakage, needles should not without a vasoconstrictor. be bent, and 30-gauge needles should not be used Consensus-based statement > Global agreement 94% for block anaesthesia. 3. Local anesthetics without vasoconstrictors should Consensus-based statement > Global agreement 94% be used with caution due to rapid systemic absorption 9. The rate of injection should be slow to minimize which may result in overdose. pain and toxicity. Consensus-based statement > Global agreement 94% Consensus-based statement > Global agreement100% 4. Topical anaesthetics may be used on surface tissues 10. Specific instructions should be given to children prior to the injection of a local anesthetic to reduce and guardians to avoid self-injury of soft tissue after discomfort associated with needle penetration. the office visit. Consensus-based statement > Global agreement 100% Consensus-based statement > Global agreement 100% a. Benzocaine should not be used in patients with a history of methemoglobinemia and should not be 11. Reviews comparing the effectiveness of used in children younger than two years of age. articaine vs. lidocaine have concluded that there is Consensus-based statement > Global agreement 94% little difference in efficacy, except articaine may be b. Systemic absorption of topical anesthetics superior to lidocaine for inferior alveolar nerve block should be considered when calculating the total in patient with irreversible pulpitis. amount of anaesthetic administered. Consensus-based recommendation > Global agreement 82% Consensus-based statement > Global agreement 88% 12. Local anaesthesia doses should be reduced when 5. Documentation of local anaesthesia should combined with sedative medications. include the technique, the type and dosage of local Consensus-based statement > Global agreement 88% anesthetic and dosage of vasoconstrictor (e.g., mandibular block, 27 gauge, 36 mg 2% lidocaine 13. Interventions to help children cope with delivery with 0.018 mg epinephrine, [or 36 mg 2% lidocaine of local anaesthesia include electronic delivery with 1/100,000 epinephrine). devices, use of distraction techniques, and hypnosis. Consensus-based statement > Global agreement 100% Consensus-based statement > Global agreement 88% How to cite: IAPD Foundational Articles and Consensus Recommendations: Local Anaesthesia in Pediatric Dentistry, 2022. http://www.iapdworld.org/2022_15_local-anaesthesia-in-pediatric-dentistry. IAPD Recommendations 1. Early diagnosis and provision of preventive or 6. Preformed metal crowns, direct composite resin early restorative intervention may avoid progressive restorations and laboratory-made restorations have breakdown and possible pulpal inflammation and been used to restore MIH-affected molars. hypersensitivity. Consensus-based statement > Global agreement 83% Consensus-based statement > Global agreement 88% 7. For mild cases of MIH in incisors a combination 2. Restorations in teeth that are severely affected with Molar Incisor Hypomineralization (MIH) are of etching, bleaching, and sealing of affected areas associated with poorer long-term outcomes than in have been used as a conservative approach. For more unaffected teeth. severe cases, micro-abrasion or composite veneers Consensus-based recommendation > Global agreement 92% may improve aesthetics. 3. MIH-affected enamel may have compromised Consensus-based statement > Global agreement 83% bonding for sealants and composite restorations. 8. Tooth extractions of first permanent molars with When possible, adhesive restorations cavity preparations should extend into sound tooth hard or without subsequent orthodontic alignment may tissue. be considered before the eruption of the second Consensus-based statement > Global agreement 87% molars when more than one tooth is affected with 4. Amalgam restorations show high failure rates severe MIH. in atypically shaped molar MIH-preparations. The Consensus-based statement > Global agreement 89% need for retentive cavity preparations might further 9. Frequent recalls and topical fluoride applications compromise existing tooth defects. Consensus-based statement > Global agreement 83% should be established for patients with MIH due to the high failure rates of restorations, secondary 5. Glass ionomer cements have high failure rate in MIH but may be used for temporization of teeth. caries, and further breakdown. Consensus-based statement > Global agreement 83% Consensus-based statement > Global agreement 83% How to cite: IAPD Foundational Articles and Consensus Recommendations: Management of Molar Incisor Hypomineralization, 2022. http://www.iapdworld.org/2022_16_management-of-molar-incisor-hypomineralization. Background Malocclusion, often beginning in early childhood causative factors include genetic traits, and tooth is a common condition in children and may have a and skeletal discrepancies. Paediatric dentists should negative impact on oral health related quality of life. recognize risk factors and establish accurate diagnosis Several risk factors predisposing to malocclusion have been described, including non-nutritive sucking of developing malocclusions to allow prevention, habits and premature loss of primary teeth. Other timely treatment or patient referral. IAPD Recommendations 1. Management of the developing dentition should Consensus-based statement > Global agreement 100% include identification of risk factors, proper diagnosis, 4. Management of an oral habit must be appropriate and timely treatment of developing malocclusions. for the child’s development, malocclusion and ability x > Global agreement 94% to cooperate. 2. Malocclusion may negatively affect the oral Consensus-based statement > Global agreement 94% health quality of life (OHRQoL) of children. Consensus-based recommendation > Global agreement 88% 5. Space maintainers may prevent premature loss of 3. Evaluation of the developing dentition should space which may lead to malocclusion. include identification of: unerupted teeth, anomalies Consensus-based statement > Global agreement 88% of tooth number, size and shape, anterior and 6. Interceptive treatment of increased overjet may posterior crossbites, tooth positions (ectopic), reduce the risk of trauma of the incisors and improve presence of habits along with their dental and skeletal sequelae, abnormal dental relation, developing facial esthetics. skeletal discrepancies, periodontal health, and Consensus-based recommendation > Global agreement airway problems. 100% How to cite: IAPD Foundational Articles and Consensus Recommendations: Management of the Developing Dentition, 2022. http://www.iapdworld.org/2022_17_management-of-the-developing-dentition. IAPD Recommendations 1. Atraumatic restorative technique (ART) is a because of biocompatibility, less sensitivity to minimally invasive dental approach that may be moisture, favorable setting time, chemical bonding used as an alternative treatment option for very to enamel and dentin, and fluoride release. young or uncooperative children, some children with Consensus-based statement > Global agreement 88% special healthcare needs, or in areas of limited health 4. ART should not be used in teeth with deep caries, resources. teeth with potential pulpal exposure, or teeth with Consensus-based statement > Global agreement 94% signs of irreversible pulpitis or abscess. 2. ART technique is indicated for use in the Consensus-based statement > Global agreement 94% management of caries involving single-surface 5. Since the ART approach often uses hand cavities for both primary and permanent dentition. instruments for caries excavation, the procedure is Consensus-based recommendation > Global agreement 76% inexpensive, atraumatic and does not require local 3. High-viscosity glass ionomer cement is the anaesthetics. preferred restorative material for ART restorations Consensus-based statement > Global agreement 82% How to cite: IAPD Foundational Articles and Consensus Recommendations: Atraumatic Restorative Treatment, 2022. http://www.iapdworld.org/2022_18_atraumatic-restorative-treatment. Background Treating children with special health care needs developmental, behavioral, or emotional conditions, (SHCN) is an integral part of the practice of pediatric and who also require health and related services of dentistry. Children with SHCN are defined as a type or amount beyond that required by children “those who have one or more chronic physical, generally.” IAPD Recommendations 1. Practitioners should speak about patients with 5. Prevention strategies should be customized and disabilities using “People First Language.” For emphasized in children with SHCN. example: “a child who …”, “a child with …” or, “a child Consensus-based statement > Global agreement 100% who has…”. Consensus-based statement > Global agreement 88% 6. Children with SHCNs should be offered the same standard of dental care as children without SHCNs 2. Pediatric dental offices should accommodate children with special health care needs (SHCNs) in the whenever possible. Deviations from the standard of design of their offices (e.g., wheelchair accessibility), care and rationale should be documented. and consider having equipment to help the child cope Consensus-based statement > Global agreement 94% with dental care (e.g., weighted blankets, sun glasses, 7. Children with SHCNs may require more noise cancellation headphones). Consensus-based statement > Global agreement 100% surgical procedures than children without SHCNs. Consequently, dentists should consider combining 3. Parent/legal guardian-derived medical histories should be validated with the child’s primary medical oral rehabilitation with other surgeries in order to provider or electronic medical record. Medical history limit exposure to general anesthesia in children with updates should be obtained at each appointment. SHCN. Consensus-based statement > Global agreement 94% Consensus-based statement > Global agreement 94% 4. Children with SHCNs are heterogeneous, therefore 8. Partnership between the pediatric dental home, caries risk assessment in children with SHCNs should and the child’s medical home should be encouraged be individualized based on the underlying medical conditions and chronic medications. to improve their oral and overall health. Consensus-based statement > Global agreement 100% Consensus-based statement > Global agreement 94% How to cite: IAPD Foundational Articles and Consensus Recommendations: Children with Special Health Care Needs, 2022. http://www.iapdworld.org/2022_19_children-with-special-health-care-needs. Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol 2002; 29(5):400- 410. Rezende KM, Canela AH, Ortega AO, et al. Chédiak-Higashi Syndrome and premature exfoliation of primary teeth. Braz Dent J 2013, 24:667-673. Tinanoff N, Tempro P, Maderazo EG. Dental treatment of Papillon-Lefèvre Syndrome: 15-year follow-up. J Clin Periodontol 1995; 22:609-614. Van den Bos T, Handoko G, Niehof A, et al. Cementum and dentin in Hypophosphatasia. J Dent Res 2005; 84:1021-1025 Background It is paramount for pediatric dentists to assess their followed with thorough documentation, clinical patients’ gingival and periodontal health. It is not photographs and dental radiographs, and when uncommon to diagnose gingivitis in pediatric patients necessary referred to medical providers to evaluate primarily due to poor oral hygiene. However, there are for systemic causes such as neutrophil qualitative/ children that may present with refractory generalized quantitative defects, leukemias, hypophosphatasia, severe gingivitis, unexplained tooth mobility and/ Langerhan Cell Histiocytosis X and Papillon-Lefèvre or alveolar bone loss. These children need to be Syndrome. IAPD Recommendations 1. Every dental examination include documentation to evaluate for cyclic neutropenia, chronic idiopathic of the health of the gingiva, periodontium and tooth neutropenia and leukemias. mobility. Once the permanent dentition is established, Consensus-based statement > Global agreement 88% dental examinations may include probing to confirm 4. To assist in triaging a child with the presentation healthy alveolar bone levels. Appropriate dental of pediatric periodontal disease, the Keels-Quinonez radiographs are an adjunct to document the health Pediatric Periodontal Matrix may be used to aid in of the alveolus; clinical photographs are helpful identifying the diagnosis. in documenting and monitoring the periodontal Consensus-based statement > Global agreement 75% condition. Consensus-based statement > Global agreement 94% 5. A child with unexplained premature loss of a primary incisors prior to age 4 should be evaluated 2. Poor oral hygiene or viral origin should be for hypophosphatasia. considered as the etiology for generalized gingivitis. Consensus-based statement > Global agreement 85% If the generalized gingivitis with improved oral hygiene persists beyond two weeks, a non-viral 6. An infant with a natal or neonatal molars should systemic cause may be considered. be evaluated for Langerhans Cell Histiocytosis X. Consensus-based statement > Global agreement 88% Consensus-based statement > Global agreement 62% 3. Differential diagnosis of persistent, severe 7. A child with persistent gingival inflammation gingivitis should include appropriate medical referral beyond two weeks, may require periodontal culturing to help evaluate anaerobic strains of bacteria that may 8. Monitoring the gingival and periodontal health be triggering an aggressive immune response, such as of patients with a diagnosis of systemic disease is a critical marker for compliance, as well as in Papillon-Lefèvre Syndrome or contributing to the effectiveness of any medication used to enhance the inflammation and bone loss as in the neutropenias. immune response. Consensus-based statement > Global agreement 81% Consensus-based statement > Global agreement 88% Pediatric Periodontal Disease Matrix Copyright MA Keels and RB Quinonez, 2003 Healthy Bone Diseased Bone (no alveolar bone loss) (alveolar bone loss) Healthy Gingiva Healthy gingiva and no bone loss Healthy gingiva and bone loss (pink, firm, stippled) Hypophosphatasia** Inconclusive Pediatric Periodontal Disease (LJP)* Dentin Dysplasia Type I Post Avulsion / Extraction Diseased Gingiva Unhealthy gingiva and no bone loss Unhealthy gingival and bone loss (erythematous, Gingivitis Neutrophil quantitative defect: (agranulocytosis, hemorrhagic) Eruption related gingivitis cyclic neutropenia,chronic idiopathic neutropenia)* Factitial Injury Neutrophil qualitative defect: (Leukocyte adhesion Mouthbreating Gingivitis deficiency)* Minimally attached gingival Inconclusive Pediatric Periodontal Disease (LJP)* Gingival Fibromatosis Langerhan Cell Histiocytosis X*** Herpetic Gingivostomatitis Papillon-Lefèvre Syndrome* ANUG Diabetes Mellitus* Thrombocytopenia Down Syndrome* Leukemia (AML / ALL) Chédiak-Higashi Syndrome* Aplastic anemia Chronic Granulomatous Disease* HIV Tuberculosis* Acrodynia Ehlers-Danlos (Type VIII)* Vitamin C deficiency Osteomyelitis* Vitamin K deficiency * bacteriological culture and sensitivity needed ** tooth biopsy needed *** gingival biopsy needed How to cite: IAPD Foundational Articles and Consensus Recommendations: Paediatric Periodontal Disease, 2022. http://www.iapdworld.org/2022_20_paediatric-periodontal-disease.