Paediatric Dentistry Undergraduate Handbook 2024 PDF

PAEDIATRIC DENTISTRY UNDERGRADUATE HANDBOOK Child Dental Health Department University Dental Hospital of Manchester 2024 Edition 1 PAEDIATRIC DENTISTRY UNDERGRADUATE HANDBOOK CHILD DENTAL HEALTH DEPARTMENT UNIVERSITY OF MANCHESTER 2024 EDITION...

PAEDIATRIC DENTISTRY UNDERGRADUATE HANDBOOK Child Dental Health Department University Dental Hospital of Manchester 2024 Edition 1 PAEDIATRIC DENTISTRY UNDERGRADUATE HANDBOOK CHILD DENTAL HEALTH DEPARTMENT UNIVERSITY OF MANCHESTER 2024 EDITION Siobhan Barry Carly Dixon Lisa Clarke Sandeep Acharya Jessica Cooper 2 TABLE OF CONTENTS INTRODUCTION 4 HISTORY, EXAMINATION & TREATMENT PLANNING 6 REGULAR DENTAL ASSESSMENTS WITH APPROPRIATE RADIOGRAPHS 15 CONSENT 16 BEHAVIOUR MANAGEMENT 20 PREVENTION OF DENTAL CARIES 30 LOCAL ANALGESIA 45 CARIES MANAGEMENT 48 PULP THERAPY 68 GENERAL ANAESTHESIA & CONSCIOUS SEDATION 80 DENTAL AND SOFT TISSUE ANOMALIES 84 MEDICALLY COMPROMISED CHILD 109 SAFEGUARDING 136 ORTHODONTIC/PAEDIATRIC INTERFACE 143 NON-CARIOUS TOOTH SURFACE LOSS 171 APPENDICES 180 3 INTRODUCTION Paediatric Dentistry (never referred to as “kids”) is by far the best specialty to train and work in. It is an age- defined specialty and involves the practice of oral health care for infants, children and adolescents between birth and sixteen years of age. It is a wonderful specialty that incorporates a broad range of techniques to provide comprehensive care to a group who are unique in their development, oral disease and behaviour. This manual aims to provide guidance for all undergraduate and postgraduate students, and all students are strongly advised to have this manual with them when working on the Paediatric Dental clinic. Objectives of this Handbook 1. To prepare dental students to provide high quality comprehensive dental care for children, in some cases by appropriate referral to secondary care. 2. Develop a positive attitude towards Paediatric Dentistry in the undergraduate student so that they will enjoy the practice of Paediatric Dentistry following graduation. 3. Develop a sound evidence base in Paediatric Dentistry that the undergraduate student can build upon following graduation. 4 Reading List Cameron A.C. and Widmer R.P. (eds)(2003) Handbook of pediatric dentistry. 2 nd edition. Edinburgh. Mosby. Duggal M.S. et al (2002) Restorative techniques in paediatric dentistry. 2nd edition. London: MartinDunitz. Welbury, R., Duggal, M. and Hosey, M. (2018). Paediatric Dentistry. 5th ed. Oxford: Oxford University Press. Curzon M.E.J., Roberts J.F. and Kennedy D.B. (1996) Kennedy’s paediatric operative dentistry. Koch G and Poulson S (eds)(2001) Pediatric dentistry: a clinical approach. Copenhagen: Munksgaard Rugg-Gunn A.J. and Nunn J.H. (1999) Nutrition, diet and oral health. Oxford: Oxford University Press. Duggal M, Cameron A and Toumba J (2012) Paediatric Dentistry AS A GLANCE. Wiley- Blackwell. Essential Guidelines BRITISH SOCIETY OF PAEDIATRIC DENTISTRY – www.bspd.co.uk EUROPEAN ACADEMY OF PAEDIATRIC DENTISTRY – www.eapd.gr 5 HISTORY, EXAMINATION & TREATMENT PLANNING Building Rapport It is very important to establish a good rapport with both the patient and any siblings/parent/guardian as soon as they enter the surgery. Remember to smile and introduce yourself. It is good practice to ask the patient who they have brought with them. This will avoid mistaking a mother for grandmother and vice versa. Good “ice breakers” for children “How old are you?” children are generally very happy to discuss their age and it will give you an idea of where to pitch your communication “I like your hair bow/shoes” It is always useful to find something to compliment the child about initially History At every visit record: The date The name of the consultant covering the session Who has attended with the patient Why the patient has attended Confirm medical history Take a history of symptoms including any history of pain/facial swelling, whether the patient needed antibiotics and if symptoms interfered with eating/drinking/sleep. Has the patient needed to access any other emergency care? Also take a history of the patient’s previous dental experience. Do they attend their GDP on a regular basis and treatment have they tolerated, for example; Local analgesia Restoration of teeth Extraction 6 It is worth remembering that mothers are very good at predicting how children will react to treatment, particularly at the first visit. Medical History The medical history questionnaire is completed on Hive and rechecked at every visit. The BMI is recorded for every child. If the BMI is outside the normal range, a letter will be written to the GP. Examination Extra-oral examination should include examination for: Facial asymmetry Facial swelling Lymphadenopathy Pyrexia Intra-oral examination should include: Examination of intra-oral soft tissues A full dental charting Simplified BPE as appropriate Orthodontic assessment Special tests include percussion, sensibility testing and radiographs. Percussion may be unreliable in children and a light tap with a gloved finger is usually enough to establish whether a tooth is tender to percussion. Sensibility testing is unreliable in primary teeth but will be appropriate for permanent teeth, especially traumatized incisors. Bitewing radiographs are essential for an accurate diagnosis unless posterior contacts are open. Bitewing radiographs show the furcation area of primary molars and this is where we expect to see pathology if it is present. 7  Bitewing radiographs showing caries URD, ULD, LLD and LRD Lateral Oblique Views are extra oral views and are useful in children who cannot tolerate intraoral views and are not tall or cooperative enough for a DPT on a BW setting. Right and left lateral oblique views showing caries 8 A DPT radiograph may be necessary to allow assessment of the developing dentition, including the presence of permanent successors and the developmental stage of lower second permanent molars (when considering the prognosis of lower first permanent molars) and to assess for any other anomalies such as supernumerary teeth and pathology. DPT radiograph showing ectopic upper canine teeth Periapical radiographs are most useful in cases of dental trauma. Periapical radiograph showing UR1, UL1 which have been avulsed, reimplanted and splinted. 9 DPT on a BW setting is useful for caries diagnosis in young children who cannot tolerate intraoral bitewing radiographs. It may also be used for assessing root formation on primary molars, the presence/absence of premolars and the developmental stage of permanent molars. DPT on a BW setting – note that anterior teeth are not included in this view Upper standard occlusal radiographs are useful to show anterior caries in children who cannot tolerate periapical views. They may also be used to assess anomalies such as supernumerary teeth and may show traumatic injury such as root fracture. Upper Standard Occlusal view showing an intrusive luxation URA 10 If for any reason a component of the examination or appropriate special test cannot be completed, this should be recorded along with the reason why. Diagnosis A treatment plan cannot be formulated without a full diagnosis. The diagnosis may involve: 1. Hard tissue diagnosis – “uncomplicated enamel dentine fracture UR1” 2. Periodontal Ligament diagnosis – “Subluxation UR1” 3. Caries diagnosis – “occlusal caries URE extending to inner third of dentine – likely to be pulpally involved” 4. Pulpal pathology – “non-vital URE” 5. Gingival pathology – “gingivitis” 6. Tooth surface loss 7. Developmental defects – “Hypomineralised UR6” 8. Periodontal pathology secondary to hard tissue or pulp pathology – “periapical periodontitis UR5” 9. Orthodontic diagnosis – “Class II division 1 incisor relationship” 10. Behaviour – Frankl Score 11. Medical diagnosis Treatment Planning Treatment options should be discussed with the patient and parent. The modality of treatment will vary depending on the cooperation of the patient, medical history, complexity of care required and patient/parent choice. There are a number of modalities of delivering care: 1. Local analgesia Topical analgesia and the injection of local analgesia (often referred to as “sleepy juice” to avoid the word “injection”) 2. Sedation For children over the age of six years, inhalational sedation which is a titrated dose of nitrous 11  oxide/oxygen may be useful as this provides sedation and mild analgesia. Children need to be able to communicate with the dentist for this to be effective, therefore it is unlikely that children under the age of six would tolerate this modality of treatment. 3. IV sedation using propofol This option must be delivered by an anaesthetists. It is available and may be suitable for children over the age of 12 years who are anxious. 4. General Anaesthetic This allows treatment to be completed in one visit. However, GA should only be considered when all other modalities of delivery are deemed inappropriate. GA is associated with risks including a very small (3- 4/million) risk of death. Treatment plans should be written in a visit-by-visit order. Each visit should have a restorative and preventive component. This is because prevention is aimed at treating the cause of the disease and the restorative component is aimed at repairing the damage. In Paediatric Dentistry we practice quadrant dentistry which means that a single quadrant is anaesthetized and all work in that quadrant performed, avoiding the need to anaesthetize a single quadrant on multiple occasions. Maxillary quadrants are usually treated first as it is easier to achieve local analgesia in the maxilla, unless the patient is experiencing pain from a mandibular tooth. The plan is not set in stone however, and may alter visit by visit depending on symptoms and patient compliance. 12 Example of Treatment Plan A 4-year-old patient attends with his mother. Mother gives a history of occasional pain URE area. There is no history of facial swelling and he has never been prescribed an antibiotic for dental infection. He is fit and well with no allergies and is not dentally anxious. His mother feels that he will cope well with treatment under local analgesia. DPT on a BW setting showing extensive occlusal caries URE, LLE, LRD and LRE with pulpal involvement. LLE, LRD and LRE have GIC temporary restorations in situ. URD, ULD, LLD show distal caries. ULE shows occlusal caries. Visit 1: History, examination, DPT on a BW setting, OHI/ deliver diet diary Visit 2: Extract URE and seps URD, ULD. Receive diet diary back. Discuss toothpaste and advise regarding appropriate fluoride level. Discuss supervised brushing until the age of 8-years-old and spit don’t rinse Visit 3: Hall crown URD, ULD, Separators ULE, LLD. Discuss diet diary and make recommendations for change. Visit 4: Hall crown ULE, LLD and extract LLE. Place fluoride varnish. Visit 5: Extract LRD, LRE. Reassess oral hygiene and tooth brushing technique. Long term: 3 monthly review with application of fluoride varnish. 13 Alternative Options: If the patient is particularly cooperative, or if there was a contraindication to extraction, you could consider a pulp therapy rather than extraction. If the patient is poorly cooperative or lost cooperative midway through treatment, extractions under a general anaesthetic would be the preferred option. 14 REGULAR DENTAL ASSESSMENTS WITH APPROPRIATE RADIOGRAPHS Dental Recall Intervals The recommended interval between oral health reviews should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease. For patients under the age of 18 NICE guidance states that a recall period of 3, 6, 9 or 12 months should be assigned. At the recall appointment, the disease risk of the patient should be re-assessed and changed if required. At each appointment, the preventative strategy should be reviewed and appropriate preventative advice and treatment given. Dietary habits and tooth brushing practice should be reviewed and action plans should be made. Any early carious lesions managed with prevention only should be reviewed and fissure sealants should be examined for wear and leakage. Radiographic Recall Guidelines The Faculty of General Dental Practitioners (FGDP) Selection Criteria for Dental Radiography sets out guidance for the frequency of bitewing radiographs to diagnose dental caries for both the primary and permanent dentition. The recommendations are summarised below. Caries risk Frequency of bitewing radiographs High 6 monthly Until no new or active lesions or until moved into new risk category Medium 12 monthly Until no new or active lesions or until moved into new risk category Low 12-18 months primary dentition 24 months permanent dentition More extended radiographic recall intervals may be appropriate if there is evidence of continued low risk. 15 CONSENT Valid Consent In order for consent to be valid according to the Department of Health guidance the following criteria must be met: given voluntarily person appropriately informed person has the capacity to consent to the intervention in question be the patient OR someone with parental responsibility (PR) for a patient under the age of18 In Britain we may encounter opposition to this by carers if they attend clinics with a generic form signed by the person with (PR) to say that they can give consent for medical interventions. Although this may have been given voluntarily and with capacity, a generic form can NEVER be informed – and therefore this is not valid consent. Gillick Competence In the case of Gillick, which was a court case regarding whether a person with PR needs to be involved in the decision to prescribe contraception to a patient under 16 years, the courts (Lord Fraser) ruled that you must ask a patient under 16-year-old to involve the person with PR in their treatment. However, if they refuse you can take their consent as valid as long as they have sufficient understanding and intelligence to fully understand the proposed intervention. Gillick Competence applies to: children under16 sufficient understanding and intelligence understand fully the proposed intervention If you deem the child not to have this understanding- they are deemed to be a child lacking capacity and therefore the person with PR must be contacted. 16 Young Adults 16-18 Young adults are another exception as the age bracket of under 18 but over 16 is controlled by the Family Law Reform Act (1969)3 This states that anyone over 16 should have the right to consent to their own medical treatment A case in America has amended the DOH guidelines for this as a 17-year-old girl was refusing treatment for anorexia this was overridden by the parents and taken to court- the parents won. Aged 16 or 17 are presumed to be capable of consenting to their own medical treatment, and any ancillary procedures involved in that treatment, such as an anaesthetic. Consent will be valid only if it is given voluntarily by an appropriately informed young person capable of consenting to the intervention. The refusal of a competent person aged 16–17 may in certain circumstances be overridden by either a person with parental responsibility or a court 2 Parental Responsibility Who has it? The child’smother The child’s father, if he is on the birth certificate (post-December 2003) The child’s legally appointed guardian A person in whose favour the court has made a residence order concerning the child Local authority designated in a care order in respect of the child 5 Unmarried Fathers Before 1 December 2003 Marry the mother of their child Obtain a parental responsibility order from the court Register a parental responsibility agreement with the court or by an application to court After 1 December 2003 Register the child’s birth jointly with the mother at the time of birth 17  Re-register the birth if they are the natural father Marry the mother of their child or obtain a parental responsibility order from the court Register with the court for parental responsibility Although this initially looks complicated, as a general rule, anyone who has parental responsibility which has been given by a court will know and have the documentation as it is a long process Looked after children According to the Children's Act 1989, section 22 entitled "General duty of local authority in relation to children looked after by them" a child is legally defined as ‘looked after’ by a local authorityif he or she: Is provided with accommodation for a continuous period for more than 24 hours Is subject to a care order; or Is subject to a placement order If a care order is in place the local authority will have PR and also be able to determine to what extent the parent/guardian may have PR. For example, the parent may have shared PR with the local authority or full or none depending on the situation. Placement order is where the child is placed with prospective adopters which is complex as they get PR shared with birth parent and local authority as soon as child placed with them until the adoption paperwork is complete. Gaining consent In the Paediatric Dentistry Department we routinely gain written consent (Form 2) for: Treatment under general anaesthetic Treatment under inhalation sedation Extractions under local anaesthetic Gaining consent for Treatment under General Anaesthetic There are two types of waiting list for general anaesthetic at UDHM: 1. Exodontia (simple dental extractions) a. This is a waiting list for children requiring extractions only. 18  b. Consent must be taken for teeth noticed in mouth to have any decay plus “any other teeth as necessary (including anterior teeth) to achieve oral health” see below 2. Comprehensive care (any dental treatment required, including radiographs, restorations, extractions etc.) a. This is a waiting list for both restorative and extraction cases b. Consent needs to be as accurate as possible- “fillings and extractions as necessary”is notacceptable unless the only way to examine the child is with general anaesthesia. (e.g. “Proposed Treatment: General anaesthetic and local analgesia for the extraction of at least one adult tooth and four primary teeth, restoration of 3 adult teeth and any other restorations and extractions as needed to secure oral health”) c. Need to consent for radiographs if planning to take these whilst the child is in theatre. d. Need to consent for extraction of further permanent teeth if restoration is not possible (if the caries is so deep the tooth is unrestorable.) Further reading Childrens Act 1989 Chapter 41 (Part III Section 22) London: Stationary Office Department of Health (2009) Reference guide to consent for examination or treatment. London: The Stationery Office. Family Law Reform Act 1969 Chapter 46 (Part I Section 8) London: Stationary Office Childrens act 1989 Chapter 41, (Part I Section 2) London: Stationary Office Department of Health (1983) Code of practice for the Mental Health Act. London: Stationary Office Adoption and Children Act 2002, Chapter 38, London: Stationary Office 19 BEHAVIOUR MANAGEMENT Attending the dentist for some children is a challenging event and previous experience may provoke anxiety and apprehension. This chapter discusses the principles of behaviour management that may influence the management of a child's behaviour in the dental setting, and provide adjuncts to aid treatment and improve a child’s dental visit and quality of your paediatric patient care. “Behaviour management and prevention, coupled with local anaesthesia when required, form the foundation of the delivery of pain-free dentistry for children.” To be a successful dentist a relationship of trust must be established with the parents and child. The way a dentist interacts and communicates with the child can have a significant influence on the success of any care from preventative advice to treatment. This process is a continuous interaction, to establish communication, alleviate fear and promote a positive attitude towards oral health. Dental Anxiety Dental anxiety is commonly reported across all patients and 51% of adults with dental anxiety report this began in childhood. There are many factors that may result in anxiety in the paediatric patient; these may occur without a specific stimulus or may be a reaction to the unknown. Some of these factors are beyond the dentist’s control, however others relate to the dental environment itself. If children’s fears are not addressed, may continue into adulthood resulting in increased missed appointments and patients only making emergency appointments (Skaretetal 2000) External Factors to Anxiety Attitude to dentistry of parents, siblings and peers Negative portrayals of dentistry in the media Previous medical or dental experiences Communication or learning difficulties. It is important to ascertain a child’s previous medical and dental experience and how well they coped with these. 20 The Waiting Room The non-clinical environment is a critical aspect of the initial patient experience for a dental appointment. The reception staff should be welcoming, with a calming décor in the waiting room, and a selection of child-friendly toys and books available. These can provide both distraction and a positive first impression to help shape both the child’s and parents’ expectations. When calling the patient in from the waiting room, the tone of voice should be welcoming and pleasant. The Surgery A bright and friendly environment is available at the University of Manchester Main Clinic. Themed single surgeries have also been designed for dental sedation. Main clinic Child Dental Health Unit 21  Themed sedation rooms The Staff All members of the dental team must establish a warm and welcoming environment; body language and communication skills are critical to creating a positive experience and establishing trust from the family. The appearance of Dentist and staff such as colour of tunic does not seem as important as general neatness and apparent cleanliness. Protective equipment, if placed on after the child has met the dentist, has less of an influence on subsequent behaviour, thus enabling the dentist to explain why they are required. Child Friendly Terms When speaking to children, it is important to find words and terms that children can relate to. These are described as “Childrenese” and can be used to describe the equipment in the dental setting. Throughout your dental career you will add more of your own names to describe clinical items, below is a list of common phrases. The key is choosing terminology which conjures little or no negative feelings. 22  Slow Handpiece Buzzy Bee Bur Diamond toothbrush Inhalation sedation Magic wind Rubber dam Rubber raincoat Aspirator Hoover Rubber dam clamp Clip or ring Extraction Wiggle out Topical anaesthetic Sleepy jelly Water rinse Tooth shower Anaesthesia Asleep Preformed metal crown Silver hat Princess crown Injection Spray with sleepy juice Examination Count Teeth Childrenese Terms: Fayle 2002 Tips and Tricks The manner in which the dental team communicates with the child and family is significant. A dentist with a calm, caring and empathetic approach is much more likely to be successful in management of the anxious child. Greet the child first and find out what name they like to be called by. Engage with the child by asking who they have brought with them for the appointment (this also helps clarify relationships for the dentist who might otherwise assume that it is mum or dad who has brought the child) Maintain good eye contact with the child during communication. Provide clear, direct instructions and avoid open questions. Question for feeling during procedures: How does that feel? Does that feel ok? Give feedback about the child’s behaviour. ‘Oh I like you’re helping me by opening your mouth so wide today’. Physical contact can reinforce positive behaviour, such as placing a hand on a child’s shoulder or offering hand to hold after a particularly difficult procedure. Things to avoid Unsolicited reassurance such as “Don’t worry, this isn’t going to hurt” or “It’s just a small scratch”. This inadvertently passes on the message that this actually might hurt. Criticising, ridiculing or belittling a patient are highly ineffective. Non-dental chitchat with another person (dental nurse or parent). 23 Frankl’s Behaviour Rating Scale Frankl assessed the behaviour exhibited by each child during different phases of treatment, and recorded their level of cooperation on a rating system known as the Frankl scale (see table below). On each visit, the dentist documents the child’s cooperation, by recording their scores on the Frankl scale; this can aid clinicians in determining whether the child has made any improvements in acclimatisation to the dental setting and monitoring compliance with individual treatments. 1 Definitely negative, Refusal of treatment, Forceful crying or any evidence of extreme negativism -- 2 Negative. Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced, sullen withdrawn - 3 Positive. Acceptance of treatment, cautious behaviour at times, willingness to comply with dentist, at times with reservation, but patient + follows the dentist’s directions cooperatively 4 Definitely positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment. ++ Frankl Behaviour Rating Scale Behaviour Shaping Behaviour shaping has been described as: “developing appropriate behaviour by reinforcing successive approximations to the desired behaviour until the desired behaviour is achieved”. During this process the aim is to discourage behaviour that is not conducive to what we are trying to achieve. The process of behaviour-shaping usually involves a basic “tell, show, do” approach, but with desired behaviour being encouraged, or “reinforced” by strategies such as praise and approval, and with undesired behaviour being made less likely to occur, or “extinguished” by discouraging or ignoring it. The key psychological principle of this type of strategy is the phenomenon of “reinforcement”, which is where a pattern of behaviour is strengthened in such a way that it increases the probability of that behaviour being displayed again in the future. 24 Tell, Show, Do This popular technique can be highly successful in providing a simple strategy to overcome the fear of the unknown (Addleton 1959). This experience helps to shape the patient’s response to procedures through de-sensitisation, well- described action and visual tactile demonstrations. The first part is to ‘Tell’: explaining the procedure using simple vocabulary suited to the child's age; this is followed by ‘Show’: providing a demonstration. With the final stage “Do!”: here the procedure is performed. A simple example which can be used on any patient is the prophy brush. The aim is to teach the patient the importance of the dental procedure, and to familiarise the patient with this to facilitate acceptance of the treatment. TELL them what is about to happen SHOW them what is about to happen DO it! Positive Reinforcement This is the process of providing appropriate feedback to the patient, including use of facial expression, verbal expression and appropriate physical demonstrations of affection by members of the dental team which can aid treatment success. Descriptive phrases can emphasise a specific cooperation “Thank you for opening your mouth so wide” “You’re doing very well keeping still” rather than generalised praise such as “Well Done”, and can reinforce a desired behaviour. These reinforcement techniques are more effective than stickers and gifts. Enhancing Control A simple option to enhance control is to provide the child with a stop signal such as raising of the arm. This provides a degree of control through the period of treatment. It is essential to practice this with the child prior to treatment so the dentist can respond. It is important the dentist responds promptly when used. It is worth noting that some patients may use this as a distraction technique in an attempt to delay treatment. Ask Tell Ask It is important to build up a conversation with patients and develop a rapport to gauge how they might find each part of the treatment in order to help to address any challenges that may arise. A simple exercise is to ask the patient about the proposed treatment, tell them in simple language and ask how they feel about that and whether they would they be able to manage that treatment, then reassess at the end by asking anything else. This teaches the patients about the proposed procedure and how this will be achieved. It is important to establish whether the patient is comfortable with the proposed treatment prior to commencement to maintain clear communication. 25 Distraction Distraction is where the attention is drawn to a totally different sensation or action, in order to divert attention from a potentially stress-inducing procedure. Whilst it is important not to breach trust by deliberately trying to deceive a child, distraction of attention from one thing to another can be useful. For example, drawing attention to the sensations of lip pulling, etc. during local analgesic needle penetration. Giving the patient a short break during a stressful procedure can also be an effective use of distraction. Positive Pre-Visit Imagery For some children, a change to a routine can be extremely distressing; to support these patients visual aids can be provided such as positive photographs of dentistry and the clinic to provide children and parents with visual information about what to expect during the dental visit. Modelling Modelling follows the physiological principle that children learn about their environment by observing behaviours. A child would observe the behaviour exhibited by another patient (usually someone who is relatable e.g. sibling or friend of similar age). This theory maintains that by observing a behaviour the likelihood of that observed behaviour being adopted is increased. This strategy would familiarise the patient with the specific steps involved in the proposed dental treatment. Systematic Desensitisation The basic principle of this technique is to allow a patient to gradually come to terms with a particular fear or phobia by repeated contacts. A hierarchy of fear-producing stimuli is constructed and the patient is exposed to them in an ordered manner starting with the lowest threat. Dental Update 2015: provides a simple overview for the use of this technique on local anaesthetic. The technique is useful for a child who can clearly identify their fear and who can verbally communicate. In most cases simple dental-based acclimatisation should be initiated first. Parental Involvement Parental behaviour and attitudes towards dentistry have been shown to have key effect on a child’s behaviour and anxiety regarding dental treatment. It is important to provide specific information about the parental role during dental treatment. Parents that frequently interrupt the flow of communication during treatment can cause distraction and confusion and lead to disruptive behaviour. Parents’ attempts of non-dental chit-chat or instruction/encouragement to the child are often provided in an attempt to help, but can expose parents’ own underlying anxieties about dental treatment. Children are very perceptive to parental non-verbal and verbal anxieties. Frankl explains the importance of how a passively observing mother can aid a child, and provide support as the “silent helper”. Having parents in the surgery can help avoid any misunderstanding if a child becomes upset during dental 26 treatment, and helps parents to appreciate how well their child has tolerated treatment or to recognise the limitations of their compliance. Negative Reinforcement Techniques Parent in/Parent out Negative reinforcement is the reinforcement of a behaviour by removing something which is perceived as negative by the patient as soon as positive behaviour is exhibited. For example, if a parent has agreed to leave the surgery due to negative behaviour by the patient, allowing the parent to come back in as soon as the patient shows positive behaviour means that the negative (the parent being outside) is removed, thus reinforcing the positivebehaviour. Voice Control Voice control is the deliberate alteration of voice volume, tone and pace to influence a child’s behaviour. It has been shown that young paediatric patients respond to the tone of voice rather than the choice of vocabulary. It is useful for the cooperative but inattentive child; however is inappropriate for children who are too young to understand or who have either an emotional or intellectual impairment. This method of behaviour management is unlikely to be acceptable to most modern parents. The Difficult Exam In the very young, and pre cooperative child, the knee-to-knee exam is a successful technique to aid clinical assessment. Lap to Lap Dental Exam For some children there is limited compliance in mouth opening. Below is a Bedi Mouth Prop, which is used for the administration of medicine, but which can be a useful aid when held on the finger for a dental exam. These disposable items can be given to the parent to aid those who may need extra help with tooth brushing. 27  Bedi FingerProp Cleaning teeth with a brush to aid examination with plastic mirror Do’s and Don’ts Arrive at the clinic early – don’t be late! Be organised – check your treatment plan beforehand. Make sure you know why the patient is here and what is planned for today’s visit Get everything prepared – think the procedure through and make sure you have all necessary equipment and materials (avoid opening sterile instruments until patient hasarrived) Make a comprehensive treatment plan (“Dentists don’t usually plan to fail – but they may fail to plan”) 28  Communicate effectively with both children and their parents/accompanying adults. Focus on success/appropriate behaviour and reinforce Set clear, easily achievable goals for both the patient and yourself – try to make each visit a “success”. Always end the appointment by focusing on what has been achieved (rather than what hasn’t). Don’t make promises (or threats) you cannot keep Make good records to ensure progress is accurately monitored Do not use put downs/ridicule Further Reading Frankl,S.H.,Shiere,F.R.andFogels,H.R.(1962)Shouldtheparentremainwithin the dental operatory? J Dent Child 29: 150 – 163 Fayle, S. and Tahmassebi, J. (2003). Paediatric Dentistry in the New Millennium: 2. Behaviour Management – Helping Children to Accept Dentistry. Dental Update, 30(6), pp.294-298. Taylor, G. and Campbell, C. (2015). A clinical guide to needle desensitization for the paediatric patient. Dental Update, 42(4), pp.373-382. Addleston HK. Child patient training. Fortnightly Rev Chicago Dent Soc 1959; 38: 7–9, 27– 29. Fenlon WL, Dobbs AR, Curzon MEJ. Parental presence during treatment of the child patient: a study with British patients. Br Dent J 1993; 174: 23–28. Guideline on Behavior Guidance for the Pediatric Dental Patient http://www.aapd.org/media/policies_guidelines/g_behavguide.pdf 29 PREVENTION OF DENTAL CARIES Dental caries is a multi-factorial disease, resulting from the interplay between environmental, behavioural and genetic factors. The prevention of dental caries underpins all dental care provided to patients and every paediatric patient whom you treat on clinic will require some preventative input. This input will depend upon the child and their caries risk. A comprehensive prevention strategy tailored to the individual needs of the child is an essential aspect of paediatric treatment planning. All preventative measures need to be coordinated and supervised by the dental team and reinforced with good patient and parental motivation. There are five components involved in the prevention of dental caries. Each of which are evidence- based will be considered in this chapter. 1) Plaque control and regular tooth brushing with fluoridated toothpaste 2) Dietary advice 3) Increasing fluoride availability 4) Fissure sealants 5) Regular dental assessments with appropriate radiographs Plaque Control and Toothbrushing Regular tooth brushing with fluoride toothpaste will reduce both dental caries and periodontal diseases. To control caries it is the fluoride in the toothpaste which is the important element as fluoride will prevent, control and arrest caries. For periodontal diseases it is the mechanical removal of plaque which will reduce the inflammatory response of the periodontal tissues. The following principles of tooth brushing should be followed: Tooth brushing should begin as soon as the first primary tooth erupts. Tooth brushing should occur last thing at night and at one other occasion throughout the day. An adult should supervise brushing until at least the age of 7. This is due to the fact that a child’s manual dexterity until this time would not facilitate effective cleaning of all surfaces. Supervised brushing even after this age should be supported to ensure good oral hygiene practice. Toothpaste should be spat out following brushing as opposed to rinsing with water to ensure that intra-oral fluoride levels are present for a longer period of time. Mouthwashes (included those containing fluoride) should not be used immediately after brushing as this also will wash away the remaining toothpaste on the teeth reducing its preventive effect. The patient’s existing method of brushing may need to be modified to maximise plaque removal, emphasising 30  the need to systematically clean all tooth surfaces. Brushing is more effective with a toothbrush with a small head and medium textured bristles. There is evidence to show that powered brushes with rotating/ oscillating action can reduce plaque and gingivitis in the short and long term compared to manual toothbrushes. It should be stressed that it is the brush, manual or powered, should be used effectively twice daily which is more important. Concentration and Quantity of Toothpaste Children under 3 years should use a toothpaste containing no less than 1,000 parts per million (ppm) of fluoride. Children under 3 years should use no more than a smear of toothpaste (a thin film of paste covering less than three- quarters of the brush). Children aged 3-6 years should use a pea-sized amount of toothpaste Family fluoride toothpaste (1,350-1,500 parts per million fluoride) is indicated for children age 7 and above and for maximum caries control for all children. Advice must be given about adult supervision and the small amounts to be used. For some high-risk patients toothpaste with a higher concentration of fluoride may be prescribed Smear of toothpaste for children under 3 Pea- sized amount of toothpaste should be used for children 3-6 years 31 Facilitating toothbrushing A number of plaque disclosing tablets and solutions are available. Children need appropriate supervision when using these agents and proper advice should be given to parents. Disclosing of plaque can be completed in the clinic or at home. Disclosing aims to show patients the plaque present on the teeth in a visual way to aid tooth brushing. Plaque charts can be used to monitor progress and identify areas where brushing is being missed. The percentage number of clean surfaces should be recorded so that patients can achieve as close to 100% as possible. The disclosing agent should firstly be used in clinic to demonstrate it to the child and the parent. Petroleum jelly should be applied to the lips prior to use to prevent staining. The child should try to remove all stained plaque and you should discuss brushing technique. The agent can also be used at home; in the first week it is advisable to instruct the patient to use the disclosing agent prior to brushing. After one week the patient should then brush first and then disclose in order to identify areas being missed. Timers can also be used to help the patient brush for the appropriate time. Materials required for disclosing Disclosing tablet used to aid tooth brushing 32 Dietary Advice Healthy eating advice should be given to all patients to promote both good oral and general health. The key messages which should be given to patients are summarised below: The amount and most importantly the frequency of food / drink containing free sugar and fermentable carbohydrates should be reduced. The number of times that food or drink containing sugars in one day should not exceed four. By confining food and drinks which contain sugars to mealtimes will reduce the number of acid attacks on the teeth. Only milk and water should be consumed in between meals. Drinks containing sugars such as sweetened milk, fruit juices and fizzy drinks increase the risk of caries. Ensure that parents are informed about hidden sugars in foods. Many foods such as crisps, yoghurts and cereals contain added sugar which patients and parents may be unawareof. Safer snacks should be encouraged such as carrot sticks and nuts. Following tooth brushing at night nothing else should be eaten or drank except for plain water. There should be no intake of foods or drinks containing sugars within 1 hour of bedtime as the salivary flow, and thus its protective effects are reduced. At 6 months children should be introduced to drinking from a free-flow cup and from 12 months drinking from a bottle should be discouraged. Public Health England (2015) advise that the recommended intake of free sugars is no more than: o 19g per day = 5 sugar cubes for 4-6 year olds o 24g per day = 6 sugar cubes for 6-10 year olds o 30g per day = 7 sugar cubes for 11 and over The importance of the frequency of sugar intake can be illustrated in the Stephan’s curve. Sugar intake causes a fall in pH level as oral bacteria convert sugar to acid causing demineralisation of tooth surfaces, the buffering action of saliva is also reduced. When sugar intakes are spaced out over hours the teeth can remineralise, which is more effective in the presence of fluoride. However when there are frequent sugar intakes demineralisation occurs more often and there is there is more limited time for the pH to rise to allow remineralisation. 33 Stephan curve demonstrating the fluctuation of pH levels following sugar intakes. Taken from Delivering Better Oral Health – An evidence based toolkit for prevention. All children should receive the basic dietary advice at their recall appointments and a discussion about how a healthy diet can reduce caries levels should take place. When giving dietary advice it is essential to use a positive approach. You should also focus on how the reduction of sugars will have wider health benefits and should give advice which is achievable. For children at a high risk of caries a more thorough analysis should take place and more support is required. The diet can be reviewed in the form of a 3- day diet diary. The diet diary is given to the patients, parents/ carers and all food and drinks should be recorded over a 3 day period. One day should be a weekend as the child’s diet may differ at this time. The diet diary should be reviewed and advice should be practical and personal for the patient and the support given should be constructive. Alternatively, a recall diet diary can be completed in surgery when the patient/ parents/carer recalls the food and drink that the child has consumed over a 24 hour period. Public Health England developed an Eatwell plate to give recommendations about a balanced diet for general health. The key messages of the Eatwell plate are: o Eat at least 5 portions of fruit and vegetables per day. o Base meals on starchy carbohydrates and choose wholegrain options. o Ensure that there is some dairy in the diet and choose low sugar and fat options. o Eat sources of protein such as meat, beans and fish, the diet should include 2 portions of fish per week with 1 portion being oily fish. Processed meats should belimited. o Choose unsaturated oils and spreads, cutting down on saturated fats. o Drink at least 1.2 litres of water per day. o Limit salt and sugar intake. Ideally, no more than 5% of the energy we consume should come from free 34  sugars. The Eatwell guide developed by Public Health England Increasing Fluoride Availability There is abundant evidence that increasing fluoride availability is effective at reducing caries level on an individual and population basis. It is the topical action of fluoride which is essential for caries prevention and it is most effective if it is available at multiple times throughout theday. The mechanisms of action of fluoride are summarised below: 1) It has an effect during tooth formation making the enamel crystals larger and more stable. 2) It inhibits plaque bacteria by blocking enzyme enolase during glycolysis. 3) It inhibits demineralisation when in solution. 4) It enhances remineralisation by forming fluorapatite when in solution. 5) It affects the crown morphology making the pits and fissures shallower and hence less likely to create stagnation areas. Fluoride is widespread in nature and can be found in fish, vegetables, tea and some natural water supplies. In addition there are a great number of fluoride products which are available for systemic and topical use to be used by the patient or delivered by a dental professional. 35 Water Fluoridation Water fluoridation is the systemic method of providing fluoride on a community basis. Currently in the UK only approximately 10% of the population benefit from a water supply which is either naturally or artificially at the optimum fluoride level for dental health. There have been multiple studies carried out across the world showing that water fluoridation decreases caries. Water fluoridation is a cheap and cost effective method and can be considered as an effective method to reduce social inequalities in caries level. The York review (McDonagh et al 2000) remains one of the most comprehensive reviews of the topic. This concluded that fluoridation of drinking water supplies reduces caries prevalence but is associated with dental fluorosis. Water fluoridation is often discussed in the media with some groups claiming that it can cause health problems. In the York review the balance of the evidence did not show an association between any bone fractures or human cancer and water fluoridation. In addition, in 2014 Public health England published a report provides further reassurance that water fluoridation is a safe and effective public health measure. Toothpastes Fluoride containing toothpastes were first introduced in the early 1970’s and since then there has been a dramatic decrease in worldwide caries levels. There are many different brands of toothpastes available to suit all patients. Strong evidence shows that toothpastes containing higher concentrations of fluoride are more effective at controlling caries whereas fluoride toothpastes (containing less than 1,000ppmF) are ineffective at controlling caries. There should be a balanced consideration between the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. A research study has shown that the risk of fluorosis from ingesting too much fluoride is linked much more to the amount of toothpaste that is used, than the concentration. Careful brushing by parents/ carers when using toothpastes containing higher levels of fluoride is required. For patients aged 10 and above, at a high caries risk, with caries present, orthodontic appliances, a highly cariogenic diet or medication, 2,800ppmF toothpaste can be prescribed. For patients aged 16 and over who are at high caries risk 5,000ppmF toothpaste can be prescribed. 36 Fluoride Mouthrinses Fluoride mouthrinses can be prescribed for patients 8 years and above who are at a high risk of dental caries. It should be used daily in addition to tooth brushing. Rinsing should occur at a different time to brushing to maximise the topical effect. The effect of tooth brushing and rinsing has been shown to be additive. All orthodontic patients should be using fluoride rinses to minimise the risk of demineralisation. Children under the age of 8 should not be recommended to use fluoride mouth rinses because of the increased risk of swallowing thesolution. Fluoride Varnishes Fluoride varnish is one of the best options for increasing the availability of levels of fluoride. There is high quality evidence of the preventive effectiveness of fluoride varnish in both the primary and permanent dentitions. The evidence supports that the varnish can also arrest existing lesions. Fluoride varnish has a number of practical advantages, it is well accepted and considered to be safe. The application is simple and trained dental nurses can also place the varnish on prescription. To apply the varnish gross plaque should first be removed, teeth should be dried with cotton wool rolls or a triple syringe. The varnish should be carefully applied with a microbrush to pits, fissures and approximal surfaces of teeth. The patient should then avoid food and drinks for 30 minutes and only soft foods should be eaten up to 4 hours after the application. Duraphat 5wt% fluoride 22,600ppm fluoride) is the most widely available fluoride varnish. There is a very small risk of allergy to one component of Duraphat (colophony), so for children who have a history of allergic episodes requiring hospital admission, including asthma, varnish application may be contraindicated. Fluoride Supplements Fluoride tablets and drops usually require good compliance from families and often have resulted in under and over - use. The fluoride supplement dose depends upon the age of the patient and also the level of fluoride in the drinking water. There is a risk of fluorosis if children under the age of 6 take more than the advised dose. Therefore the 37 Delivering better oral health guidance states that other sources of fluoride may be preferable and should be considered first. Brushing with a toothpaste containing at least 1,000ppmF or higher is the priority step for prevention of dental caries. In addition a systematic review of fluoride tablets, drops, lozenges and chewing gums concluded that the evidence of the effect of these additional sources of fluoride ‘was unclear on deciduous teeth’. Fissure Sealants Pit and fissure sealants are materials applied to the tooth to obliterate the fissures and remove the sheltered environment where caries may develop. Fissure sealants are an effective measure in preventing caries and a Cochrane review concluded that sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant (Ahovuo- Saloranta et al 2013). Several sealant materials are available, these can usually be grouped into resin materials and glass ionomer sealants. The application of glass ionomer sealants is less technique sensitive than for resins but they have poorer retention. Glass ionomer sealants may be indicated if the patient is pre cooperative, the tooth is partially erupted and the caries risk is very high or there are some concerns over the ability to get good moisture control. During the placement of fissure sealants isolation is critical to the success. The operator and nurse must work together to ensure appropriate isolation using cotton wool rolls and suction. Some parties recommend the use of rubber dam due to the superior isolation, however this is often not practical due to the stage of eruption of the tooth or the level of cooperation. It would not be appropriate to delay the placement of the sealant to allow further eruption to place the dam. In addition the placement of fissure sealants is often used as a non-invasive technique to acclimatise the patient. For the placement of rubber dam and clamps local anaesthetic would be required and thus this is not justified if only placing sealants. Placement under rubber dam would be appropriate if isolating the quadrant when placing restorations. The placement of the fissure sealant should be into all pits and grooves of the tooth, not forgetting the buccal pits of lower teeth and the palatal surfaces of upper teeth. Fissure sealants should be checked visually for wear and physically with a probe for integrity/ leakage at every recall visit. In terms of patient selection, fissure sealants should be placed in the permanent teeth of patients with a high caries risk, this includes patients with special needs and patients who are medically compromised. The BSPD document for fissure sealants (2000) gives the following advice in regards to patient and tooth selection: Children and young people with caries in their primary teeth (dmfs=2 or more) should have all susceptible sites on permanent teeth sealed Children with caries free primary dentition do not need permanent molars sealed routinely in absence of risk factors. 38  Place fissure sealants as soon as teeth have erupted sufficiently for good moisture control. Where there is caries in one permanent molar, seal all other permanent molars. Fissure sealants can also be used in some cases for the management of carious pits and fissures in permanent teeth. For fissure caries conventional restorations should be placed when thereis: Microcavitation Shadowing visible under the enamel adjacent to the fissure after cleaning and drying the tooth. Dentinal caries clearly visible on a bitewing radiograph. Otherwise place a fissure sealant alone, and review the tooth at every recall visit. Technique for placement of fissure sealants (see clinical photos) 1) Clean the tooth if obvious debris is present. 2) Isolate the tooth surface with cotton wool rolls, use high volume suction and a dry guard may be beneficial. 3) Apply etch 37% phosphoric acid for 20-30 seconds 4) Wash and dry the surface, maintaining isolation, dry the tooth until there is a frosty appearance. 5) Apply bond using a microbrush, lightly dry with the triple syringe and light cure. 6) Apply resin to the pits and fissures using a spoon excavator. 7) Light cure the resin. 8) Check for adequacy with a probe, if the sealant comes away with the probe it will need to be replaced. The use of bonding agent between etching and the resin sealant is now supported in the literature. It has been shown that adding a bonding layer may improve the retention of fissure sealants, especially when contaminated with saliva. In most studies the bond and resin are applied in one layer to reduce treatment time, however it is recommended that if moisture control allows it that the separate layers are cured separately. 39  1. Isolate the tooth 2. 37% phosphoric acid should be used 3. Etch the tooth for 20-30 seconds 4. Wash and dry the tooth until it has a frosty appearance 5. Apply the bond in a Dappens pot 6. Apply bond to the tooth using a microbrush 7. Air dry the bond 8. Light cure the bond for 10-20 seconds 40 9. Apply resin cured sealant to a Dappens pot 10. Apply sealant to all pits and fissures of the tooth 11. Light cure the sealant (following 12. Check the sealant with a probe manufacturer’s instructions) 13. Final sealant 41 Key Evidence The following evidence is from Cochrane systematic reviews which can be read in full in the Cochrane library, a summary of each review is provided below and their references can be found in the recommended reading section: 1. Marinho et al 2003 - Fluoride toothpastes for preventing dental caries in children and adolescents. Fluoride toothpastes prevent dental caries by 24%. The effect of fluoride toothpaste increased with, higher baseline levels of decayed, missing or filled surfaces (D(M)FS), higher fluoride concentration, higher frequency of use and supervised brushing. 2. Walsh et al 2010 - Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. This review confirms the benefits of using fluoride toothpaste in preventing caries in children and adolescents when compared to placebo, but only significantly for fluoride concentrations of 1000 ppm and above. The higher the concentration of fluoride the more preventive effect shown. The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis. 3. Marinho et al 2013 - Fluoride varnishes for preventing dental caries in children and adolescents Fluoride varnish is successful in reducing caries. In permanent teeth a 43% reduction in D(M)FS was found. In primary teeth there was a 37% reduction in d(m)fs. 4. Marinho et al 2016 (update from original review 2003) - Fluoride mouthrinses for preventing dental caries in children and adolescents Fluoride mouthrinses showed a 27% reduction in D(M)FS in permanent teeth with fluoride mouthrinse compared with placebo or no mouthrinse. 42  5. Marinho et al 2004 - Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents Topical fluorides (mouthrinses, gels, or varnishes) used in addition to fluoride toothpaste achieved a 10% reduction in D(M)FS compared to toothpaste used alone. 6. Kashbour et al 2020 – Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Fluoride varnish or resin-based fissure sealants help prevent occlusal caries in first permanent molars, however, neither appear to be superior to one another. Recommended Reading – Key references in purple Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington H. Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews. 2017;. Bentley E, Ellwood R, Davies R. Fluoride ingestion from toothpaste by young children. British Dental Journal. 1999;186(9):460-462. British Dental Association. A Policy document on fissure sealants in paediatric dentistry. BSPD;2000. Dental checks: intervals between oral health reviews. London: NICE; 2004. Department of Health. Delivering Better Oral Health: An Evidence based toolkit for prevention. Updated 2021. Kashbour W, Puneet G, Worthington HV, Rogers D. Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews, 2020. Marinho V, Worthington H, Walsh T, Clarkson J. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. 2013;. Marinho V, Chong L, Worthington H, Walsh T. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. 2016;. Marinho V, Higgins J, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews.2004;. 43  Mc Cafferty J, O Connell A. A randomised Controlled Clinical Trial on The use of Intermediate Bonding on the retention of Fissure Sealants in Children. International Journal of Paediatric Dentistry 2016; 26: 110–115. Prevention and Management of Dental Caries in Children Dental Clinical Guidance. Dundee: SDCEP;2010. Public Health England. Water fluoridation: health monitoring report for England. London: Public Health England; 2014. Public Health England. The Eatwell Guide. 2016. Public Health England. Selection Criteria for Dental Radiography. 3rd ed. 2013. Welbury, R., Duggal, M. and Hosey, M. (2018). Paediatric Dentistry. 5th ed. Oxford: Oxford University Press. Tubert-Jeannin S, Auclair C, Amsallem E, Tramini P, Gerbaud L, Ruffieux C et al. Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children. Cochrane Database of Systematic Reviews. 2011;. Walsh T, Worthington H, Glenny A, Appelbe P, Marinho V, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. 2010; Wong M, Glenny A, Tsang B, Lo E, Worthington H, Marinho V. Cochrane review: Topical fluoride as a cause of dental fluorosis in children. Evidence-Based Child Health: A Cochrane Review Journal. 2011;6(2):388-439. Yaacob M, Worthington H, Deacon S, Deery C, Walmsley A, Robinson P et al. Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews. 2014; 44 LOCAL ANALGESIA Local Analgesia (LA) should be routinely used in all age groups. Age of the patient should not be a contraindication for its use, even for mandibular blocks. Explanation The full procedure should be explained in simple terms to the child using terms such as ‘putting the tooth to sleep’. An agreed signal whereby the child can indicate when they feel discomfort can help to enhance control. Signals such as putting their hand up can be used. Topical/surface analgesia Topical Analgesia should always be used. One of the most commonly used topical is 20% benzocaine and this is the topical of choice in the Paediatric Dental department. Other agents such Xylonor (5% lidocaine) are also available. Apply in small quantity on cotton roll or cotton bed. Ensure that area of application is dry. Apply for at least 3 minutes for best effect. 20% Benzoaine Xylonor 45  Application of topical anaesthetic Commonly used LA Lignocaine 2% with 1:80000 epinephrine Prilocaine 2% with felypressin 0.54μg/ml Articaine 4% with 1:100 000 epinephrine Lignocaine 2% with epinephrine remains the most commonly used anaesthetic solution in dentistry. However, in the last few years the use of articaine has increased. There is some limited evidence that the use of infiltration with 4% articaine with 1:100000 epinephrine gives profound analgesia. Articaine should not be used for Inferior Dental Blocks (IDB) as it may be neurotoxic. Maximum dosages of local anaesthetic Solutions Max Dose Max dose by age (mls) 1 year 3 years 5 years (10kg) (15Kg) (20kg) 2% Lignocaine/1:80000 4.4mg/Kg 2.2 3.3 4.4 adrenaline (20mg/ml lignocaine) 3% prilocaine/felypressin 6.6mg/kg 2.2 3.3 4.4 (30mg/ml prilocaine) 4% Articaine/1:100000 7mg/kg 1.75 2.63 3.5 adrenaline (40mg/ml) 46 Technique Infiltration is frequently used for procedures in the maxillary arch and for soft tissue surgery. In order to secure palatal analgesia for placement of rubber dam clamps or for extractions, an indirect palatal injection can be given. This technique is administered through the buccal papilla after administering buccal infiltration. The needle is advanced through to the palatal mucosa where solution is deposited slowly. The palatal mucosa will appear to blanch when local analgesia is deposited. This can produce sufficient analgesia for clamp placement however, an additional direct infiltration maybe required for extractions. Indirect palatal infiltration “The Wand” Anaesthetic System The Wand is a computerised LA system that is able to deliver local anaesthetic solution slowly, at a fixed speed. The system is made up of a microprocessor control until, disposable hand piece and foot control (activation switch). The Wand delivers LA at a slow fixed rate which is thought to provide ‘pain free local analgesia’. This technique can be useful in providing LA in children who are anxious or ‘needle phobic’. The Wand 47 CARIES MANAGEMENT Although levels of dental decay have fallen significantly since the introduction of fluoride toothpaste in the 1970s, there remains a large population of children who suffer from an extensively decayed primary dentition. The Public Health England survey of oral health of 5-year-old children is completed every 2 years. It was last completed in 2022 and found the prevalence of dentine caries in England to be 23.7%, similar to the results found in the 2019 survey. The prevalence of dentine caries in 5-year-olds in the North West was the highest in England, at 30.6%. Children from areas with a higher rate of socioeconomic depravation are also more likely to have a greater number of teeth with dental decay and a lower incidence of restorable teeth. 40% of children with dental decay experience toothache and infection. PHE report 2022 – note that the average dmft in 5-year-olds in the North West is the highest nationally Risk Factors Caries risk can be dependent of many factors, these include: Previous caries experience and high levels of mutans streptococci Dietary habits including the frequency of sugary food and drink consumption, demand feeding and the prolonged use of a bottle Social factors such as socioeconomic status Fluoride use and plaque control Medical history including developmental delays, physical disabilities and utilisation of medications high in sugar Reduced salivary flow as a result of medical conditions or drug therapy Diagnosis Caries diagnosis should be evidence based and structured, including disease staging. Aids to caries diagnosis include: Radiographs taken as per FGDP guidelines. 48  Bitewing radiographs, even in very young children can aid the diagnosis of interproximal and occlusal caries. It is recommended that high caries risk children have six-monthly bitewings taken until no new or active lesions are apparent and the child has entered another caries risk level. Bitewings should be taken annually in children with a moderate caries risk and every 12-18 months for those with a low caries risk. Occlusal radiography can also aid diagnosis of anterior caries. Fibre-optic transillumination can be used as an adjunct to radiographs and can detect dentinal caries on approximal surfaces. Temporary tooth separation with orthodontic separators can be used as a method to directly assess caries on approximal surfaces of the teeth. Electric caries monitor. Laser Fluorescence. Magnification. Treatment Planning Caries in the Primary Dentition The management of caries in the primary dentition is markedly different from the permanent dentition. This is due to reduced autonomy of children and the limited lifespan of the primary dentition, which provides an opportunity for a slightly different approach. Following clinical and radiographic diagnosis of caries, it is important to consider the following factors when considering your treatment plan: ▪ Age and cooperation of the patient ▪ Motivation of patient and parents ▪ Extent of decay and the surfaces affected ▪ Pulpal symptoms There are a number of treatment approaches when it comes to managing caries in the primary dentition. These approaches are summarised below: Treatment Approaches Preventative Biological Surgical 49 These approaches can be used to treat all of the carious teeth in the child’s mouth, or different approaches can be used for individual teeth. In general, conventional surgical approaches (caries removal and the placement of a direct restoration) can be more difficult for children to accept over preventative or biological techniques. Preventative Approach Preventative measures are dependent on a patients age and caries risk. Preventative guidance can be taken from the Delivering Better Oral Health Toolkit (Public Health England) or the Prevention and Management of Dental Caries in Children Guidance (SDCEP). Recall NICE guidelines for dental checks: intervals between oral health reviews (2004) are used as an aid for clinicians to assign recall intervals between oral health reviews that are appropriate to the needs of individual patients. The guidelines specify that the shortest interval between oral health assessments should be 3 months. The longest recall interval for patients under the age of 18 should be 12 months. There is evidence that the rate of progression of dental caries can be more rapid in children and adolescents than in older people, and it seems to be faster in primary teeth than in permanent teeth. Recall intervals of no longer than 12 months give the opportunity for delivering and reinforcing preventive advice and for raising awareness of the importance of good oral health. This is particularly important in young children, to lay the foundations for life-long dental health. Diet Independent of caries risk, all patients should receive dietary advice at their recall visits. However, those with a higher caries risk will likely need further encouragement and support in order to promote behaviour change in their dietary habits. Dietary advice should focus on the amount and frequency of intake of foods and drinks containing free sugars and fermentable carbohydrates. Children with a high risk of caries may require further support with their dietary advice, in the form of a 3-day diet diary. This should be completed over 2 weekdays and 1 weekend day. Advice should also be given related to the Eatwell plate, developed by Public Health England, aiming to give recommendations related to eating a healthy, balanced diet. Fluoride Increasing awareness and exposure to fluoride is recommended for patients with high caries risk. There are many sources of fluoride, both natural (fish, tea, naturally fluoridated water supplied) and artificial (toothpaste, gel, varnish, mouthrinse, supplements, artificially fluoridated water and milk). Toothpaste Evidence strongly supports the benefits of using fluoridated toothpaste to prevent dental caries. The Delivering Better Oral Health Toolkit recommends the following: Children aged up to 3 should be using a smear of toothpaste containing at least 1000ppm fluoride 50  Children aged 3 to 6 years should be using a pea sized amount of toothpaste containing at least 1000ppm fluoride Children aged up to 6 years giving concern because of caries risk should be using a pea sized amount of toothpaste containing 1350ppm to 1500ppm fluoride Children from 7 years should be using a pea sized amount of toothpaste containing 1350ppm to 1500ppm fluoride Children aged 10 and above with active dental caries can be prescribed 2800ppm fluoride toothpaste until their caries risk is reduced Children aged 16 and above with active dental caries can be prescribed either 2800ppm or 5000ppm fluoride toothpaste until their caries risk is reduced Mouthwash Children aged 8 and above giving concern due to caries risk can be prescribed a sodium fluoride mouthrinse (0.05%, 230ppm fluoride, used daily at a different time to brushing). Randomised controlled trials have found the use of fluoride mouthrinses to greatly reduce the incidence of caries in permanent teeth, with no adverse effects Careful patient selection must be undertaken when prescribing a fluoride mouthrinse. Use should be avoided in patients with learning difficulties or those unable to rinse. Varnish Fluoride varnish (2.25%, 23000ppm fluoride) can be used as a preventative tool or to arrest early carious lesions. Utilisation of fluoride varnish as per the delivering better oral health toolkit can provide a 37% reduction in caries incidence in the primary dentition. Water Water fluoridation is a cost effective, caries preventative measure known to reduce the social inequalities of healthcare. There are many arguments for and against water fluoridation. The York report 2000 evaluated the safety of water fluoridation, finding that fluoride levels of 1ppm are safe and resulted in a 15% reduction of caries experience. However, those against fluoridation of water supplies compare it to mass medication, taking away their freedom of choice. In the UK approximately 10% of water is fluoridated. There is a strong evidence base for water fluoridation however it must be used in appropriate therapeutic ranges to avoid toxicity. Adverse effects of fluoride include fluorosis (caused by high systemic uptake at a young age), gastrointestinal upsets or in extreme scenarios, death. Fluoride toxicity Is most commonly caused by children ingesting too much toothpaste, and is mainly seen in children under the age of 6. The known toxicity level of fluoride in adults and children is 5mg per kg, with a lethal dose of 16mg/kg in children. Fissure sealants 51 Though there is evidence that fissure sealants are an effective caries preventative tool in permanent teeth, there is insufficient, low-quality evidence to support their use for the prevention of caries in primary teeth. Contraindications to a preventive approach: - Pain, pulp necrosis or sepsis - Medical history or disability that would be exacerbated if pain, pulp necrosis, or infection develop Biological Approach This approach involves incomplete caries removal along with sealing of carious lesions to prevent progression. Obvious benefits to this approach, include the reduced likelihood of pulpal exposure, conservation of tooth tissue and maximum pulpal floor dentinal thickness. A recent Cochrane systematic review found that for symptomless, vital teeth, biological approaches had clinical advantages over complete caries removal. There was no difference in restoration longevity or presence of pulpal pathology, however there were significantly fewer pulpal exposures. Ricketts, D., Lamont, T., Innes, N.P., Kidd, E. and Clarkson, J.E. (2013) Operative caries management in adults and children. Cochrane Database Syst Rev: CD003808. Biological caries management techniques include: Stainless steel crowns using the Hall technique Indirect pulp capping SDF application Parents must be fully informed of all other available treatment options, before deciding on this treatment modality. Indications Contraindications - No pain, pulp necrosis, - Pain, pulp necrosis, pathology or sepsis pathology or sepsis - Surgical caries removal not - Pre-cooperative child, possible (due to unable to tolerate any cooperation, extent of radiographs or treatment 52  treatment or pathology) - Caries extending into pulp - Bitewing radiographs can - Medical history or be taken disability that would be - Clear band of dentine exacerbated if pain, pulp visible between caries and necrosis, or infection pulp develop - No medical history or disability that would be exacerbated if pain, pulp necrosis, or infection develop Indications and contraindications of a biological treatment approach. Silver Diamine Fluoride Silver Diamine Fluoride (SDF) is a topical solution used in the desensitisation of non-carious lesions, molar incisor hypomineralisation and to prevent and arrest caries. Though currently only licensed as a desensitising agent in the UK, SDF is often used to arrest lesions in high caries risk children who are unable to tolerate invasive treatment. Use of SDF can help avoid restorations or extractions in those who may find them challenging, thereby maintaining space in primary or mixed dentitions. It can also be useful for acclimatisation and caries management in pre- cooperative children. Riva Star is a frequently used brand of SDF Silver Diamine Fluoride is composed of sliver, fluoride and ammonium ions. It is available in three concentrations: 53  12% SDF (14,200ppm F) 30% SDF (35,400ppm F) 38% SDF (44,800ppm F and 254,000 ppm silver) Combined with the antibacterial properties of silver, the solution has shown to be the most cariostatic of all topical fluoride containing agents. Ammonia acts as a stabilising agent for the solution. Mode of Action When SDF is applied to the tooth a chemical reaction takes place. This results in: Blockage of the dentinal tubules which prevents sensitivity. Bacterial action on cariogenic bacteria e.g. streptococcus mutans. Remineralisation of tooth structure. Inhibition of demineralisation of enamel and dentine. Collagenase inhibition resulting in reduction of dentine collagen matrix destruction. This reaction will permanently stain carious lesions black, however the colour of the surrounding sound tooth structure will remain unchanged. Potassium iodide can be applied to the tooth following SDF application which may reduce long-term staining. Off License Use A medicine can be used off-label in clinical situations that are in the patient’s best interests. In the UK SDF can be prescribed ‘off-label’ if there is a body of evidence supporting its use. There must also be no alternative licenced medicine available. Technique for SDF Application 1. Remove soft, necrotic, infected dentine from cavity if possible. 2. Apply petroleum jelly to lips and/or gingivae surrounding the lesion to reduce the risk of staining. 3. Isolate the area with cotton rolls or rubber dam. 54  4. Dry the lesion with a 3 in 1 or cotton roll. 5. Apply SDF with a micro-brush onto the lesion directly. 6. Allow the SDF to be absorbed for 1-3 minutes 7. Blot away excess solution with cotton wool or gauze. 8. If potassium iodide is to be used it should be applied to the tooth until the initial white precipitate turns colourless before being washed and air dried. The patient should be followed up 2-4 weeks following initial application to monitor the lesion. SDF should be re- applied twice yearly to improve the arrest rate of the lesion. A systematic review in 2016 concluded that SDF at a high concentration (38%, 44,800ppm fluoride) could arrest caries in 81% of active lesions in primary teeth over 30 months. 55 Gao, S.S., Zhao, I.S., Hiraishi, N., Duangthip, D., Lei, M.L., Lo, E.C.M and Chu, C.H. (2016). Clinical trials of silver diamine fluoride in arresting caries among children. A systematic review. JDR Clin Trans Res, 1(3), pp. 201–10. A more recent systematic review in 2018 concluded that “when applied to carious lesions in primary teeth SDF, compared to no treatment, placebo or fluoride varnish appears to effectively prevent caries in the entire dentition.” Oliveira, B.H., Rajendra, A., Veitz-Keenan, A., and Niederman, R. (2018). The Effect of Silver Diamine Fluoride in Preventing Caries in the Primary Dentition: A Systematic Review and Meta-Analysis. Caries Res, 53(1), pp. 24-32. Adverse Side Effects SDF has a high pH (10-13), therefore careful isolation with cotton rolls is necessary during application to avoid chemical burns of surrounding soft tissues. It will also stain surrounding soft tissues or items of clothing. Use of SDF as a cariostatic agent is not always successful and relies on cleansability of lesions. It can be difficult to monitor its success and may not work rapidly enough to prevent lesions progressing, resulting in pulpal involvement, pain and/ or infection. Indications/Contraindications for SDF Indications Contraindications - Asymptomatic cavitated carious - Clinical or radiographic signs of lesions extending into dentine in infection. primary teeth. - Teeth causing pain. - Lesions that can be made - Ongoing active carious lesions cleansable. which are not arresting. - Non-restorable caries extending - Restorations in the aesthetic zone into dentine. - Those who are unlikely to or cannot - Several carious lesions which maintain good oral hygiene. cannot be restored in one visit. - Those with ulceration, - Non-carious cervical lesions causing desquamative gingivitis, mucositis sensitivity. or stomatitis. - Molar incisor hypomineralisation to - Those with allergy to silver, reduce sensitivity. fluoride, ammonia or potassium - Caries detection agent (carious iodide. lesions will be stained black 56  whereas sound teeth will remain unchanged). - Pre-cooperative children. - Children/ adults with behavioural/ medical conditions which limit their ability to undergo invasive dental treatment. - As a temporary measure when there is a delay for treatment to be undertaken under sedation or general anaesthetic. Indications and contraindications of SDF SMART Technique SMART stands for Silver Modified Atraumatic Restorative Technique. This is a relatively new technique and involves the carious lesion first being treated with SDF and then being restored with a glass-ionomer restoration. The benefits of using GIC in addition to the SDF include: Sealing the SDF in place Fluoride release Improved aesthetics – to cover over the dark staining of SDF This technique may be particularly useful for a patient cohort who have trouble attending multiple appointments and lack regular access to care. The Hall Technique Stainless steel crown (also known as preformed metal crowns) are the gold standard restoration for primary molar teeth and are simple to place. They come in a range of sizes from 2-7 with 2 being the smallest size and 7 the largest. 57 The Hall technique is a technique whereby decay is sealed under preformed metal crowns without local analgesia, tooth preparation of any caries removal. Clinical trials have shown the Hall technique to be effective and acceptable to most children and parents. Indications for a SSC using the Hall technique: - Proximal carious lesions in primary molars - Class I lesions in primary molars if patient unable to accept conventional restoration Contraindications for a SSC using the Hall technique: - Signs or symptoms of irreversible pulpitis or sepsis - Clinical or radiographic signs of pulpal involvement or pathology - Unrestorable crown of tooth - Child at risk of bacterial endocarditis Technique for the placement of a SSC using the Hall technique: 1. Placement of orthodontic separators - If there is insufficient space for the seating of a crown, orthodontic separators may be placed a week before the fitting of the SSC. 2. Placing the crown – the patient is not supine as there is a risk of aspiration of the crown. Seat the child in an upright position and place some gauze lingual to the tooth being restored to protect the airway. 3. Gauze placed lingual to LRD to protect airway 4. Choosing the size - the size selected will usually be bigger than with conventional crowns as you will not be preparing the tooth. Choose a crown and try it on the tooth – it should feel as if it would seat between the contact points. Do not seat the crown fully as it will be difficult to take off for cementation 58  5. When you have chosen the appropriate crown, cement it using a luting cement in the same manner as conventional SSC. Ask the patient to bite the crown on using a cotton roll. 6. Remove excess cement using cotton wool rolls and floss 7. Advise the patient that the bite will feel high for the the first week or so, advise regarding analgesia Indirect Pulp Capping This treatment option can be considered in cases where there is a deep carious lesion in a symptom-free, vital tooth. The advancing front of a carious lesion is low in cariogenic bacteria. Provided that the bulk of infected dentine is removed, a small amount of softened dentine can be left at the base of the cavity. 1. Caries cleaned from the margins of the cavity with slow-speed steel round bur 2. Gentle excavation above the pulp floor, removing as much of the softened dentine as possible 3. Thin layer of calcium hydroxide placed on the cavity floor 4. Definitive restoration placed. The coronal seal is the most important indicator of success, a stainless steel crown is therefore the gold standard. Regular clinical and radiographic reviews are necessary to monitor the pulp’s response. Surgical Approach (Conventional Restorative Options) 59 Conventional restorations may be completed in cases where preformed metal crowns are contraindicated or when parents/ children are against their use due to aesthetic challenges. Caries removal methods include the stepwise technique, partial caries removal and complete caries removal. Minimal cavity preparation and composite restorations are the preferred conventional option for the restoration of primary teeth. The remaining susceptible tooth surfaces should be fissure sealed at the same time. Where caries is more extensive, or involves more than two surfaces, stainless steel crowns are the preferred treatment modality. Often this will start with a relatively simple visit to introduce the child to the operative environment. The appointments are initially short, to place less stress on the child, and usually is planned quadrant by quadrant. Cavity preparation: Emphasis should be toward minimal preparation, removing only the affected toothsubstance. Quadrant dentistry: It should be the aim of every student to practice quadrant dentistry. This will enhance behaviour management by reducing treatment time and need for repeated localanalgesia. Equipment Burs - Small flat fissure bur for cavity prep in posterior teeth, flame shaped bur and pear-shaped bur for the preparation of conventional crown preparation in primary molars. Handpieces – paediatric handpieces preferred, air turbine to be used for preparation of cavities, slow speed with various sizes of round burs to remove caries Restorative Materials - Amalgam is not used in the Department of Paediatric Dentistry. Students are encouraged to use composite resin for the restoration of occlusal cavities and small interproximal cavities Rubber Dam Rubber dam is mandatory for all posterior restorations in the Department of Paediatric Dentistry, apart from the restoration of primary molars using the Hall technique. Dry dam is mandatory for all anterior restorations in the Department of Paediatric Dentistry. Indications Rubber dam is used to ensure moisture control for routine procedures such as fissure sealants, composites and endodontic treatment. Rubber dam is often described to children as ‘raincoat’. Contraindications Latex allergy has been a concern in the past but latex free rubber dam sheets are readily available now. Advantages Moisture-free operating field is ideal for the placement of moisture sensitive restorative materials such as composites 60  Improves access by retraction of soft tissues including tongue/buccal mucosa Improves patient comfort. Patients often feel more secure Improves efficiency of restoring multiple teeth (trough technique) Reducing the risk of aspiration Minimise mouth breathing (especially useful when inhalation sedation is used) Reducing cross-infection by minimising aerosol Rubber Dam Clamps LA is mandatory prior to the placement of a rubber dam clamp. It is important to choose a correctly-fitting clamp to achieve 4-point contact with the tooth. Otherwise, the clamp is at risk of “pinging” off mid treatment. In general, a FW clamp is the most appropriate clamp for a permanent molar tooth and a DW