Pediatric Dentistry PDF

57 Pediatric Dentistry L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms.. escribe what is involved in the diagnosis and treatment...

57 Pediatric Dentistry L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms.. escribe what is involved in the diagnosis and treatment 2. Discuss the appearance and setting of a pediatric dental planning of a pediatric patient. practice.. iscuss the importance of preventive dentistr in pediatrics. 3. Discuss the pediatric patient, which includes the following: 7. List the types of procedures that are performed for the he stages of childhood from birth through adolescence. pediatric patient compared with those performed to treat ehavior techni ues that work as positive reinforcement patients with permanent teeth. when treating children. 8. Discuss types of pediatric dental trauma and their treatments. 4. Explain why children and adults with special needs are treated. iscuss how to handle suspected child abuse and neglect. in a pediatric practice. Performance Outcomes On completion of this chapter, the student will be able to meet competency standards in the following skills: Assist in a pulpotom of a primar tooth. Assist in the placement of a stainless steel crown. KEY TERMS analogy (uh-NAL-uh-jee) comparison of similarities between intrusion (in-TROO-zhun) displacement of a tooth into its socket things that are otherwise not alike as a result of in ur athetosis (ATH-e-toe-sis) t pe of involuntar movement of the luxation (luk-SAY-shun) dislocation bod face and e tremities mental age measure of the level of intellectual capacit and autonomy (aw-TON-uh-mee) childhood process of becoming development of pediatric patients independent neural (NUR-uhl) referring to the brain nervous s stem and avulsed (uh-VULST) torn awa or dislodged b force nerve pathwa s cerebral palsy (suh-REE-brul PAWL-zee) neural disorder of motor open bay concept of open design used in pediatric dental function caused b brain damage practices chronologic (KRON-uh-loj-ik) age actual age (months, years) of papoose (pa-POOS) board t pe of protective stabili ation device pediatric patients that holds the pediatric patient’s hands, arms, and legs still contour (KON-toor) to shape or conform an ob ect pediatric (pee-dee-AT-rik) dentistry dental specialty concerned Down syndrome chromosomal defect that results in abnormal with neonatal through adolescent patients, as well as patients physical characteristics and mental impairment; also called with special needs in these age groups trisomy 21 postnatal (post-NAY-tul) after birth emotional age measure of the level of emotional maturit of prenatal before birth pediatric patients pulpotomy (pul-POT-uh-mee) removal of the coronal portion of a extrusion (ek-STROO-zhun) displacement of a tooth from its vital pulp from a tooth socket as a result of in ur spasticity (spas-TIS-i-tee) e aggerated movement of the arms Frankl (FRANG-kul) scale type of measurement designed to and legs evaluate patient behavior T-band t pe of matri band used for primar teeth intellectual disability disorder that limits a person in intellectual functions and adaptive behavior which includes social and practical skills 890  CHAPTER 57 Pediatric Dentistry 891 P ediatric dentistry is the specialized area of dentistry that The Pediatric Dental Assistant focuses on providing oral healthcare according to the needs of infants, children, adolescents, and individuals with special As a dental assistant in a pediatric setting, you must have the needs. Emphasis of the pediatric dental practice is placed on preven- compassion and patience to enjoy working with children, tion, early detection, diagnosis, and treatment. Although many of adolescents, and patients with special needs. Pediatric dentistry the procedures completed for children are like those for adult provides a clinical practice (“hands-on”) environment in which patients, pediatric patients require special adaptations and techniques you will have an active role in the patient’s dental care. Many in the way dental treatment is provided (Fig. 57.1). pediatric dental offices employ a certified dental assistant to perform preventive procedures that are legal to perform in that state, province, or territory. If coronal polishing, application of The Pediatric Dental Team and Office sealants, and taking of preliminary impressions are legal func- tions, these expanded functions would be completed in a pediatric The Pediatric Dentist setting. A pediatric dentist will continue his or her education for an additional 2 to 3 years after dental school in an accredited pediatric The Pediatric Dental Office program based in a dental school setting. The program of study and hands-on experience prepares the specialist to meet the needs The pediatric dental office must display a cheerful and pleasant of infants, children, adolescents, and persons with special needs. environment with a nonthreatening decor. Many offices will have a “theme” in the overall decor, such as a rainforest, outer space, or even a popular movie (Fig. 57.2). When entering a pediatric dental practice, you will notice that the treatment areas are not confining or structured. Many practices are designed with the open bay concept, in which several dental chairs are arranged in one large area. The advantage of this design is that it provides reassurance by allowing pediatric patients to see other children who are receiving care. This can be psychologically effective because children are often hesitant to express fear or to misbehave in the presence of other children. If an isolated area is required for patient care, most practices will use a “quiet room.” This room is separate from the open area and can be used for children whose behavior requires special attention or may upset other children. A variety of reading materials, such as magazines and edu- cational brochures, should be available for both the pediatric patient and the parent. Some offices install computer and video Fig. 57.1 Patient at a pediatric dental office. (Copyright iStock.com/ equipment with programs intended for patient education and XiXinXing.) entertainment. Fig. 57.2 Example of pleasing, patient-friendly reception area of a pediatric dental office. (Courtesy Patterson Dental, St Paul, MN.) 892 PART 10 Assisting in Comprehensive Dental Care Many pediatric offices are less “medical looking” about how the stress of an upcoming dental appointment and could temporarily dental personnel dress. It is common for scrubs to be worn in regress to a more immature level of behavior. bright coordinating colors or designs (Fig. 57.3). Name tags worn by the staff may even resemble a tooth, with the assistant’s name Erikson’s Stages of Development inscribed. Learning Basic Trust Chronologically, from birth to 12 months is the period of infancy. RECALL The child has all of the basic needs met and is well handled, 1. Would it be possible to see a 25-year-old patient in a pediatric office? nurtured, and loved, to develop trust and security. 2. What is unique about the treatment setting of a pediatric practice? 3. What types of patients are seen in a pediatric practice? Learning Autonomy From 1 to 2 years of age, the toddler learns to sit, stand, walk, and run. Vocally, they progress from babbling to using simple The Pediatric Patient sentences. Socially, they learn to identify familiar faces and alternate through periods of being friendly and being fearful of strangers. Children constitute an important and special portion of the dental Around the age of 2 years old, children begin to have basic population. As with adults, children have individual likes and fears associated with separation from the parent and a related fear dislikes, as well as fears and complex personalities. The pediatric of strangers. These “toddlers” are too young to be expected to patient is treated with the same respect of dignity and individuality understand and be cooperative with dental treatment. It is easier as is provided to an adult. The child must be understood in terms for the parent to be with the child during the initial examination. If of his or her chronologic, mental, and emotional ages: further treatment is required, the child may require premedication. Chronologic age is the child’s actual age in terms of years and months. Play Age Mental age refers to the child’s level of intellectual capacity A child 3 to 5 years of age has two primary and somewhat conflicting and development. needs (Fig. 57.4). First, the child has gone through a process of Emotional age describes the child’s level of emotional developing autonomy and initiative. Second, the child requires maturity. control and structure in his or her environment. Children can These ages are not necessarily the same for each child. For follow simple instructions, and they welcome having an active role instance, a child at the chronologic age of 6 may have a mental in the treatment experience. The child’s role is to help by following age of 8 (i.e., mentally, the child is comprehending information directions and “sitting still,” “keeping your hands by your side,” at the level of the average 8-year-old) and an emotional age of 4 and “opening your mouth wide.” By allowing the child to have (i.e., emotionally, he or she is reacting at the level of the average choices, the dental team should show regard for the child’s need 4-year-old). for autonomy and initiative. According to well-known psychiatrist Erik Erikson, the socializa- tion process consists of stages. These stages were formulated to School Age understand the social and emotional development of children and For children, ages 6 to 11 is a period of socialization, which involves teenagers. A guideline (norm) for the average child’s development learning to “get along” with people, learning the rules and guidelines can be used as a simple index to the child’s anticipated behavior of society, and learning to accept these social requirements. Through level at a certain age. A child who differs widely from these norms their experiences with others, children at this age have learned to may be diagnosed as physically or emotionally challenged. It is overcome fears of objects and situations that were once quite important to remember, though, that some children may be under frightening to them. They have learned that situations typically Fig. 57.3 Clinical assistants should dress professionally but in a non- Fig. 57.4At this age, children are developing autonomy and initiative at threatening manner for the pediatric dental patient. varying times. (Copyright iStock.com/FatCamera.)  CHAPTER 57 Pediatric Dentistry 893 are less threatening than they had imagined and that generally for the child. The rapport developed during the initial examination they need not be afraid. can establish an attitude toward dental health that will last for a child’s lifetime. Adolescence Many dentists will follow a behavior scale early in the treatment This is a transitional stage of physical and psychological human of a pediatric patient. The child’s behavior then can be evaluated development generally occurring during the period from puberty and followed through the child’s experience in the practice. Dr. to young adulthood. The period of adolescence is most closely Spencer Frankl developed one of the most widely used systems, the associated with the teenage years, although its physical, psychologi- Frankl scale, to measure a pediatric patient’s behavior (Table 57.1). cal, and cultural expressions can begin earlier and end later. From ages 12 to 20, young people acquire self-certainty (Fig. 57.5). They Guidelines for Child Behavior experiment with different roles, and sexual identity is being The development of trust between the parent/child and the dentist established. The adolescent will seek leadership (someone to inspire serves as the basis for a productive, effective means of providing them) and will gradually develop a set of ideals. dental healthcare. The American Academy of Pediatric Dentistry provides guidelines on the use of behavior management. Dental procedures can be accomplished for patients of all ages if the dental Behavior Management team practices the following procedural guidelines: The initial examination is important for both the child and the Be honest with the child. Make sure that what is said to the dental team. Remember that this often is the first dental experience child is true from the child’s point of view. Helpful “child languages.” Words used by the dental team for explaining procedures, such as “sugar bugs” for decay, “tooth pillow” for mouth prop, “straw” for the suction, and “sleepy juice” for the anesthetic. Also, the child must understand the words that are used. For example, it is better to use a word such as “pinch” rather than “mosquito bite,” especially if the child may know that a mosquito bite hurts. Always “tell, show, and do.” Tell the child what is to be done, show the child what is to be done, and then proceed to do exactly what the child has been led to expect. The dental team should not assume that a procedure or instrument is so harmless that it will not concern a child. The team should include this “tell, show, and do” process in any new procedure. Give positive reinforcement. Reinforce and reward appropriate behaviors; avoid rewarding undesirable behavior. EXAMPLES OF WAYS TO INCLUDE A YOUNG CHILD IN A PROCEDURE Have the child select the type of safety eyewear that he or she would like to wear today. Say to the child, Point to the tooth you would like me to start with. Have the child point to the tooth that was smiling for the camera (radiograph). Fig. 57.5 Adolescence is an extremely complex stage of development Allow the child to choose the flavor of fluoride. because of the many new opportunities and challenges thrust on the Ask the child to hold the saliva ejector during the procedure. teenager. (Copyright ferlistockphoto/iStock/Getty Images.) TABLE 57.1 Frankl Scale for Pediatric Dental Patient Behavior Rating Definition Patient Behavior 1 Definitely negative Refusal of treatment, crying forcefully, fearful, other evidence of extreme negativism 2 Negative Reluctance to accept treatment; uncooperative; some evidence of negative attitude but not pronounced, that is, no sudden withdrawal 3 Positive Acceptance of treatment; cautious at times; willingness to comply, at times with reservation, but follows directions 4 Definitely positive Good rapport with dentist; interested in dental procedures; laughing and enjoying the situation Courtesy Dr. Spencer Frankl. 894 PART 10 Assisting in Comprehensive Dental Care patient with special needs who may have limited control of his or The Challenging Patient her movement. Treating an anxious, fearful, or uncooperative child can be chal- When the dentist takes steps in using pharmacologic or protective lenging for the dentist, assistant, parents, and especially for the stabilization with a child, the parents must be made aware and child. In some situations, a child will remain uncooperative even must provide consent. An immediate and documented explanation though the dental team has used every possible approach to provide should be given to parents as to why such actions are to be taken. a positive dental experience. Occasionally, a child’s behavior during The child should also be informed appropriately. treatment requires a firmer management style to be used to protect him or her from possible injury. Voice control (speaking calmly but firmly) will usually prevent the need for additional steps. RECALL In certain cases, a form of restraint may be required for a 4. Is it possible for a child to be 10 years old but to act like a 7-year-old? patient’s protection. The use of restraint can be either pharmacologic If so, what are you describing about this patient? or physical to help lessen a patient’s movement or activity to a 5. At what developmental stage do children first want control and minimum. If the dentist knows that restraint will be needed, structure of their environment? premedication can be prescribed to calm and ease the patient 6. How would Dr. Frankl describe a positive child? 7. When would a papoose board be used? before treatment. Nitrous oxide is the most frequently used sedation, and sedative/antianxiety agents administered orally are the second most use pharmacologic techniques with children. If a child is Patients With Special Needs especially fearful and/or requires extensive dental treatment, other sedative techniques or intravenous sedation may be recommended Certain physical and mental disorders can slow or challenge a (see Chapter 37). person’s psychological and social growth. When a child has been Physical restraint can be as simple as the dentist or assistant diagnosed with a condition such as intellectual disability, Down holding a child’s hands during treatment. By holding the child’s syndrome, autism, or cerebral palsy, parents and families take on hands, you can prevent possible injury to the child, the dentist, the responsibility for assisting with more of the child’s daily physical and yourself, if, for instance, the child was to quickly reach for and oral health needs. the syringe during an injection or for the dentist’s arm while using The environment of a pediatric dental office better suits a patient the handpiece. who has been diagnosed with special needs. The severity of each For young toddlers and preschool-age children, a parent may patient’s disorder dictates whether treatment is provided in the be asked to help keep the child calm and under control. A problem pediatric dental office or in the hospital setting. Evaluation of a with this scenario is that if a parent is anxious or nervous about patient’s medical and social history helps disclose whether modifica- the child’s care, bringing him or her back into the clinical setting tions to the treatment plan are needed. may actually impair the situation and create an even more nervous environment. Intellectual Disability Additional steps for restraining a child can be taken with the use of protective stabilization. Protective stabilization is any manual Intellectual disability is a state of functioning that begins in method, physical or mechanical device, material, or equipment childhood and is characterized by limitations in intelligence and that immobilizes or reduces the ability of a patient to move his in adaptive skills. For descriptive purposes, intellectually disabled or her arms, legs, body, or head freely. The papoose board is a individuals are classified into four groups that reflect their degree device that gently “hugs” or wraps around the child’s arms, legs, of intellectual impairment: mild, moderate, severe, and and middle section during a procedure. The papoose board uses profound. Velcro straps that fasten over the child and restrain the movement Mild intellectual disability describes individuals with intelligence of the child’s hands, arms, and legs (Fig. 57.6). This device can quotients (IQs) ranging from 50 up to 70. These individuals be adapted for the younger child who has been sedated or for the characteristically develop social and communication skills during the preschool years, with minimal impairment in sensorimotor areas; they often seem to be developing normally until a later age. Dental care is provided in the usual manner. Because comprehension is slow, a patient may require extra patience, understanding, and reassurance. With help from the dental team, a person with mild intellectual disability can be a good dental patient. When communicating with the patient who has mild intellectual disability, do the following: Minimize distractions. se short explanations. se simple language. Ta e more time to present information. A oid explanation of causes. ocus on e ects of lac of oral hygiene. Teach acti ities rather than concepts. Encourage consistency. se tell-sho -do. Fig. 57.6 The papoose board provides a way of holding the arms and se positi e reinforcement. legs still to prevent patients from injuring themselves or others. se erbal praise.  CHAPTER 57 Pediatric Dentistry 895 Moderate intellectual disability describes individuals with IQs sedation, restraint, and general anesthesia may be necessary when ranging from 35 up to 55. These individuals talk or learn to oral disease is extensive. communicate during the preschool years. They may gain from Patients who have autism have a known desire for sweet foods vocational training and, with moderate supervision, can take care and generally have poor oral hygiene. Therefore these patients are of themselves; however, they are unlikely to progress beyond the at risk for increased dental caries and periodontal disease. Patients second-grade level in academic subjects. They adapt well to life in with autism are often receiving psychotropic medications, which the community, but they need supervision and guidance when can cause xerostomia. under stress and usually live in supervised group homes. A patient with moderate intellectual disability probably will require special Cerebral Palsy care in receiving dental treatment, including premedication, restraints, or care while under general anesthesia. Cerebral palsy is a broad term that is used to describe a group of Severe intellectual disability describes individuals with IQs ranging nonprogressive neural disorders caused by prenatal or postnatal from 20 up to 40. During the preschool period, these individuals brain damage before the central nervous system has reached maturity. display poor motor development and acquire little or no com- The resultant brain damage manifests (presents) as a malfunction municative speech. In their adult years, they may be able to perform of motor centers and is characterized by paralysis, muscle weakness, simple tasks under close supervision. Specialized dental treatment lack of coordination, and other disorders of motor function. involving general anesthesia is frequently necessary for patients In addition to motor disabilities, many individuals with cerebral with severe intellectual disabilities. palsy have other symptoms of brain damage, such as seizure dis- Profound intellectual disability describes individuals with IQs orders, intellectual disability, and sensory and learning disorders. below 20 to 25. During the early years, these children display These conditions may be complicated further by behavioral and minimal capacity for sensorimotor functioning. A highly structured emotional disorders. environment with constant aid and supervision is necessary Cerebral palsy most often is classified according to the type of throughout life. These individuals require specialized dental care, motor disturbance. The two most common types are spasticity and which usually is provided in an institutional setting. athetosis. Spasticity is characterized by a state of increased muscle tension that manifests as an exaggerated stretch reflex. Athetosis is marked by uncontrollable, involuntary, purposeless, and poorly Down Syndrome coordinated movements of the body, face, and extremities; grimac- Patients with Down syndrome, also known as trisomy 21, have a ing, drooling, and speech defects are present. chromosomal deficit that commonly results in certain abnormal Premedication frequently is used to help control and relax the physical characteristics and mental impairment. The intellectual patient with cerebral palsy. Along with patience, understanding, disability may range from mild to moderate. The common physical and flexibility of the dental team, premedication makes routine characteristics unique to a Down patient are that the back of the dental care possible. For some patients, however, general anesthesia head is flattened, the eyes are slanted and almond shaped, and the may be necessary. bridge of the nose is slightly depressed. Muscle strength and muscle Oral hygiene in most patients with cerebral palsy is poor, in tone usually are reduced, and one third of these children are part because of the nature of their disease and the resultant physical diagnosed with heart problems. limitations. The patient and the caregiver should receive a thorough Frequently, patients with Down syndrome have anomalies in orientation to a home care program, with modifications as necessary dental development. Eruption of teeth may be delayed, with the to meet the patient’s special needs. Frequently, an electric toothbrush primary incisors not erupting until after 1 year of age. Teeth may can be used effectively. Special adaptations of the toothbrush handle be small and peg-shaped, often with malocclusion. Periodontal and other aids to hygiene also may be helpful. problems are common because of misaligned teeth, mouth breathing, or poor dental care at home. The forward position of the mandible and underdeveloped nasal and maxillary bones RECALL do not provide enough space for the tongue. The resulting open-mouth, forward-tongue position gives the appearance of an 8. What types of skills are limited in an intellectually disabled child? enlarged tongue. 9. What is another term for Down syndrome? Dental treatment for patients with Down syndrome depends 10. Would it be common for you to treat a cerebral palsy patient in a on the person’s psychological development and physical problems. wheelchair? If so, why? The patient should be approached in terms of mental age and abilities, not in terms of chronologic age. Diagnosis and Treatment Planning Autism According to the American Academy of Pediatric Dentistry (AAPD), Autism is a developmental disorder that affects how information the first dental appointment for a child should take place around is processed in the brain by altering how nerve cells and their his or her first birthday or when the first tooth erupts. This appoint- synapses connect and organize. Signs of this disorder are evident ment is scheduled to collect information, introduce the child to before a child reaches 3 years of age, and the disorder can be the dentist and staff, and help the child feel comfortable in the characterized by difficulty in social interaction, difficulty in verbal office surroundings. It also gives the dental team an opportunity and nonverbal communication, and repetitive behaviors. to educate the parents on preventive techniques and pediatric care. This patient may exhibit behavioral problems with management It is then recommended that the child begin regular examinations difficulties. Behavior management techniques may include behavior at age 2. Once dental care has begun, the patient will be instructed modification, positive reinforcement, and desensitization; however, to return for recall appointments. 896 PART 10 Assisting in Comprehensive Dental Care The child’s parent or legal guardian must give consent before any dental care is provided for a child younger than 18 years of age. Introduce yourself to the child and the parent and welcome them to the office. While interacting with the parent and the child, establish a friendly but professional rapport to aid in the develop- ment of confidence among dental team members. Medical and Dental History The medical and dental history should include information about the child’s general medical and dental health background; these details are reviewed with the parent and the child. SPECIFIC INFORMATION NOTED IN THE PEDIATRIC MEDICAL AND DENTAL HISTORY Fig. 57.7 Position the child on the parent’s lap while being examined. Medical History (Copyright iStock.com/Petri Oeschger.) Past hospitalizations and procedures while under general anesthesia Date of last visit to the physician and current treatment Medications taken in the past Daily medications Unfavorable reaction to any medicine Match the size of the lm to the child s le el of comfort. n Allergies, including to any prescribed or over-the-counter medications some cases, bending the anterior corners facilitates bitewing taken placement. Weight at birth and any problems that occurred at birth Expose the easiest lms rst. sually occlusal pro ections are Parental report on level of learning most comfortable for the child (Fig. 57.8). Dental History Extraoral Examination Primary concern about the child’s dental health The extraoral examination is used to evaluate the patient’s profile Satisfaction with appearance of teeth Bleeding gums with brushing to determine skeletal characteristics. Any facial deviation or asym- Finger, thumb, or pacifier habits metry of the eyes, ears, or nose may be a symptom of an undiagnosed Fluoride and toothbrush habits syndrome, and the child should be referred to an appropriate Inherited family dental characteristics professional for complete evaluation. Intraoral Soft Tissue Examination It is important for the dentist or the hygienist to evaluate the Initial Clinical Examination child’s gingiva and periodontium using a gingival score and/or a periodontal plaque score (see Chapter 55). Depending on the child’s age, the dentist will complete an extraoral examination, an intraoral soft tissue examination, a clinical examina- Examination and Charting of Teeth tion, which includes charting of the teeth, and expose radiographic The initial clinical examination requires the use of a mouth mirror images (Fig. 57.7). and an explorer. Very young children may be hesitant in allowing the dentist or hygienist to place an instrument and instead may Radiographic Imaging allow “only fingers” in their mouth. In general, children often require radiographs on a more routine The primary or mixed dentition is examined with the occlusion basis than adults. Because their mouths grow and change rapidly, to determine spacing and crowding of teeth. Chapter 28 describes children can be more susceptible to tooth decay. The AAPD recom- the type of charting system used with the primary dentition. mends radiographs every 6 months for children with a high risk for tooth decay (less frequently in children at low risk). A radiographic examination is necessary if a complete diagnosis RECALL is to be made. Young children often have difficulty cooperating with the radiographic procedure, which may have to be postponed 11. When should a child first see the dentist? until the child is better able to withstand the size of the film in 12. If a patient is at high risk for decay, how often should radiographs be the mouth and to refrain from any movement. When radiographs taken? are possible, the following steps are helpful in introducing the child to the procedure: se ords such as camera and ta ing a picture as an analogy Preventive Dentistry for Children to help explain the equipment and the process. se the tell sho do concept. y positioning the lm and Prevention is one of the most encompassing areas for a pediatric the x-ray unit, you can determine whether the child will sit dental practice. It not only involves the complete dental team in for the exposure, without exposing the child to unnecessary educating the patient and parents, it also reaches to the community radiation. and to local school systems. The role of the pediatric dentist is to  CHAPTER 57 Pediatric Dentistry 897 Fluorides As discussed in Chapter 15, fluoride is safe and necessary, but only at appropriate levels. Children between the ages of 6 months and 16 years should have a daily intake of fluoride. Discuss with the parent how much fluoride is in their drinking water. If they drink well water or bottled water, assist them in getting an analysis of its fluoride content. After knowing how much fluoride the child receives, the pediatric dentist can decide whether the child needs a fluoride supplement. Instruct the parent to watch the child’s use of fluoridated toothpaste as the second step. A pea-sized amount on the brush is plenty for fluoride protection. Teach the child to spit out the toothpaste and not to swallow after brushing. Fluoride Varnish Some patients are more susceptible to decay, and, for them, fluoride rinses may not be as beneficial. Fluoride varnish is being used on a routine basis for caries prevention. The varnish is a gel-like substance designed to release fluoride on enamel and root structure (see Chapters 15 and 44 for additional information). A Diet A healthy diet is one that is balanced and that naturally supplies all the nutrients a child needs for growth. Chapter 16 describes the types of foods that children should eat for normal growth and identifies foods that may increase caries activity. An important role for the pediatric dental team is to do the following: elp assess the child s diet. nstruct parents to shop smart and not to routinely stoc their pantry with sugary or starchy snacks. It is okay to buy “fun foods,” but just for special times. Discuss limiting the number of snac times and choosing nutritious snacks. Re ie a balanced diet and tal about sa ing foods ith sugar or starch for mealtimes. Encourage parents to not put a young child to bed ith a bottle of milk, formula, or juice. Discuss hether the child che s gum or drin s soda and tal B about choosing other options without added sugar. Fig. 57.8 Maxillary occlusal projection. (A) Technique. (B) Radiographic image. (From Dean JA, Avery DR, McDonald RE: McDonald and Avery Sealants dentistry for the child and adolescent, ed 9, St Louis, 2011, Elsevier.) Sealants protect the grooved and pitted surfaces of teeth, especially the chewing surfaces of back teeth, where most cavities in children are found. Made of clear or shaded plastic, sealants are applied to communicate the importance of preventive dental health in such the teeth to help keep them cavity-free (see Chapter 59). areas as oral hygiene, fluoride use, diet, and preventive procedures. Orofacial Development Oral Hygiene It is never too early for the pediatric dentist to start to evaluate a Oral hygiene instructions are geared toward improving a child’s child’s oral and facial (orofacial) development. The pediatric dentist brushing and flossing techniques. This teaching eventually will will be the first to identify malocclusion, crowded or crooked lead to cleaner teeth and healthier gums, thus preventing decay. teeth, and habits that can affect the dentition later. The pediatric By learning the habit of brushing effectively twice a day with fluoride dentist can actively intervene or can refer the patient to an ortho- toothpaste and flossing once a day, children will maintain proper dontist to guide the teeth as they emerge in the mouth. Early oral habits throughout their lives (see Chapter 15). preventive and interceptive orthodontic treatment can prevent the The AAPD recommends a dental checkup twice a year for most need for more extensive treatment later. children (Fig. 57.9). Some children need more frequent dental Preventive treatment allows the dentist to prevent or eliminate visits because of increased risk for tooth decay, unusual growth irregularities and malposition in the developing dentofacial region. patterns, or poor oral hygiene. Preventive orthodontics includes the following: 898 PART 10 Assisting in Comprehensive Dental Care Fig. 57.9 Example of dental report card used for recall appointments. (Courtesy Dr. John Christensen, Chapel Hill, NC.) ontrol of decay to pre ent the premature loss of primary teeth se of appliances to correct oral habits such as thumb which may result in loss of space for the eruption of permanent sucking that may be damaging to the permanent dentition teeth. (Fig. 57.11). se of a space maintainer to sa e space for the eruption of Early detection of genetic and congenital anomalies that may permanent teeth (Fig. 57.10). Space maintainers most often influence dental development. are cemented into place and are retained until the permanent Super ision of the natural exfoliation shedding of the primary tooth erupts. teeth. If retained for too long, primary teeth may cause permanent  CHAPTER 57 Pediatric Dentistry 899 Fig. 57.10Space maintainer used to “reserve” the space until the per- manent tooth erupts. (From Dean JA, Avery DR, McDonald RE: McDonald and Avery dentistry for the child and adolescent, ed 10, St Louis, 2016, Elsevier.) Fig. 57.12 Radiographic image of the shedding of primary teeth and eruption of permanent teeth. (Copyright iStock.com/JordiDelgado.) Fig. 57.11 An appliance is placed to interfere with the finger position during thumb sucking. (From Dean JA, Avery DR, McDonald RE: McDon- ald and Avery dentistry for the child and adolescent, ed 10, St Louis, 2016, Elsevier.) Fig. 57.13 Example of fixed appliance used to correct cross-bite. (Cour- tesy Dr. Frank Hodges, Sonoma, CA.) teeth to erupt out of alignment or to become impacted (Fig. 57.12). Interceptive treatment allows the dentist to intercede or correct problems as they develop. Examples of problems include the following: Extraction of primary teeth that may be contributing to malalign- ment or crowding of the permanent dentition orrection of a cross-bite using a remo able or xed appliance (Fig. 57.13) orrection of a a size discrepancy ith a remo able or xed appliance (Fig. 57.14) Sports Safety The fields of sports medicine and dentistry have documented the benefits of wearing protective face equipment during recreational Fig. 57.14 Palatal expansion appliance used to widen the maxillary arch. (Courtesy Dr. Frank Hodges, Sonoma, CA.) sports that might injure the mouth area. Mouth protectors are an important piece of protective face gear. Many states have regulations that require student athletes in contact sports to wear protective mouth guards to help prevent traumatic injuries to the teeth. RECALL Professional athletes in sports that expose them to potential oral 13. Would fluoride varnish be used on a child? injury are required to wear mouth guards. 14. What procedure is recommended for children to protect the pits and Three types of mouth guards are used: commercial mouth guards, fissures of posterior teeth? mouth-formed protectors, and custom-fitted vacuum-formed guards. 15. Is an appliance that is placed to stop a patient from sucking the thumb Custom mouth guards can be fabricated easily in the dental office considered interceptive or preventive orthodontics? (Fig. 57.15). 16. As a swimmer, should you wear a mouth guard? 900 PART 10 Assisting in Comprehensive Dental Care t protects the patient from aspirating dental materials or items used in the procedure. Instrument Size Dental instruments, handpieces, and rotary instruments are scaled down in size for use with the pediatric patient. Smaller sizes provide the dentist easier access to areas within the mouth and do not require the child to open the mouth as wide. Matrix System Two types of matrices are used when primary teeth are restored: The T-band and the spot-welded band (see Chapter 49). Both custom bands are designed to better fit the width and height of the primary tooth. Endodontic Procedures Pulp Therapy Fig. 57.15Under Armour mouth guard. (Courtesy Bite Tech Inc., Exclu- Pulp therapy is an attempt to stimulate and preserve pulpal sive Licensee, Under Armour Performance Mouthwear.) regeneration in primary teeth. The two factors that most com- monly affect the pulpal health of teeth are deep caries and traumatic injury. Deep caries is much more likely to affect the Pediatric Procedures posterior teeth, and trauma is much more likely to affect the anterior teeth. The basic principles of operative or restorative treatment of primary Indirect and direct pulp capping can be indicated for a newly teeth are generally the same as those for permanent teeth. Primary erupted permanent tooth to promote pulpal healing and stimulate teeth are charted with the same classifications as permanent teeth, the production of reparative dentin (see Chapter 54). and amalgam and composite resin materials are used for restorative purposes. The only difference is that the pediatric dentist adapts Pulpotomy to a smaller dentition and mouth size by using special instruments, Pulpotomy is the complete removal of the coronal portion of the accessories, and techniques. dental pulp. The goal of this procedure is to remove the portion of the pulp that is inflamed while maintaining the healthy vital Restorative Procedures pulp tissue within the canals of the primary tooth. A pulpotomy can be accomplished with two different types of medicaments: Anesthesia and Pain Control Mineral trioxide aggregate MTA is replacing the popular use It is important to create a positive, painless experience early on in of a formocresol pulpotomy, which was most often used for a child s dental isit. sing simple distraction techni ues can help primary teeth. Because of the material’s toxicity, it is not recom- divert the patient to lessen the experience. Depending on the age, mended. MTA is an endodontic cement that is biocompatible some of the following techniques provide a positive experience: and is capable of stimulating healing and osteogenesis. Refer to the procedure as placing sleepy uice on the tooth. The calcium hydroxide pulpotomy is used primarily for young a e the topical and syringe prepared and co ered ith a patient permanent teeth with open apices (Fig. 57.16). A common napkin when seating the patient. indication on the fractured tooth is significant exposure of the Position the patient ith the chin up. Pro ide a poster or mobile pulp. This type of treatment allows continued apical development on the ceiling for the patient to look at. so that endodontic treatment can be performed later. Transfer the syringe behind the patient s head to pre ent the See Procedure 57.1: Assisting in Pulpotomy of a Primary Tooth. patient from seeing what you are doing. ontinue tal ing to the patient to eep the child preoccupied. Prosthodontic Procedures During the application of anesthesia place your arm closest to the patient across the patient to provide security and support. Stainless Steel Crown At the conclusion of a procedure, it is important to instruct Because of the importance of maintaining primary teeth throughout the parent and the patient that the patient’s lip may be numb and adolescent years, the dentist may use a crown system to cover will feel funny. Instruct the patient not to chew or bite the lip. severely decayed and endodontically treated teeth without the cost and time investment of a fixed prosthesis. A stainless-steel crown Use of the Dental Dam is the restoration of choice for the following reasons: The placement of the dental dam in pediatric dentistry offers many Stainless steel cro ns can be prepared and placed at a single advantages for the pediatric patient: appointment, which is especially important in young children, Refer to the procedure as a raincoat for the tooth the child patients with behavioral problems, and patients with special can understand the need for the tooth to stay dry. needs. The dam can decrease the time of a procedure. ro ns are su ciently durable to last until the primary teeth t can help eep the child from tal ing throughout the procedure. are replaced by the permanent teeth. t pro ides protection from sali a and debris during the ro ns are almost al ays ell tolerated by the gingi a of young procedure. patients.  CHAPTER 57 Pediatric Dentistry 901 Fig. 57.17 Traumatized maxillary incisor. (Courtesy Dr. Frank Hodges, Sonoma, CA.) include bicycle accidents, sports injuries, automobile accidents, Fig. 57.16 A deep calcium hydroxide pulpotomy completed on the and child abuse. It is important to educate parents and school central incisor. (From Hargreaves KM, Cohen S: Cohen’s pathways of the nurses on proper actions to take when a dental emergency occurs pulp, ed 10, St Louis, 2011, Mosby.) (Fig. 57.18). Fractured Anterior Teeth Stainless steel cro ns are much less expensi e than cast restorations. Fractures of the anterior teeth are common emergencies in a pediatric dental practice (Fig. 57.19). The dentist should see children with Types of Crowns fractured teeth as soon as possible. Complete documentation of Stainless steel crowns are available in a variety of sizes for the the accident, clinical examination, vitality testing, and radiographic various primary and permanent teeth. The two types typically used examination are completed at the emergency visit. in pediatric dentistry are pretrimmed and precontoured stainless The dentist often prefers to delay restorative treatment for 3 steel crowns. to 6 weeks to avoid any further trauma to the pulp of an injured Pretrimmed crowns have straight sides but undergo festooning tooth. This time gives the pulp an opportunity to recover without to follow a line parallel to the gingival crest. These must be additional injury. During this recovery period, the dentist (1) trimmed and contoured to fit the tooth. provides temporary relief by covering all exposed dentin with Precontoured crowns are already festooned and contoured. Some calcium hydroxide to prevent thermal sensitivity and (2) places additional trimming and contouring may be necessary, but this an interim covering of resin material. Radiographs and vitality need is usually minimal. tests are provided at subsequent appointments to determine the See Procedure 57.2: Assisting in Placement of a Stainless Steel status of the injured tooth. If the pulp is still vital, more definitive Crown. restorative procedures can be performed. Traumatic Intrusion RECALL Traumatic intrusion is the result of an injury in which the tooth 17. What types of matrices are commonly used on primary teeth? 18. What endodontic procedure would most likely be performed on a is forcibly driven into the alveolus so that only a portion of the primary tooth? crown is visible. Traumatic intrusion can occur to primary and 19. Would a child be referred to a prosthodontist for placement of a permanent dentition. Teeth that are intruded should be allowed stainless steel crown? to re-erupt naturally; these teeth often require endodontic treatment at a later time. Damage to the developing permanent tooth can occur when a primary tooth is intruded. The extent of damage to Dental Trauma the permanent tooth cannot be determined until it erupts. An injury to the tooth of a young child can have long-term Extrusion and Lateral Luxation Injuries consequences, including discoloration and possible loss. Injuries to primary teeth commonly occur around 1 to 2 1 2 years of age—the Extrusion and lateral luxation injuries occur when the teeth are “toddler” stage. The teeth that are injured most frequently in the displaced from their position. Severe damage to the periodontal primary dentition are the maxillary central incisors (Fig. 57.17). ligaments usually occurs with these injuries. The dentist repositions The concern with this type of injury to a primary tooth is that displaced teeth as soon as possible. A temporary splint of resin the permanent tooth is developing directly under the injured tooth material or ligature wire is used to stabilize the repositioned per- and may also become affected. Causes of dental injury to children manent teeth.  902 PART 10 Assisting in Comprehensive Dental Care Fig. 57.18 Flyer describing actions to take in a dental emergency as distributed to school personnel. (Courtesy Dr. John Christensen, Chapel Hill, NC.)  CHAPTER 57 Pediatric Dentistry 903 lotted blood is remo ed from the al eolus soc et ith a surgical curette. The a ulsed tooth is ashed in saline solution and is inserted into the alveolus. The tooth is splinted into place ith ire acrylic or orthodontic splints. Postoperati e radiographs are ta en. Endodontic treatment is performed to ee s after replantation. RECALL 20. Which teeth are injured most frequently? 21. What happens when a tooth is avulsed? 22. How would a dentist stabilize a tooth after an injury? Fig. 57.19 Fracture of an anterior tooth. (Courtesy Dr. Frank Hodges, Sonoma, CA.) Child Abuse and Neglect By law, in all 50 states, healthcare professionals (physicians, dentists, nurses, and social workers) are required to report any case in which they suspect that a child is being neglected or abused. The state or county child protective services agency is the government body that should be contacted. The name of the person who makes the report will not be revealed. Although dental assistants and clerical staff are not legally required to report abuse, each member of the dental team has a moral responsibility to report known or suspected abuse cases to the dentist. Reporting of suspected child abuse may be done by telephone, in person, or in writing. Specific information is required to file a report. For various reasons—because of embarrassment, fear of losing custody of the child, or the wish to avoid a fine or imprisonment— abusive parents tend to make up stories about how the child “fell” or sustained some other injury to the head. Child abuse must be Fig. 57.20 Avulsion of maxillary central incisors. (Courtesy Dr. Frank suspected as the cause when a child presents with unexplained Hodges, Sonoma, CA.) signs such as the following: n uries at arious stages of healing indicating that the trauma Endodontic treatment is often required later for these teeth. has occurred over time rather than as a single incident) Primary teeth tend to undergo root resorption more quickly after Repeated in uries injuries of this type, and they tend to become mobile. These teeth hipped or in ured teeth should be observed for signs of infection and removed if indicated. Scars inside the lips or on the tongue Tears of labial frena attering or other in uries around the head and nec Avulsed Teeth acial bruising s elling of the facial structures or blac ened Permanent teeth that have been avulsed can be replanted with eye(s) varying degrees of success (Fig. 57.20). Primary teeth usually will ractured nose not be replanted. The more quickly a tooth can be replanted, the ite mar s greater is the chance for success. Therefore, when an injury of this n uries not consistent ith the explanation presented by the type occurs, the adult who is present should be instructed to do parent the following: Reco er the tooth immediately. rap the tooth in moistened piece of cloth or to el. WHAT TO INCLUDE WHEN REPORTING CHILD o immediately to the dentist s o ce. ABUSE Name, address, gender, age, height, and weight of the child Replanting an Avulsed Tooth Name and address of the adult who has custody of the child The success rate for replantation of permanent teeth is highest Description of the current physical and emotional abuse or neglect of when the tooth is replanted within 30 minutes of the accident. the child The procedure for replantation is as follows: Evidence of previous injuries or negligence The local anesthetic agent is administered. Information that may assist in establishing the causes of injuries Radiographs are ta en. ften both periapical and occlusal Sketches or photographs documenting the nature and location of radiographs are indicated to reveal any fragments of tooth or injuries bone. 904 PART 10 Assisting in Comprehensive Dental Care RECALL rising. Caries has become such an epidemic that the American Dental Society and the American Academy of Pediatric Dentistry 23. Are you legally required to report child abuse? are emphasizing that dental professionals must educate their patients 24. Could a fractured or broken nose be a result of child abuse? about their nutrition and diet. 25. Who in the dental office should report child abuse? Critical Thinking Patient Education 1. You are assisting today with a new patient named Katie. After reviewing the patient registration form, you see that she is 3 Children are sponge-like in that they absorb and remember years old. When you go out to call Katie, she runs to her mother everything you say and do. Always be mindful of their presence and clings to her leg. What techniques could you use to encour- when they are in the dental chair. Allow children to feel comfortable age her to come with you for her appointment? about asking questions. When you answer their questions, think 2. You are applying sealants to the primary molars of a 6-year-old about their age, how they grasp concepts, and how you can make boy. You are using cotton rolls for moisture control. When you them more interested in taking better care of their oral health. place the cotton roll on the lower lingual side, the boy pushes it up ith his tongue. o can you maintain a dry area and Legal and Ethical Implications still complete the procedure? 3. An emergency patient has just arrived. The patient, 1-year-old Because the clinical assistant takes on such an important role in Lori, has fallen and hit primary tooth E. You have been asked the clinical component of the pediatric patient, it is easy to acquire to ta e a periapical radiograph of the area. o ill you ta e responsibilities that may not be legal for an assistant to practice. a periapical view of this very young girl? Review your state, province, or territory laws and discuss with 4. Your next oral hygiene patient is Luke, a 10-year-old boy with your dentist what role you want to take in the practice. Come up Down syndrome. Describe how you will prepare for this patient with a plan for how you can be legally involved to your maximum and identify what techniques can be used to make Luke feel potential. more comfortable and have a positive experience. 5. Explain why a different type of matrix system is used with Eye to the Future primary teeth. Which additional supplies would you require to set up this system? For many years, the rate of tooth decay has declined, primarily because of water fluoridation and the use of products with fluoride. o e er pediatric and general dentists no are seeing an increase ELECTRONIC RESOURCES in rampant decay in children and adolescents. The problem is the Additional information related to content in Chapter 57 can be result of consuming candy, sodas, fruit juices, and sports drinks. found on the companion Evolve Web site. Preteens and teenagers are taking in large quantities of sugar- Practice Quiz containing products, with interproximal and cervical decay rates anadian ontent orner PROCEDURE 57.1 Assisting in Pulpotomy of a Primary Tooth Consider the following with this procedure: Personal protective equipment (PPE) is required for the healthcare team, the student is required to identify and prepare the instrument setup, moisture control is included to prevent contamination, and the procedure is to be documented in the patient record. Equipment and Supplies Local anesthetic agent setup Basic setup Dental dam setup Low-speed handpiece Round burs Spoon excavators (various sizes) Sterile cotton pellets Mineral trioxide aggregate (MTA) pulpal material inc oxide eugenol ( OE) base Final restorative material and instruments for placement  CHAPTER 57 Pediatric Dentistry 905 PROCEDURE 57.1 Assisting in Pulpotomy of a Primary Tooth—cont’d Procedural Steps 8. The pulp chamber is filled with the OE base. 1. The local anesthetic agent is administered. 9. The final restoration is placed. 2. The dental dam is placed. 10. Document the procedure. 3. The dentist will use a round bur in the low-speed handpiece to remove Date Tooth Surface Charting Notes the dental caries and expose the pulp chamber. 9/4/20 C — Pulpotomy, 1 cartridge Xylocaine, 4. Transfer a spoon excavator for the dentist to remove all pulp tissue 1 : 100,000 w/o epi. Dam isolation, inside the coronal chamber. tooth opened, MTA placed. ZOE 5. Prepare MTA pulpal material (1 : 1 ratio). base, amalgam. Pt tolerated 6. Prepare a sterile cotton pellet with chlorhexidine solution and transfer procedure well. to dentist to wipe the cavity preparation. T. Clark, CDA/L. Stewart, DDS 7. Transfer applicator for the material to be placed over the floor of the cavity preparation. PROCEDURE 57.2 Assisting in Placement of a Stainless Steel Crown Consider the following with this procedure: Personal protective equipment Procedural Steps (PPE) is required for the healthcare team, the student is required to identify Preparing the Tooth and prepare the instrument setup, moisture control is included to prevent 1. After the local anesthetic agent has been administered and has taken contamination, and the procedure is to be documented in the patient record. effect, cotton rolls or the dental dam is placed. 2. The dentist will use the high-speed handpiece and a tapered diamond Equipment and Supplies or carbide bur to prepare the tooth in a method similar to that used for Basic setup a cast crown. Local anesthetic agent setup 3. The dentist reduces the entire circumference of the tooth, as well as Dental dam setup the height of the tooth. Low-speed and high-speed handpieces 4. All dental caries are removed with hand instruments and burs. High-volume oral evacuator (HVE) tip Friction grip burs (dentist’s choice of diamond or carbide) Selecting and Sizing the Stainless Steel Crown Spoon excavator 5. The crown is selected and is tried on the prepared tooth for fit. Selection of stainless steel crowns 6. The stainless steel crown is properly sized when it fits snugly on the Crown and bridge scissors prepared tooth and has both mesial and distal contact. Contouring and crimping pliers 7. Clean and sterilize any crowns that were tried in the mouth but not Mandrel used; then return them to storage. Finishing and polishing discs Mounted green stones Cotton rolls Cementation setup Dental floss Articulating paper and holder Continued 906 PART 10 Assisting in Comprehensive Dental Care PROCEDURE 57.2 Assisting in Placement of a Stainless Steel Crown—cont’d Trimming and Contouring the Crown 8. The dentist will use crown and bridge scissors to reduce the height of the crown until it is approximately the same as that of adjacent teeth. 16. Transfer an explorer to the dentist to remove the excess cement from around the tooth. 17. Use dental floss to remove any remaining cement from the interproximal areas. 9. The dentist may use a green stone to smooth the rough edges of the crown along the cervical margin. 10. The cervical margin of the crown may be polished with a rubber abrasive wheel. 11. The occlusion is checked and adjusted as needed. 12. The dentist uses the contouring pliers to crimp the cervical margins of the crown toward the tooth to obtain a tight fit and a proper cervical contour. 18. Use the air-water syringe and the HVE tip to rinse the patient’s mouth before dismissal. 19. Document the procedure. Date Tooth Surface Charting Notes 9/5/20 B Stainless steel crown, 1 cartridge Xylocaine 1 : 100,000 w/o epi. Cotton roll isolation, crown Cementation cemented w/Duralon. Pt tolerated 13. Rinse and dry the tooth thoroughly. Place cotton rolls to maintain dry procedure well. conditions. T. Clark, CDA/L. Stewart, DDS 14. Mix the permanent cement (polycarboxylate is often selected). 15. Line the crown with the cement and transfer to the dentist for placement. All photos in this procedure from Hatrick CD, Eakle WS: Dental materials: clinical applications for dental assistants and dental hygienists, ed 3, St Louis, 2016, Elsevier.