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Pediatric Dentistry


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Pediatric Dentistry encompasses allaspects of oral health care for children

and adolescents. Oral health: a state of sound and well

functioning dental and oral structures. Child: every human being below the age

of 18 years Robert Bunon- 1743 (Father of Pediatric

Dentistry) The first dental care program for children

was put forward by Dr Talma, dentist toKing Leopold of Belgium.


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Cognitive development

Child management

Dental caries and prevention

Dental Trauma

Oral conditions that can be first seen

by medical doctors

Use of antibiotics in paediatric dentistry


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Psychology of the child

Why do we learn the normal psychology?

o To meet the specific need of the child

o Interpretation of child behavior

o Understanding your own reaction


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Phases and stadia ofdevelopment

No universal line for development

Piaget's cognitive theory:

Cognitive cognito = thinking


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Piaget's cognitive theory

Sensorimotors

(0-2)

Formaloperation

12+

Concretephase(7-

12)

Preoperation

al phase(2-6)


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Sensorimotor phase (0-2)

contact with the environment by using hissenses.

Complete dependencyReacts through : Crying, arching his backObject permanence does not exist until the

6th monthImitate actions of adults.Understand simple commandsSocial contact: 2 m smiles at every one

3-4 m familiar faces7-12 m dislike

strangers(Medical care provider)


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Preoperational phase(2-7)2-3(early stage)

Ritualistic

Up to 3 egocentric Imitate animals

Still dependant

3 age of treatment maturity


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late stage 3+: Seeking independency

Understands symbols: word. Aware of gender.

Role playing.

Less egocentric

Imitation of animals: brave like a bear.. Fear of separations(3).

Visual fear (3), Auditory fear (4) bodily harmfear(5)


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Formal Operational stage 12+

Return to egocentrism

Think about future and consequences

They can discuss the management.

Perception of treatment can be idealized andinfluenced by the media


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Fear of the dentist is one of the top fivecauses of fear!!

Dental fear: reaction to threatening

stimuli. Dental anxiety: Non specific feeling of

apprehension.


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Principles of child managementtechniques

A-Non pharmacological:

Distraction

Modeling Dentist

Rewarding


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Method of application of localanalgesia

Topical (ointment, spray)

Infiltration: application of local anesthesiaaround the nerve endings.

Blocks: placement of anesthetic near amain nerve trunk.

Intraosseous anesthesia: involves

achieving access to the bone and injectingthe anesthetic solution.


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2-Sedation:

depressed level of consciousness that may vary

from light to deep.Indications :

Psychological indications

Phobia

Fainting during the procedureGagging reflex

Medical indications:

Controlled ischemic heart diseases

HypertensionEpilepsy

Spasticity disorders (cerebral palsy)


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Sedation

A. Oral sedation: Midazolam, diazepam

B. Intravenous sedationAnaesthetist

Drugs: propofol, ketamine, midazolam


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Sedation

C. Inhalation sedationTrained Dentist or

Anaesthetist

Drug : nitrous oxide (laughing gas)


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Contraindications of laughing gas:

Unaccompanied patientPsychiatric patients

Thyroid dysfunction

Pregnancy

Common cold (nitrous oxide sedation)Contraindications to sedation withbenzodiazepines:

hepatic insufficiency

PorphyryMyasthenia gravis

Allergy to benzodiazepine group of drugs.


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3- General anesthesia: a controlledstatus of unconsciousness accompanied bypartial or total loss of protective reflexes

Anaesthetist


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Dental caries

The most common chronic disease in childhood

Definition : local loss of dental hard tissuesmediated by dental plaque.

Dental plaque: is a biofilm formed when the totooth consist of microrganisms 75% of plaquevolume , organic components (extracellular

polysaccharides , glycoprotein, desquamatedcells) and inorganic components


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Dental caries

The main bacteria responsible for

initiation of dental caries are streptococcimutans. Others : Lactobacillusacidophilus, actinomyces viscosus.

Streptococci mutans bacteria have theability to adhere to the tooth surface andmetabolize dietary sugars.


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Origin of the bacteria:

Colonization of streptococci mutans must first takeplace before caries develops.

Transmission of bacteria from the mother or thecare giver.

Presence of a tooth (needed for bacterialattachment!!).


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The acidic products of the bacteria

decrease the ph (> 5.5) and dissolve thedental hard tissues.


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Prevention of dental caries

Diet modification: decrease intake ofsnakes, soft drinks, bottle feeding withcarbohydrate sticky food.

Frequency of intake is more importantthan quantity.

Avoid sucrose containing food.

Use sucrose substitutes like sorbitol andxylitol.


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Tooth brushing and fluoride:

Tooth brushing should be initiated from theeruption of the first tooth.

Fluoride (tooth paste, water, food) leads todecrease in dental caries.

Attention:Fluoride concentration should be optimized

for young children.

6months-2years 500ppm

starting 1.5 years2-6 years 1000 ppm

6+ 1450 ppm


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Fissure sealants: is a thin plastic likecoating applied to the chewing surfaces ofthe molar teeth(posterior teeth).


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Should we treat caries in primaryteeth


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Pain.

Abscess Facial cellulites

Ludwigs angina: cellulites involving thefacial spaces

at the floor of the mouth (life threatening) Cavernous sinus thrombosis.

Premature loss of primary teeth

malposition of the permanent the teeth


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Early childhood caries

Severe dental cariesthat affect the childrenin young age( 71

months). Cause : interaction of

factorsBacteria + nursing bottle

at bed time.Unrestricted breast

feeding (controversial)


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Role of the medical doctors

The mouth is part of the body!!!

The physician should contribute to the oral healthby educating the parents about the importance oforal health and advising them to:

1. Initiate tooth brushing at least two times/day.

2. Use a fluoridated tooth paste when it is

applicable.

3. Decreases the frequency of snacks intake.


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Behavior management:

To prevent behavior management problems create

a safe and trustable environment: Every one in the clinic (Dentist, Nurse,..)

should transmit a positive behavior.

Use distracting objects in the surgery as well as

in the reception( posters , TV, toys.).


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Dental caries

4. The parents to start regular dental check up

5. Patients with congenital heart defectsshould be referred for dental check up notlater than 6 months after eruption of thefirst tooth.

6. Recognition of cases of Early childhoodcaries (ECC )and refer them to his dentalcolleague.


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Dental trauma

One of the common presentations of youngchildren to emergency clinics.

30% of children suffer trauma to primaryteeth

Boys: girls, 2:1. Upper anterior teeth are the most common

site. Etiology of trauma:falls, traffic accidents, sport, violence, child

abuse.


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Classification :1. Injuries to the dental hard tissues:

A. Crown fracture.B. Root fracture.C. Crown-root fracture2- injuries to the periodontal ligament:A. Concussion : tooth is sensitive but not

displaced.B. Subluxation: tooth is loose but not

displacedC. Luxation: tooth is displacedD. Avulsion: Complete displacement of the

tooth from the mouth


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Management:ABCsHistory taking.Examination:A. General assessment( head injuries ,

assessment of cranial nerves, etc).

B. Dental assessment.Attention: Dont forget to check tetanus

immunizationInvestigations:

radiographs: depends on the injury, intraoralradiographs, lateral oblique, occipitomental,c-t scan

etc..


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Management of dental trauma

1-Crown fracture:Reattachment of the

fractured part orrestoring the tooth

withdental filling materialAttention:Fractured part of the

tooth should bekept wet (stored inwater)awaiting forreattachment.


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Root fracture, concussion subluxation andluxation: the treatment varies from havingsoft diet to splinting the tooth

Soft tissue injuries: any debris should be

removed and cleaned with antiseptic(chlorhexidine acetate 0.5%).

suturing should be considered.

Fracture of the mandible and maxilla:fixation


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Management of avulsion(tooth is displaced outof the mouth):

A. First aid :timing is essential for survival of

the tooth. Replant the tooth immediately if the tooth is

clean If the tooth is dirty , rinse the tooth in milk

and then replant. Or restore the teeth in the Childs mouth

between anterior teeth and the lip. Or put the tooth in glass of milk, normal

saline. Seek dental aid immediately.Attention: dont use water as storage medium

for avulsed toothdont replant primary teeth!!


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Greet the child without a mask.

Presence or absence of family members.

Physical proximity: the intimate zone ofthe child is 45 cm.

Timing of the visit

Communication with the parents and thechild.


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B-The dentist will then splint the tooth

with wire and a dental compositematerial.

Antibiotics should be prescribed.

Role of the ph sician in dental


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Role of the physician in dentaltrauma

A. All physician should receive educationregarding dental traumas

B. They must be trained to provide first aid

(tetanus vaccination, avulsed teeth, etc..)

C. They must refer the child immediately to

the dental colleague, as in many casesthe early treatment by the dentist canhelp to improve the prognosis.


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Dental trauma

D. They can collaborate with their dental

colleagues to identify cases of NAI (nonaccidental injuries) and report them

A child is considered to be abused if he/she be treated in a way that isunacceptable in a given culture at a giventime


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NAI

L b R W lb


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Lecture by R.Welbury


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How to identify cases of child abuse

50% of abused children suffer injuries tothe head and neck.

Signs:

Injuries of various stage of healing. Repeated injuries

Injuries in babies and pre-mobile

children.


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NAI

Bruises is on of the most commoninjuries( in shape of implement used).

Injuries whose clinical presentation is notin consistent with the story of the patient

Attention: children normally lie to protectthe parents.

Lecture by R Welbury


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Lecture by R.Welbury

Oral conditions that could be recognized by


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Oral conditions that could be recognized bythe physician

Teething: a normal process of eruption ofa tooth but sometimes the infant showssigns of systemic distress by systemicdistress: slight fever, diarrhea, local

irritation, redness of the gum anddrooling.

Management:

Teething remedy (teething gel)Rehydration


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Natal teeth: is one that erupt within 30

days of birth.1 case per 2000-3000.

My cause trauma to the breast.

If extremely mobile ,then should beextracted.


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Bacterial infection:

Facial cellulites.

Signs and symptoms: patient is febrile, sick ,upset and dehydrated.

Parents are distressed and anxious.


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Management:

This is an emergency and can be a life

threatening condition .Antibiotics

Pain control

Fluids maintinance

Removal of the causative tooth (primarytooth)or root canal therapy(permanent tooth)

Warm saline mouth rinse


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Viral infection

Primary herpetic gingivostomatitis:Most common cause of severe oral ulceration.Self limitingCaused by herpes simplex type-1 virusIncubation time is 3-5 days.Signs and symptoms: irritability, pyrexia and

malaisered and edematous gingiva.Vesicles painful ulcers

healingManagement: oral fluids, mouthwashes, topical

anesthetic and analgesics.

rupture


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Fungal infection

CandidosisThe most common form in children is oral

thrush.White plaque hemorrhagic base.

Causative fungi: Candida albicansPredisposing factors: low immunity(HIV,

diabetes), broad spectrum antibiotics,chemotherapy and radiotherapy.

Diagnosis: clinicalManagement: Antifungal medication for 8 daysLocal: Nystatin ointment, systemic: Amphotericin

B.

removal


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Use of antibiotics in pediatric


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pdentistry

Conservative use of antibioticsresistance

1- contaminated intra oral wounds: minimum5-7 days.

2-Acute facial swelling of dental origin.Intravenous antibiotics may be indicated.

Attention : painful tooth without systemicinvolvement (fever, malaise) or extra-oralswelling is not an indication of antibiotics.

3-Dental trauma(Avulsion)4-Pediatric periodontal disease5-Prophylaxis .

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