Paediatric Dentistry at a Glance

Titles in the dentistry At a Glance series

Orthodontics at a GlanceDaljit S. Gill978-1-4051-2788-2

Periodontology at a GlanceValerie Clerehugh, Aradhna Tugnait, Robert J. Genco978-1-4051-2383-9

Dental Materials at a GlanceJ. A. von Fraunhofer978-0-8138-1614-2

Oral Microbiology at a GlanceRichard J. Lamont, Howard F. Jenkinson978-0-8138-2892-3

Implant Dentistry at a GlanceJacques Malet, Francis Mora, Philippe Bouchard978-1-4443-3744-0

Prosthodontics at a GlanceIrfan Ahmad978-1-4051-7691-0

Paediatric Dentistry at a GlanceMonty Duggal, Angus Cameron, Jack Toumba978-1-4443-3676-4

Paediatric Dentistry at a GlanceMonty Duggal BDS, MDS, FDS (Paeds), RCS (Eng), PhD

Professor and Head of Paediatric DentistryDepartment of Paediatric DentistryLeeds Dental InstituteLeedsUK

Angus Cameron BDS, MDSc, FDSRCS (Eng), FRACDS, FICD

Head of Department, Paediatric Dentistry and OrthodonticsWestmead HospitalandClinical Associate Professor and Head, Paediatric DentistryThe University of SydneyNSWAustralia

Jack Toumba BSc (Hons), BChD, MSc, FDS (Paeds), RCS (Eng), PhD

Professor of Paediatric and Preventive DentistryDepartment of Paediatric DentistryLeeds Dental InstituteLeedsUK

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Library of Congress Cataloging-in-Publication Data

Duggal, Monty S. Paediatric dentistry at a glance / Monty Duggal, Angus Cameron, Jack Toumba. p. ; cm. – (At a glance series) Includes bibliographical references and index. ISBN 978-1-4443-3676-4 (pbk. : alk. paper) I. Cameron, Angus C. II. Toumba, Jack. III. Title. IV. Series: At a glance series (Oxford, England) [DNLM: 1. Dental Care for Children–Handbooks. 2. Child–Handbooks. 3. Tooth Diseases–Handbooks. WU 49] 617.6'45–dc23 2012015790

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1 2013

Contents

Treatment planning, growth and development  1  Planning treatment for children  6  2  Growth and development  8  3  Child cognitive and psychological development  10

Strategies for management of the child patient  4  Behaviour management  12  5  Aversive conditioning and management of phobia  14  6  Local analgesia  16  7  Conscious sedation  18  8  General anaesthesia  20  9  Rubber dam  2210  Dental radiography  24

Prevention of caries and erosion11  Preventive care for children  2612  Topical fluorides I  2813  Topical fluorides II  3014  Systemic fluoridation and fluoride toxicity  3215  Cariology  3416  Caries risk assessment and detection  3617  Dental erosion  38

Restorative management in the primary dentition

18  Early childhood caries  4019  Strip crowns for primary incisors  4220  Plastic restorations in primary molars  4421  Pulp therapy  4622  Crowns for primary molars  4823  Management of extensive caries  50

Management of first permanent molars24  Preservation of the first permanent molar  5225  Molar incisor hypomineralisation  54

Space management26  Space maintenance  56

Dento-alveolar trauma27  Assessment of trauma in children  5828  Trauma to primary teeth  6029  Crown fractures in permanent teeth  6230  Complicated crown and crown/root fractures  6431  Non-vital immature teeth  6632  Root fractures  6833  Luxations and avulsion  70

Paediatric oral medicine and pathology34  Diagnosis, biopsy and investigation of pathology in children  7235  Differential diagnosis of pathology of the jaws  7436  Management of odontogenic infections in children  7637  Ulcers and vesiculobullous lesions in children  7838  Swellings and enlargements of the gingiva  8039  Oral pathology in the newborn  82

Dental and oro-facial anomalies40  Premature loss of primary teeth  8441  Missing teeth and extra teeth  8642  Disorders of tooth shape and size  8843  Enamel disorders  9044  Disorders of dentine and eruptive defects  92

Management of children with special needs45  Physical and learning disabilities I  9446  Physical and learning disabilities II  9647  Bleeding disorders  9848  Thalassaemia and other blood dyscrasias  10049  Children with congenital heart defects  10250  Children with cancer  10451  The diabetic child  10652  Kidney and liver disease and organ transplantation  10853  Prescribing drugs for children  110

References  113Index  115

Contents 5

6  Chapter 1  Planning treatment for children

1 Planning treatment for children

Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd.

Figure 1.1 Intra-oral view showing the carious upper (a) and lower (b) primary molars.

(a)

(b)Figure 1.2 Bitewing radiographs showing extent of caries.

(a)

(b)

Figure 1.3 Intra-oral view showing upper (a) and lower (b) arches at the end of treatment.

(a)

(b)

Figure 1.4 Postoperative radiographs of the treated case.

(a) (b)

Figure 1.5 Follow-up visit revealed that first permanent molars had erupted and these were fissure sealed.

(a) (b)

Table 1.1 Step-by-step plan of the proposed treatment where prevention is carried out alongside restorative care.

Visit Treatment Preventative

One Examination and treatment plan

Correspondence with paediatrician

Oral hygiene instructionsUse of adult tooth pasteDiet sheet was given

Two Full mouth prophylaxis55 – Fissure sealant65 – Fissure sealant75 – Fissure sealant85 – Fissure sealantTemporisation of 54 and 64

Reinforce oral hygiene instructions

Collect diet sheetDuraphat™ (22 600 ppm F)Plaque score

Three 64 – Composite restoration Reinforce oral hygiene measuresDiet counsellingDuraphat™ (22 600 ppm F)

Four 54 – Stainless steel crown Reinforce diet advicePlaque scoreDuraphat™ (22 600 ppm F)

Five 74 – Composite restoration Reinforce oral hygiene measures

Planning treatment for children  Chapter 1  7

Diagnosis should be specific. For example, a diagnosis “dental caries” in itself is incomplete as it does not specify the reason the child has dental caries. The root cause of the problem cannot be addressed unless a specific diagnosis is made.

Formulating treatment planAn example of a treated case and the step-by-step treatment plan is shown is Figs. 1.1–1.5 and Table 1.1 respectively. When managing caries in children this should relate to:• prognosis of the affected teeth;• child’s behaviour and likely acceptance of the treatment.

Restore or extract• Extent of caries. Are the teeth restorable?• Impact that either option will have not only on developing dentition but child’s long-term well-being.• When all primary molars are involved, give consideration to restor-ing the second and extraction of the first primary molars.Each treatment plan should be tailor-made for the child. For some children, comprehensive restorative care using one of the behavioural approaches is appropriate. For others extraction of some primary teeth and restoration of the others with local analgesia (LA) or general anaesthesia (GA) is more appropriate.

Management strategy – LA, LA with sedation or GA?Most children are amenable to behaviour guidance. However, when planning treatment, the child’s well-being, and also the impact that multiple visits of invasive treatment under local analgesia might have on the child’s future behaviour and attitude towards dental treatment should be considered. Access to good GA facilities is essential.

Preventive strategyDepending on the caries risk, a preventive strategy is devised.

Choice of materialsThis depends on tooth to be restored, past caries history and coopera-tion of the child. An important consideration in children is that the tooth should only need restoring once. In very young children where a restoration is required to last 4–5 years, due consideration should be given to the use of stainless steel crowns.

Developmental anomaliesFormulate a short-, medium- and long-term plan.

Medical history and treatment planning• Liaise with medical practitioner.• Understand the impact of the medical condition on the provision of treatment.In the following chapters all the aspects that play a role in the manage-ment of children’s oral and dental health are discussed.

General philosophy of the authorsDentists who treat children are in a unique position not only to provide dental treatment when required, but to influence the future behaviour, attitudes to oral health and attitude towards dentistry in general. Chil-dren deserve the highest quality care and highest quality restorative dentistry should be provided to them, supplemented with rigorous pre-vention. Prevention of dental caries in children should be a priority but sadly nearly half of 5-year-olds, even in developed countries, still develop dental caries. A non-interventionist approach, as has been advocated in some countries such as the UK, or poor restorative patchwork dentistry, is doomed to failure and only leads to pain, infec-tion and suffering in children, requiring more invasive interventions. These are traumatic and expensive and negatively influence the child’s future behaviour and attitudes to dentistry. Good restorative and pre-ventive care obviates the need for extraction of primary teeth under general anaesthesia, a practice which should have only a small place in the dental care of young children. In addition, in a developing child, the dentist has the task of monitoring the dentition, diagnosis and management of anomalies as well as having a knowledge of medical conditions and the provision of safe restorative care for children.

Philosophy of treatment planning• Gain the trust and cooperation of the child.• Make an accurate diagnosis and devise a treatment plan appropriate to the child’s need.• Comprehensive preventive care.• Deliver care in a manner the child finds acceptable.• Use materials and techniques which provide effective and long-lasting results.

HistoryThis should include medical history, social history, history of the present complaint and the past dental history. What were the “likes” and “dislikes” of the child at previous dental visits? In addition, parents’ assessment of the previous and expected child’s behaviour is useful.

Examination• A good examination using tell–show–do, including charting for teeth present and caries, including areas of early decalcification.• Any missing teeth.• Gingival health.• Developmental defects.• Tooth surface loss.• Initial occlusal assessment.

Radiographs and other investigationsAppropriate radiographs such as bitewings or OPG (Chapter 10) or any other special tests such as pulp sensibility tests.

DiagnosisIn children the diagnosis needs to encompass two aspects:• diagnosis of the dental/oral condition;• the child’s behaviour and the behavioural approach likely to succeed in provision of the treatment.

8  Chapter 2  Growth and development

2 Growth and development

Table 2.1 Growth period. Lowrey’s classification (1973).

Growth period Chronological age

Prenatal Conception to birth (40 weeks)

Infancy Birth to 2 years

Early childhood (preschool) 3–6 yearsToddlers – second and third yearPlay stage – 4–6 years

Late childhood (prepubertal) 7–12 yearsPuberty age range for girls 10–14 years, puberty

age range for boys 12–16 years

Adolescence 13–20 years

Table 2.2 Disturbances in prenatal development.

Genetic disturbances Environmental disturbances

Chromosomal: Down syndrome, chromosome 18Polygenic (several genes), e.g. cleft lip/palateMonogenic (single gene), e.g. enzyme deficiencies,

amelogenesis imperfecta, chondrodysplasia, some craniofacial syndromes

Medication: thalidomideMaternal infections: rubella, toxoplasmosisX-ray radiationAnorexiaMaternal malnutritionMaternal alcoholism

Table 2.3 Disturbances in postnatal development.

Primary Secondary

Skeletal dysplasias – 100 disorders where genetic damage or defect to skeletal system

Chromosomal aberrations/disorders, e.g. Down syndrome, Turner’s syndrome

Congenital errors of metabolism, e.g. mucopolysaccharidoses (genetic conditioned failures in the intercellular substance in the connective tissues), Hunter syndrome, Hurler syndrome

Miscellaneous syndromes. Unknown aetiology but seen at birthGenetic short stature (familial)

Malnutrition: if prolonged and severe. Poverty and poor nutrition. Emotional and physical abuse

Systemic and metabolic disorders, e.g. coeliac disease, cystic fibrosis, chronic renal disease

Deprivation dwarfism (psychosocial growth retardation), caused by disturbances in emotional contact between child, parents and environment

Endocrine disorders: growth, sex or thyroid hormone deficiency, hypothyroidismConstitutional growth delay and puberty (normal variant): children with delayed skeletal

maturity. They tend to have delayed growth and sexual maturation but their final height will be normal

Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd.

Growth and development  Chapter 2  9

• Chronological age.• Neurological age.• Morphological age.• Skeletal age.• Mental age.• Secondary sex characteristics.• Dental age.

Methods of monitoring somatic growth• Length/height.• Weight.• Head circumference.• Behavioural milestones.• Dental age.Height and weight are usually monitored using standard growth charts. For height the most common one used is height velocity chart and for weight the BMI-for-age chart.

Dental age – why is it important?Dental age correlates well with chronological age. It is important for dentists to have a knowledge of growth and development, especially of the dentition, for the following reasons:• tooth eruption sequence is important – if any problems with the occlusion occur, it is important to check whether the eruption sequence is correct, especially in cases where teeth might be developmentally absent;• tooth emergence dates are used in orthodontics for timing of treatment;• timing of fluoride supplements (systemic fluoride) depends on the dental age (prevention advice);• stages of development are important when considering loss of the permanent first molars;• stage of apical development in incisors is important in cases of trauma to monitor pulp healing.It is also important for paediatric dentists to understand the difference in growth between males and females to help in the management of the developing dentition and provision of interceptive orthodontic care:• growth in height between boys and girls is almost parallel up to age 10 years;• in girls, age 11–13 years, female oestrogens causes rapid growth and bony epiphyses uniting at age 14–16 years;• in boys, testosterone causes later prolonged growth (age 13–17 years).Disturbances in prenatal and postnatal development are shown in Tables 2.2 and 2.3.

Development of the nasomaxillary complex• Grows downwards and forwards relative to the cranial base and greatest during pubertal growth spurt.• Areas near sutures found at maxilla and cranial base have bone deposition as brain grows and soft tissue of face forms.• During pubertal growth spurt, facial skeleton growth starts and is almost completed at age 15.5 years in girls and later in boys.

Mandibular growth• Greatest during pubertal growth spurt.• Growth of mandible coordinates with growth of maxilla and cranial base in forward and downward direction (translation of the mandible).• Bony deposition at ramus and in condyles allows mandible to grow downwards and forward.• Mandibular condylar cartilage (reactive growth site) is involved in bone formation with cartilage proliferation and its replacement by bone.

Tooth developmentTeeth start to form very early on, around the 5th week of the embryo. The dental lamina gives rise to epithelial buds that then differentiate into the tooth germ, within which reside the cells for the development of the various tooth structures. The odontoblasts form dentine and ameloblasts form the enamel. The epithelial structure known as the root sheath of Hertwig arises from an apical migration of the epithelial cells at the cervical loop of the enamel organ and is responsible for the development of the roots of the teeth.

Tooth eruptionEruption times for the primary teeth (in months)Lower central incisor: 7–8Upper incisors: 10–11Upper lateral: 11Lower lateral: 13First primary molars: 16Canines: 19Second primary molars: 27–29

Eruption times permanent dentition (in years)First molar and lower central incisor: 6Upper central and lower lateral incisors: 7Upper lateral incisor: 8Lower canines and first premolars: 10Upper canine and second premolars: 11Second molars: 12Third molars: 16 onwards

Methods of assessing growthThe growth periods as described by Lowrey (1973) are shown in Table 2.1.

10  Chapter 3  Child cognitive and psychological development

3 Child cognitive and psychological development

Figure 3.1 Characteristics of attachment according to John Bowlby (1969).

Proximity Maintenance Safe Haven

ATTACHMENT

Secure Base Separation Distress

Table 3.1 Erikson’s psychosocial theory – stages of development and crisis/conflicts at each stage.

Stages Crisis or conflict

Stage 1 Trust vs mistrust

Stage 2 Autonomy vs shame or guilt

Stage 3 Initiative vs guilt

Stage 4 Industry vs inferiority

Stage 5 Identity vs confusion

Stage 6 Intimacy vs isolation

Stage 7 Generativity vs stagnation

Stage 8 Integrity vs despair

Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd.

Child cognitive and psychological development  Chapter 3  11

IntroductionIn order to understand behaviour management for helping children accept dental care, a basic knowledge of the child’s cognitive and psychological development is essential.

Theories of cognitive and psychological developmentThe cognitive capability of children changes from birth through to adulthood. Various theories divide this process into a number of stages for clarity and ease of description.

John Piaget’s theory of cognitive developmentThis important theory has three important concepts, schema, assimila-tion and accommodation. Schemas are categories of knowledge that help us to interpret and understand the world. The process of taking in new information into our previously existing schemas is known as assimilation. Accommodation involves altering existing schemas, or ideas, as a result of new information or new experiences.

Piaget believed that all children try to strike a balance between assimilation and accommodation, which is achieved through a mecha-nism called equilibration. As children progress through the stages of cognitive development, it is important to maintain a balance between applying previous knowledge (assimilation) and changing behaviour to account for new knowledge (accommodation). Equilibration helps explain how children are able to move from one stage of thought into the next.

According to Piaget there are four stages of cognitive development:1. sensorimotor period;2. preoperational period;3. concrete operational stage;4. formal operational period.

Erikson’s psychosocial theory (Table 3.1)Erikson believed that personality develops in stages with each stage characterised by a conflict or a crisis (Table 3.1). The stages are:• Stage 1. Infancy: age 0–1 years.• Stage 2. Toddler: age 1–2 years.• Stage 3. Early childhood: age 2–6 years.• Stage 4. Elementary and middle school years: age 6–12 years.• Stage 5. Adolescence: age 12–18 years.• Stage 6, 7 and 8 relate to young adulthood through late adulthood.

Freud’s psychosexual theoryFreud’s theory stressed the importance of childhood events and experi-ences, but are focused almost solely on mental disorders rather than normal functioning. For this reason this is of limited importance for paediatric dentists, but is discussed here for the sake of completeness.• Oral stage. Age 0–1.5 years.• Anal stage. Age 1.5–3 years.• Phallic stage. Age 4–5 years.• Latency. Age 5 years to puberty.• Genital stage. Puberty onwards.

Behavioural theories of child development1. Classical conditioning by Pavlov. This is learning through asso-ciation. The theory is based on conditioned and unconditioned stimu-lus and response. An unconditioned stimulus unconditionally and

automatically triggers a response. A conditioned stimulus is one that is previously a neutral stimulus but after becoming associated with the unconditioned stimulus, eventually comes to trigger a conditioned response, which is learned.2. Operant conditioning by Skinner. This is learning through con-sequences. The term operant refers to any “active behaviour that operates upon the environment to generate consequences”. This is a method of learning that is possible through rewards and punishments for behaviour. Through this form of conditioning, an association is made between behaviour and a consequence for that behaviour. This theory is of great significance in paediatric dentistry as it is the basis of the behaviour management technique called behaviour shaping. It has three main principles:

• Reinforcement: a consequence that causes behaviour to occur with greater frequency in future. Positive reinforcement is the addi-tion of a favourable, pleasant stimulus following behaviour, such as praise or giving a small gift, for example stickers. Negative rein-forcement is the removal of an aversive, unpleasant stimulus follow-ing behaviour.• Punishment: a consequence that causes behaviour to occur with less frequency in the future. Positive punishment can be adminis-tered through the addition of an unpleasant stimulus following behaviour whereas negative punishment implies the removal of a pleasant stimulus following behaviour.• Extinction is the lack of any consequences following behaviour. Such an inconsequential behaviour will occur with less frequency in future.

3. Observational learning. Learning by observation. It does not require direct personal experience with stimuli, reinforcers or punish-ers. Children learn by simply watching the behaviour of another person called a model and later imitating the model’s behaviour. This technique is used often to manage behaviour of children in paediatric dentistry.

Social theories of child developmentThe attachment theory by John Bowlby (Fig. 3.1)Child development is best understood within the framework of pat-terns of interaction between the child and the primary caregiver. If there were problems in this relationship then the child is likely to form insecure and anxious patterns. According to Bowlby there are four characteristics of attachment:• proximity maintenance – the desire to be near the people we are attached to;• safe haven – returning to the attachment figure for comfort and safety in the face of a fear or threat;• secure base – the attachment figure acts as a base of security from which the child can explore the surrounding environment;• separation distress – anxiety that occurs in the absence of the attachment figure.

Vygotsky’s sociocultural theorySociocultural theory stresses the important contributions that society makes to individual development. Cognitive growth and complex thinking evolve out of social interactions. An important concept of this theory is the “zone of proximal development”, which stresses the ability of the child to learn under guidance and knowledge and skills that a person cannot yet understand or perform on their own yet, but is capable of learning through collaboration with more capable peers.