Paul S. Casamassimo

 Outline

Historical Perspective

Until the mid-1950s, in at least one state of the United States, a major dental supplier gave all new clients opening dental offices a very handsome sign that said: No children under age 13 treated in this office. Fortunately, such attitudes are now gone, the result of improved education and science as they relate to pediatric dentistry. Specific educational guidelines for pediatric dentistry are now an integral part of the fabric of dental education imposed on all dental schools accredited by the Commission on Dental Accreditation. Graduates of all accredited dental schools in the United States have both didactic and clinical education in dentistry for children. Furthermore, through the efforts of organized dentistry and other advocates of the oral health of children, the notion that the “baby teeth don’t deserve care because you lose them anyway” has largely disappeared.

The historical premise that dental care should begin at 3 years of age or later was based on the belief that a child under 3 years was too difficult to treat, except by a specialist and often using pharmacologic techniques, readily available to only a few specialists. Though it is true that treatment is often difficult, the threshold of age 3 years meant that many children would experience dental caries and enter the dental office with restorative and pain management needs. The American Academy of Pediatric Dentistry today advocates a dental visit on or before the first birthday.¹ In May 2003, the American Academy of Pediatrics (AAP) issued guidance to its membership of more than 50,000 pediatricians to perform oral health assessment at 6 months of age during well child visits along with application of fluoride varnish.¹⁰ Unquestionably, the appropriateness of this recommendation for earlier attention to dental care by health professionals is due to the recognition today that early childhood caries cannot be eliminated through restoration or selected tooth extraction, and that children afflicted with early childhood caries are more prone to dental caries in their permanent dentition.

Milestones in Dentistry for Children in the United States

Table 1-1 provides a timeline that depicts the evolution of dentistry for children. Like the specialty of endodontics, pediatric dentistry grew out of restorative dentistry, championed by general dentists who enjoyed working with children and had compassion for the suffering they underwent with unchecked dental caries in the pre-fluoride era. Care of children was at first simply a dentist’s preference, and then it was officially recognized as a specialty midway in the last century. During its rise to specialty status, pediatric dentistry followed a path similar to other dental specialties, beginning with interest groups of dentists, the formation and gradual proliferation of a number of pediatric dentistry training programs, and eventual recognition by organized dentistry. Pediatric dentistry eventually focused on treatment of infants, children, and adolescents and also became the group in organized dentistry caring for persons with special health care needs. In the mid-1990s, the official definition of the specialty focused on children and adolescents, but in practice, many adults with disabilities remained in the care of pediatric dentists and do so today because of the difficulties in transitioning to general practitioners.

For several reasons, the general dentist community remains the overwhelming provider of oral health care for children. Most children simply need basic dental services, predominantly diagnostic and preventive in nature. This is true for very young children and infants who have no dental disease and simply need a dental home. Graduates of today’s dental education system are well-prepared to address all but the most difficult of pediatric oral health issues. Another important reason is that pediatric dentists are not plentiful, and even with a major effort to educate more pediatric dentists over the last two decades, the number practicing is well below 10,000 nationally, compared with over 200,000 general dentists. Convenience and compliance also strongly support the concept of family dentistry, whereby all family members can have the same dental home.

Challenges for Pediatric Dentistry in the 21st Century

With the recent recognition of the increase in early childhood caries in the United States and other industrialized nations, and the localization of this disease in poor and minority children, the focus of pediatric dentistry has shifted. A dentist treating children needs to be aware of the new challenges in keeping a child caries-free throughout childhood. Dental disease initiation and conversely, its prevention and control, are now believed to be highly influenced by factors beyond the biological ones traditionally attributed to the Keyes model of interaction of bacteria, sugar, and teeth. These other factors include the effect of the community, the system, and the family and are not biological in nature. What this means is that the dentist treating children must consider many different elements, and not just the child and family and the biology of the mouth. Preventive dentistry includes understanding the role of exogenous, nonbiological factors in caries initiation and progression, especially for poor and diverse populations. Important in today’s care of children are these considerations: