The Practical Importance of Pediatric Dentistry
Pediatric dentistry is synonymous with dentistry for children. Pediatric dentistry exists because children have dental and orofacial problems. Dentistry for children unquestionably grew out of the need to manage dental caries and its sequelae of pulpitis, inflammation, and pain associated with infected pulpal tissue and suppuration in alveolar bone.
It was logical that from its extraction-oriented beginnings, pediatric dentistry grew to include caries interception with an emphasis on diagnostic procedures and the maintenance of arch integrity in instances of tooth loss due to decay or trauma. The malocclusion consequences of unbridled tooth removal were soon determined to be preventable. Restorative techniques, pulpal therapy, space maintenance, and interceptive orthodontics were the main themes of this era, which sadly is still not over. Because of the lingering problem of early childhood caries and its recent increase, these treatment techniques are covered in detail in this book.
Pediatric dentistry today emphasizes prevention of dental diseases, which is a primary focus of this book, and it is addressed specifically for each of the four age groups that reflect the organization of this book. Caries risk assessment, as it relates to individualized prevention, is also featured in this edition to reflect the evolution of evidence-based oral health care.
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.
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.
|1900||Few children are treated in dental offices. Little or no instruction in the care of “baby teeth” is given in the 50 dental schools in the United States.|
|1924||First comprehensive textbook on dentistry for children is published.|
|1926||The Gies Report on dental education notes that only 5 of the 43 dental schools in the United States have facilities especially designed for treating children.|
|1927||After almost a decade of frustration in getting a group organized to promote dentistry for children, the American Society for the Promotion of Dentistry for Children is established at the meeting of the American Dental Association (ADA) in Detroit.|
|1932||A report of the College Committee of the American Society for the Promotion of Dentistry for Children states that in 1928, 15 dental schools provided no clinical experience with children, and 22 schools had no didactic information in this area.|
|1935||Six graduate programs and eight postgraduate programs exist in pedodontics.|
|1940||The American Society for the Promotion of Dentistry for Children changes its name to the American Society of Dentistry for Children.|
|1941||Children’s Dental Health Day is observed in Cleveland, Ohio, and Children’s Dental Health Week is observed in Akron, Ohio.|
|1942||The effectiveness of topical fluoride applications at preventing caries is described. The Council on Dental Education recommends that all dental schools have pedodontics as part of their curriculum.|
|1945||First artificial water fluoridation plant is begun at Grand Rapids, Michigan.|
|1947||The American Academy of Pedodontics is formed. (To a large degree, the start of the Academy was prompted by the need for a more scientifically focused organization concerned with the dental health of children.)|
|1948||The American Board of Pedodontics, a group formulated to certify candidates in the practice of dentistry for children, is formally recognized by the Council on Dental Education of the ADA.|
|1949||The first full week of February is designated National Children’s Dental Health Week.|
|1955||The acid-etch technique is described.|
|1960||Eighteen graduate programs and 17 postgraduate programs in pedodontics exist.|
|1964||Crest becomes the first ADA-approved fluoridated toothpaste.|
|1974||The International Workshop on Fluorides and Dental Caries Reductions recommends that appropriate fluoride supplementation begin as soon after birth as possible. (This recommendation was later modified by authorities to start at 6 months of age.)|
|1981||February is designated National Children’s Dental Health Month.|
|1983||A Consensus Development Conference held at the National Institutes of Dental Health endorses the effectiveness and usefulness of sealants.|
|1984||The American Academy of Pedodontics changes its name to the American Academy of Pediatric Dentistry.|
|1995||A new definition is adopted for the specialty of pediatric dentistry by the ADA’s House of Delegates: Pediatric dentistry is an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.|
|2003||The AAP establishes “Policy Statement on Oral Health Risk Assessment Timing and Establishment of a Dental Home,” and issuance of this policy statement will be manifested in several outcomes, including the need to identify effective means for rapid screening in pediatricians’ offices, and the mechanisms for swift referral and intervention for high-risk children.|
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.
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:
• The importance of infant oral health as the best opportunity to prevent early childhood caries by providing families with preventive information and the general dentist’s role working with nondental professionals
• Acid-etch techniques, sealants, and composite resins and their place in pediatric dentistry, which now also includes consideration of relative life span compared with other restorative approaches and concerns about toxicity in dental materials
• Dentistry for the disabled patient and other children with special needs who are now living longer because of medical advances, but whose dental treatment often requires consideration of medications, organ function, and other medical needs
• Sophistication of radiographic techniques as digital and three-dimensional imaging become more common and provide advanced detailed diagnostic information along with concerns about exposure of children to radiation during their growing years