Notes on Pediatric Dentistry
The main pediatric dentistry problems can be addressed easily if they are considered in relation to the age of the child, taking into account the most frequent diseases from birth to the end of the pediatric age, tooth development phases and eruption times, hygiene and eating habits, the child’s behavior, and the effectiveness of preventive measures.
Even in the earliest months of life some children need dental care and procedures for early caries, attributable to the incorrect use of baby bottles containing sweetened drinks. Chamomile or sweetened herbal teas are often given to children to relieve the pain of infant colic at night. This can lead to a condition known as early childhood caries (ECC) or baby bottle tooth decay (BBTD) (Figure 14-1).
Caries is a transmissible infectious disease of bacterial origin. It is one of the most widespread diseases in the world. The most common chronic infection in childhood, it is 5 times more frequent than fever and 14 times more common than chronic bronchitis (Evans and Kleinman, 2000). It affects the following populations:
Caries has a multifactorial etiology: bacterial flora, host susceptibility, diet, and the time factor play key roles in the development of lesions (Figure 14-2). The carious process consists of the acid dissolution of the tooth structure.
At birth the newborn’s mouth is virtually sterile. Bacterial colonization usually occurs through the saliva of parents or caregivers by direct contact such as kissing, or indirectly by sharing the same spoon during meals or saliva contact with the dummy or pacifier.
When a child exhibits carious lesions during the first years of life, ECC can be diagnosed based on the following typical signs of the disease (European Journal of Paediatric Dentistry, 2004) (Figure 14-5):
Figure 14-5 Diagram of mother-infant bacterial infection.
The DMFT index expresses the average number of decayed, missing, and filled teeth as a result of caries, and it is the most effective method for conducting caries prevalence studies. When written in the lowercase (dmft), the acronym refers to deciduous teeth, whereas DMFT refers to the permanent ones.
One of the preventive measures that has proven to be effective in reducing the caries risk in the first years of life is fluoride prophylaxis. There are various sources of fluoride intake. For years the main route of intake was drinking water, in which fluoride could be present both naturally and as a result of fluoridation. In a number of countries, however, tap water has now been replaced by bottled water. According to a European Economic Community (EEC) Directive passed in May 2003, as of December 2006 the concentration of fluoride must be indicated on the label of bottled water, warning that concentrations higher than 1.5 mg/L can be harmful to infants and children who drink it on a regular basis.
The European Association of Dental Public Health (EADPH) recommends systemic fluoride prophylaxis from the end of breastfeeding until 3 years of age. At 3 years of age, when the swallowing reflex has developed, topical fluoride prophylaxis with toothpaste containing 1000 ppm of fluoride can commence.
When children are 12 months of age it is important to encourage parents to stop using the bottle and replace it with a cup in order to reduce the mechanical stimulation of the teat on the palate and dental arches, which can cause developmental alterations and malocclusions. Furthermore, the constant consumption of sugary drinks should be avoided, and the child should be encouraged to eat chewable foods.
Tooth injuries are among the most frequent dental emergencies in children. Epidemiologic studies state that one out of two children will sustain a dental injury from accidental falls, sports, traffic accidents, or violence.
In the first years of life lesions are mainly caused by the carelessness on the part of caregivers (falls from the changing table or bed), the child’s overactiveness, falls resulting from the lack of motor coordination that characterizes the first stages of autonomous walking, injuries caused by improper child restraint measures in the car, and child abuse (nonaccidental injuries [NAIs]). Traumatic injuries in deciduous dentition usually involve the soft tissues of the oral cavity (lips, gingival mucosa), and the supporting tissues of the tooth (concussions, dislocations, avulsions). Correct diagnosis and proper treatment are crucial to reduce the risk of consequences for the corresponding permanent teeth.
It is important to note that the pediatrician is the one who takes care of prevention from birth. Therefore, he or she can be considered the most important point of reference for both children and parents. When there is an emergency, the pediatrician works with the dentist to inform the parents and caregivers about the correct measures to take. The pediatrician will provide guidance on how to practice first aid, stressing the importance of adequate follow-up to avoid long-term complications (Figure 14-6).
Figure 14-6 First aid in the case of trauma involving the deciduous dentition according to the guidelines of the IADT (International Association of Dental Traumatology) and the SITD (Società Italiana di Traumatologia Dentale [Italian Society of Dental Traumatology]). (1) Wash the wound thoroughly with plenty of water. (Usually dental trauma also affects the soft tissues.) (2) Stop bleeding by compressing the traumatized area for 5 minutes. (3) Consult a dentist for emergency treatment.
At 3 years of age the deciduous dentition should be complete. At this point occlusion can be reevaluated, and any alterations of the dental formula or functional abnormalities (bruxism) should be investigated.
Dental visits should not be a source of anxiety for the child: The dentist should be able to relate to the young patient, explaining every maneuver before performing it. Radiographic examinations should be performed with extreme caution and only if they are strictly necessary, given that additional exposure may be required for other general health problems.
The role of educators is crucial. Oral hygiene messages are often better reinforced and accepted if they come from a school environment such as daycare. Unfortunately, oral hygiene education is still given little attention at school owing to the difficulties involved in managing a large group of children and the risk of exchanging of toothbrushes.
Figure 14-7 Coronal fracture. First aid in the case of trauma involving the deciduous dentition according to IADT (International Association of Dental Traumatology) and SITD (Società Italiana di Traumatologia Dentale [Italian Society of Dental Traumatology]) guidelines.
Figure 14-8 Avulsion. First aid in the case of trauma involving the deciduous dentition according to IADT (International Association of Dental Traumatology) and SITD (Società Italiana di Traumatologia Dentale [Italian Society of Dental Traumatology]) guidelines.
Prevention of malocclusion begins with the pediatrician and dentist, who should note and correct habits such as finger and pacifier sucking, atypical swallowing, lip interposition, and lip sucking. In fact, certain functional conditions can adversely affect the development of the stomatognathic system.
Fluoride and sealants are currently the most effective protective measures against caries (Figure 14-10). Patients with high caries risk should be treated with preventive sealing of pits and fissures of the first permanent molars (Figure 14-11).
Figure 14-10 Sealants and fluoride protection against caries.
Figure 14-11 Sealing of a first permanent molar.
At 8 years of age the child should be able to perform oral hygiene practices autonomously, understand the importance of regular dental checkups, and learn to communicate directly with the dentist. Proper oral health education that starts in the earliest years of life can positively influence the child’s perception of the dentist and the dental environment (Figure 14-12).
Figure 14-12 A child’s drawing of the dental office.
When the permanent incisors erupt (Figure 14-13) they may show signs of fluorosis, particularly in children who have used naturally fluoridated water and those in whom fluoride prophylaxis was administered overenthusiastically (Figure 14-14). It is important to exclude all other causes of enamel alteration, such as celiac disease, trauma to the deciduous dentition, and structural abnormalities that are genetic and pharmacologic in nature.
Figure 14-14 Signs of fluorosis in a young patient.
When the child is 10 years old, parents should be reminded to minimize the intake of foods containing fermentable carbohydrates such as snacks, explaining that their intake during meals is less damaging—provided that it is followed immediately by good oral hygiene practices.
Given the unquestionable effectiveness of prevention, as early as the age of 10 children should be informed about the consequences of the abuse of certain substances on the oral cavity (Figure 14-15).
By age 16, deciduous tooth shedding has already been completed for some time and the dentition is relatively stable. Therefore attention must paid to third molars, and their presence and the space available for their eruption should be checked. At this point the orthodontist will evaluate the timing and possible need for extraction (Figure 14-16).
Figure 14-16 Outcomes of the extraction of the first right lower molar. On a clinical level, it is evident that tooth 28 is not in the arch. The radiographic image shows a bone resorption area. After treatment the periodontal status reverted to normal. The tooth began to erupt 3 months later, but the alveolar bone loss was significant.
The dentist should never stop stressing the dangers of an unhealthy diet to their young patients, emphasizing the importance of reducing the frequency of food intake and the amount of fermentable carbohydrates. It is important to bear in mind that the cariogenic potential of these foods is influenced not only by sugar content, but also acidity. An acid pH corrodes the teeth, and this effect may prevail over that of sugar concentration. Consequently, the cariogenic effect of drinks that are high in sugar, carbonated, or acidic (pH around 4) is similar to that of beverages with the same pH but a lower carbohydrate content.
|Iced tea||20-50 mg|
|Cola drinks||34-45 mg|
|Noncarbonated cola drinks||40-55 mg|
|Caffeinated water||45-90 mg|
|Chocolate milk||20-50 mg|
|Chocolate bars||25-35 mg|
From American Academy of Pediatric Dentistry.
Today body piercing is extremely popular among young people, and it has been estimated that 20% of Italian teenagers have at least one piercing. Therefore any complications that may arise from this practice should not be underestimated.
In particular, oral and perioral piercing complications may arise during the procedure or immediately after placement of the object, but also long after. The former include hemorrhaging and damage to nerve structures (often after tongue/>