Procedures in Paediatric Dentistry

Procedures in Paediatric Dentistry

Sanjeev Sood


Paediatric dentistry relates to the care of young patients. It focuses on: preventive dental care; the diagnosis, treatment planning and delivery of care requiring non‐pharmacological behaviour management; management of dental trauma and its consequences; the management of patients with special needs and children that are medically compromised; management of dental anxiety with the use of sedation techniques; and comprehensive oral care for patients under general anaesthesia.

Children have a right to the enjoyment of the highest attainable standard of health, and to facilities for the treatment of illness and rehabilitation of health.

United Nations Convention on the Rights of the Child, Article 24

Management of dental caries includes assessment of the child’s caries risk, understanding of the disease process at an individual level, appropriate assessment of the disease process, managing where deemed suitable with targeted prevention and when necessary a restorative intervention. This chapter will focus on the restorative management of caries in the primary dentition as other chapters will cover the restorative management in the permanent dentition. Several of the techniques for restorative procedures in primary teeth are similar to those for the permanent dentition and these should always be kept in mind. The individual elements of the care plan are common to all forms of dentistry; however, it is of the utmost importance to treat the child and not the tooth.

There are a number of challenges that clinicians face when treating children. Despite these challenges, there are many reasons why time, effort and resources should be spent to manage this patient group successfully (Table 17.1).

Table 17.1 Factors influencing the management of children in practice.

Issues that make treating children challenging Reasons for treating children
  • The child’s behaviour.
  • Stages of development:
    • Behavioural
    • Dental
  • Shorter attention spans.
  • Differing tooth morphology.
  • Challenging operator access.
  • Choices of restorations.
  • Demanding parents.
  • Consent.
  • Prevention.
  • Fostering good attitudes towards dentistry.
  • General health and wellbeing.
  • Relief of pain.
  • Prevent damage to the permanent dentition.
  • Prevent adverse consequences caused by premature tooth loss.
  • Treating children is a practice builder.
  • It is rewarding.

The principle aims when providing dental care for paediatric patients include:

  • Keeping the primary and permanent dentition free from dental disease.
  • Applying targeted prevention plans based on the patient’s caries risk status and using best available evidence and guidance.
  • Reducing the risk of the child experiencing pain and anxiety due to dental disease or from treatment provided.
  • Managing caries in the primary dentition at an early stage using the best techniques available ensuring that the teeth exfoliate at the natural time without causing pain.
  • Instilling a positive dental attitude towards dental care now and for the future.

Untreated dental decay in children has a significant impact on their lives (Table 17.2).

Table 17.2 Possible adverse effects of dental neglect.

  • Pain and sepsis.
  • Greater risk of new carious lesions developing in both the primary and permanent dentition.
  • Disruption to the quality of life.
  • Missing school.
  • Greater social impact on the family unit.
  • Increased incidence of hospitalisation.

The decision to restore carious primary teeth is complex. There are a number of factors that must be considered which are usually out of the control of the patient. The assessment of the patient should include a comprehensive clinical examination (extra‐ and intraoral), visual detection and radiographic evaluation of the carious lesions (Figure 17.1). Very young children and those who are anxious about dental treatment may find a full dental assessment frightening and may not cope with the full range of required diagnostic procedures. Behaviour management and modifications in approach, including a gradual introduction, should overcome these barriers. To make this decision several factors (Figure 17.2) must be considered.

Image described by caption.

Figure 17.1 (a) Clinical and (b) radiographic detection of caries. Note tooth 64 appears clinically sound; however, the bitewing radiograph shows the distal caries, together with an early enamel lesion in tooth 65.

Flow chart illustrating the decision-making processes in paediatric patients from clinical diagnosis to therapy decisions, to behavior management, to recall and review.

Figure 17.2 Flow chart for decision‐making processes in paediatric patients.

Radiographic Assessment

There must be sound clinical indications to justify the exposure of children to x‐rays to obtain dental radiographs, as they are particularly susceptible to the effects of ionising radiation. Careful clinical examination should indicate the most appropriate radiograph to confirm the diagnosis and previous radiographs should always be examined. The importance of radiographs in treatment cannot be overstated (Figure 17.3).

Image described by caption.

Figure 17.3 Grade 1 right and left bitewing radiographs in an 8‐year‐old.

The benefits of bitewing radiographs include:

  • Detection of caries that cannot otherwise be seen.
  • The use of bitewing radiography, in addition to clinical examination, increases the number of interproximal lesions detected by a factor of between 2 and 8.
  • Estimation of the extent of lesions.
  • Monitoring of lesion progression (repeat radiographs, depending on the patient’s caries risk status).

The frequency and recall with regards to radiographic exposure is dependent on the risk status of the child. For all high caries risk individuals, bitewing radiographs should be taken at the initial examination and at 6‐monthly intervals until no new or active lesions are apparent and the individual has entered another risk category. A child with little or no caries activity does not require bitewing radiographs at every recall appointment. Children with low caries risk should be radiographed at approximately 12–18 month intervals in the primary dentition and at approximately 2‐year intervals in the permanent dentition.

Once the decision has been made to restore a tooth, the operator must remember the differences in the anatomy of primary and permanent teeth. There are several key anatomical differences which affect disease progression, cavity design and restorative choices. Having knowledge of these will help with successful outcomes and reduce failure of the restorative care provided (Table 17.3).

Table 17.3 Primary tooth anatomy clinical implications.

Primary tooth anatomy Implication
Thinner enamel and dentine
  • Affects cavity design.
  • Less tooth structure for support.
  • Disease progression through the hard tissues is more rapid.
Larger pulps: pulp chamber of primary teeth is relativity larger when compared with permanent teeth with the pulp horns being more superficial
  • Pulpal involvement in the caries process is more rapid.
  • Iatrogenic damage to the pulp during restorative procedures is more likely.
Broad contact ‘areas’
  • Detection of interproximal caries is more difficult in these areas.
  • Large stagnant areas with limited self‐cleaning results in rapid progression of caries.
  • Adaption of the interproximal area for occlusal‐proximal restorations requires modification.
Bulbous crowns
  • Difficulty with matrix band adaptation and placement.
Narrower occlusal table: convergence of the buccal and lingual walls results in a narrower occlusal table
  • Overpreparation of an occlusal cavity can lead to weakening of the cusps.
Altered angulation of the enamel prisms: cervically, one‐third of the enamel prisms are inclined in an occlusal direction
  • No need to bevel the gingival floor.
Thin pulpal floor and accessory canals
  • Radiolucent areas and infection is usually present in the interfurcal area.
  • Clinically a sinus will be seen higher on the gingival margin.
Root form: proportionally longer roots, more flared and flattened
  • Root canal therapy (RCT) difficult in primary teeth.
  • Fracture of roots during extractions more likely.
Developing successor
  • During RCT and extractions, care must be taken not to damage the developing successor.

Care Planning

The care plan for the patient will be determined by a number of the factors mentioned previously. The motivation of the child and parent, the extent of decay, the age of the child, the likely survival of the primary tooth, with any associated symptoms, will dictate your plan.

With this information, a care plan and philosophy of preventative management can be formulated (Tables 17.4 and 17.5). It is essential for any restorative intervention that there is good pain control accompanied by good behaviour management (Table 17.6). Usually this involves quadrant dentistry, minimising the number of visits and the use of local anaesthetic, and building up treatment in stages of complexity while gaining the child’s trust and confidence. This can be achieved by starting off with a simple procedure (e.g. fissure sealants) then moving onto move complex treatment (e.g. composite restorations) and if possible leaving extractions to the end.

Table 17.4 High caries risk factors to assess when care planning your patients.

  Risk category  
Caries risk factors Clinical evidence Dietary habits Social history Use of fluoride Plaque control Saliva Medical history
High Risk New lesions
Premature extractions
Anterior caries or restoration
Multiple restorations
No fissure sealants
Fixed appliance orthodontics
Partial dentures
Frequent sugar intake Social deprivation
High caries in siblings
Low knowledge of dental disease
Irregular attendance
Ready availability of snacks
Low dental aspirations
Drinking water not fluoridated
No fluoride supplements
No fluoride toothpaste
Infrequent, ineffective cleaning
Poor manual control
Low flow rate
Low buffering
High Streptococcus mutans and lactobacillus counts
Medically compromised
Physical disability
Long term cariogenic medicine

Table 17.5 Prevention plans for delivering better oral health: summary guidance for primary care teams (2017). Reproduced with permission of Public Health England.

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Prevention of caries in children age 0–6yrs
Advice to be given EB Professional intervention EB
Children aged up to 3 years
  • Breast feeding provides the best nutrition for babies
  • From 6 months of age infants should be introduced to drinking from a free‐flow cup, and from age 1 year feeding from a bottle should be discouraged
  • Sugar should not be added to weaning foods or drinks
  • Parents/carers should brush or supervise toothbrusing
  • As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste
  • Brush last thing at night and on one other occasion
  • Use fluoridated toothpaste containing no less than 1000 pm fluoride
  • It is good practice to use only a smear of toothpaste
No alt text required.
  • The frequency and amount of sugary food and drinks should be reduced
  • Sugar‐free medicines should be recommended
All children aged 3–6 years
  • Brush at least twice daily, with a fluoridated toothpaste
  • Apply fluoride varnish to teeth two times a year (2.2% NaF‐)
  • Brush last thing at night and at least on one other occasion
  • Brushing should be supervised by a parent/acrer
  • Use fluoridated toothpaste containing more than 1000 ppm fluoride
  • It is good practice to use onfy a pea size amount
No alt text required.
  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels
  • The frequency and amount of sugary food and drinks should be reduced
  • Sugar‐free medicines should be recommended
Children aged 0–6 giving concern [e.g., those likely to develop caries, those with special needs All advice as above plus:

  • Use fluoridated toothpaste containing 1350‐1500 ppm fluoride
  • It is good practioe to use only a smear or pea size amount
  • Where medication is given frequently or long term request thai it is sugar free, or used to minimise cariogenic effects
No alt text required.
No alt text required.
  • Apply fluoride varnish to teeth two or more times. a year (2.2%NaF‐)
  • Reduce recall interval
  • Investigate diet and assist adoption of good dietary practice in line with the eatwell plate
  • Where medication is given frequently or long term, liaise with medical practitioner to request it is sugar free, or used to minimise cariogenic effects
No alt text required.
Prevention of caries in children aged from 7 years and young adults
Advice EB Professional intervention EB
All patients
  • Brush at least twice daily, with a fluoridated toothpaste
  • Appy fluoride varnish to teeth two times a year (2.2% NaF‐)
  • Brush last thing at night and at least on one other occasion
  • Use fluoridated toothpaste (1350‐1500 ppm fluoride)
  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels
  • The frequency and amount of sugary food and drinks should be reduced
Jan 22, 2018 | Posted by in General Dentistry | Comments Off on Procedures in Paediatric Dentistry
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