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Pediatric Dentistry � A Guide for General Practitioner

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Pediatric Dentistry
– A Guide for General Practitioner
Mandeep S. Virdi
PDM Dental College and Research Institute, Bahadurgarh, Haryana
India

1. Introduction
Children a resource of the world are the promise of what our future is going to be. A healthy
child is a better promise of a better world than an unhealthy child. Oral health is a very
important aspect to ensure a healthy future therefore oral health for children is a worthy
concern regardless of child’s nationality, ethnicity or geographic location. Dentistry for
children has come a long way from its humble beginning in 1924 with the publishing of first
comprehensive text book on dentistry for children followed by formation of The American
Academy of Pedodontics in the late forties, which was also recognized by council of dental
education a part of the ADA to certify candidates to practice specialized dentistry for
children. Mid eighties saw the present name American Academy of Pediatric Dentistry
being adopted followed by defining pediatric dentistry which in the present day is defined
as 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 needs1.
Pediatric Dentistry as the definition implies is a body of knowledge that is dependent upon
curriculum of other dental subjects along with the latest development happening in various
specialties of dentistry. To be able to give primary, comprehensive and preventive oral
health care to children of all ages the pediatric dentist relies on preventive dentistry, pulpal
therapy, instrumentation and restoration of teeth, dental material, oral surgery, preventive
and interceptive orthodontics, and principals of prosthetics. Besides the dental knowledge, a
working knowledge is also required of pediatric medicine, general and oral pathology along
with growth and development. For the development of appropriate preventive strategy it is
imperative that the pediatric dentist have knowledge of nutrition and systemic as well as
topical effects of fluoride. To be able to deal effectively with children behavior management
and a thorough knowledge of psychological development is imperative because child needs
to be treated differently than the adult.

1.1 Prenatal stage

The prenatal period is a gestation of approximately nine months, beginning with the period
of ovum that lasts for about two weeks and is marked by blast cyst getting attached to the
wall of the uterus. This is followed by the period of embryo lasting for about next six weeks
and is characterized by development of the organ systems. Following which the period of
52 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

fetus lasting right up to the delivery of the child is the time when maturation of the newly
formed organs takes place.
The role of pediatric dentist starts at pre natal stage in guiding the expecting parents to
maintain oral health as the mouth is an obvious portal of entry to the body, and oral health
reflects and influences general health and well being. Maternal oral health has significant
implications for birth outcomes and infant oral health. Maternal periodontal disease, that is,
a chronic infection of the gingiva and supporting tooth structures, has been associated with
preterm birth, development of preeclampsia, and delivery of a small-for-gestational age
infant. Prematurely born children have higher prevalence of enamel defects. In very low
birth-weight children, the prevalence of enamel defects could be even higher. Both systemic
and local factors contribute to the etiology of dental defects.
Low birth-weight children are often intubated at birth, and left-sided defects on maxillary
anterior teeth occurred twice as frequently as right-sided defects, probably the result of
trauma from left sided laryngoscopy.
Maternal oral flora is transmitted to the newborn infant, and increased cariogenic flora in
the mother predisposes the infant to the development of caries. It is intriguing to consider
preconception, pregnancy, or intrapartum treatment of oral health conditions as a
mechanism to improve women's oral and general health, pregnancy outcomes, and their
children's dental health. However, given the relationship between oral health and general
health, oral health care should be a goal in its own right for all individuals. Regardless of the
potential for improved oral health to improve pregnancy outcomes, public policies that
support comprehensive dental services for vulnerable women of childbearing age should be
expanded so that their own oral and general health is safeguarded and their children's risk
of caries is reduced. Oral health promotion should include education of women and their
health care providers’ ways to prevent oral disease from occurring, and referral for dental
services when disease is present 2.

2. Role of pediatric dentist at birth

Infant oral health, along with perinatal oral health, is one of the foundations upon which
preventive education and dental care must be built to enhance the opportunity for a lifetime
free from preventable oral disease. Caries is perhaps the most prevalent infectious disease in
children. Almost half children have caries by the time they reach kindergarten. Early
childhood caries (ECC) can be a particularly virulent form of caries, beginning soon after
tooth eruption, developing on smooth surfaces, progressing rapidly, and having a lasting
detrimental impact on the dentition. This disease affects the general population but is
more likely to occur in infants who consume a diet high in sugar, and whose mothers
have a low education level. Caries in primary teeth can affect children’s growth, result in
significant pain and potentially life-threatening infection, and diminish overall quality of
life.
Caries is a disease that is, by and large, preventable. Early risk assessment allows for
identification of parent-infant groups who are at risk for ECC and would benefit from early
preventive intervention. The ultimate goal of early assessment is the timely delivery of
educational information to populations at high risk for developing caries in order to prevent
the need for later surgical intervention.
Pediatric Dentistry
– A Guide for General Practitioner 53

An oral health risk assessment for infants by 6 months of age allows for the institution of
appropriate preventive strategies as the primary dentition begins to erupt. Caries risk
assessment can be used to determine the patient’s relative risk for caries. Even the most
judiciously designed and implemented caries risk assessment tool, however, can fail to
identify all infants at risk for developing ECC. In these cases, the mother may not be the
colonization source of the child’s oral flora, the dietary intake of simple carbohydrates may
be extremely high, or other uncontrollable factors may combine to place the patient at risk
for developing caries. Therefore, screening for risk of caries in the parent and patient
coupled with oral health counseling, although a feasible and equitable approach to ECC
control is not a substitute for the early establishment of the dental home. Whenever possible,
the ideal approach to infant oral health care, including ECC prevention and management, is
the early establishment of a dental home.

3. Anticipatory guidance
General anticipatory guidance given by AAPD for the mother (or other intimate caregiver)
includes the following:
• Oral hygiene: Tooth-brushing and flossing by the mother on a daily basis are important
to help dislodge food and reduce bacterial plaque levels.
• Diet: Important components of dietary education for the parents include the
cariogenicity of certain foods and beverages, role of frequency of consumption of these
substances, and the demineralization/remineralization process.
• Fluoride: Using a fluoridated toothpaste approved by the relevant Dental Association
and rinsing every night with an alcohol-free, over-the-counter mouth rinse containing
0.05% sodium fluoride have been suggested to help reduce plaque levels and help
enamel remineralization.
• Caries removal: Routine professional dental care for the mothers can help keep their
oral health in optimal condition. Removal of active caries with subsequent restoration
is important to suppress maternal MS reservoirs and has the potential to minimize
the transfer of MS to the infant, thereby decreasing the infant’s risk of developing
ECC.
• Delay of colonization: Education of the parents, especially mothers, on avoiding saliva-
sharing behaviors (eg. sharing spoons and other utensils, sharing cups, cleaning a
dropped pacifier or toy with their mouth) can help prevent early colonization of MS in
their infants.
• Xylitol chewing gums: Evidence demonstrates that mothers’ use of xylitol chewing
gum can prevent dental caries in their children by prohibiting the transmission of
MS.
General anticipatory guidance for the young patient (0 to 3 years of age) includes the
following:
• Oral hygiene: Oral hygiene measures should be implemented no later than the time of
the eruption of the first primary tooth. Cleansing the infant’s teeth as soon as they erupt
with either a washcloth or soft toothbrush will help reduce bacterial colonization.
Children’s teeth should be brushed twice daily with fluoridated toothpaste and a soft,
age-appropriate sized toothbrush. A “smear” of toothpaste is recommended for
children less than 2 years of age, while a “pea-size” amount of paste is recommended
54 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

for children 2-5 years of age. Flossing should be initiated when adjacent tooth surfaces
cannot be cleansed with a toothbrush.
• Diet: High-risk dietary practices appear to be established early, probably by 12 months
of age, and are maintained throughout early childhood. Frequent night time bottle
feeding, ad libitum breast-feeding, and extended and repeated use of a sippy or no-spill
cup are associated with, but not consistently implicated in ECC. Likewise, frequent
consumption of snacks or drinks containing fermentable carbohydrates (e.g., juice, milk,
formula, soda) also can increase the child’s caries risk.
• Fluoride: Optimal exposure to fluoride is important to all dentate infants and children.
The use of fluoride for the prevention and control of caries is documented to be both
safe and effective. Twice-daily brushing with fluoridated toothpaste is recommended
for all children as a preventive procedure. Professionally-applied fluoride, as well as at
home fluoride treatments, should be considered for children at high caries risk based
upon caries risk assessment. Systemically-administered fluoride should be considered
for all children drinking fluoride deficient water (<0.6 ppm).Caution is indicated in the
use of all fluoride-containing products. Fluorosis has been associated with cumulative
fluoride intake during enamel development, with the severity dependent on the dose,
duration, and timing of intake. Decisions concerning the administration of additional
fluoride are based on the unique needs of each patient.
• Injury prevention: Practitioners should provide age appropriate injury prevention
counseling for orofacial trauma. Initially, discussions would include play objects,
pacifiers, car seats, and electric cords.
• Non-nutritive habits: Non-nutritive oral habits (e.g., digit or pacifier sucking, bruxism,
abnormal tongue thrust) may apply forces to teeth and dentoalveolar structures. It is
important to discuss the need for early sucking and the need to wean infants from these
habits before malocclusion or skeletal dysplasia’s occur.

4. Birth to the eruption of first teeth

Besides the anticipatory guidelines some time conditions are present which require
immediate attention these could include developmental anomalies such as
• Partial ankyglosia (tongue tie)
Tongue-tie is a condition in which the lingual frenulum is either too short or anteriorly
placed limiting the mobility of the tongue.
Early in fetal development, the tongue is attached to the floor of the mouth. With cell death
and atrophy, the only attachment is the frenulum. Tongue-tie results when the frenulum is
short and this may limit the movement of the tongue. When there is an attempt to stick the
tongue out, there may be a V shaped notch at the tip. The incidence is 0.5/1000 Physical
exam will easily demonstrate the short or anteriorly placed lingual frenulum.
Years ago it was routine to clip the frenulum at the time of delivery. Midwives had a long
sharp nail to cut the frenulum and obstetricians would inspect the mouth and cut the
frenulum immediately after the delivery. Tongue-tie is associated with speech abnormalities
especially lisping and inability to pronounce certain sounds.
Tongue-tie actually represents partial ankyloglossia and fusion represents complete
ankyloglossia. Case reports indicate that squeals of ankyloglossia may include speech
Pediatric Dentistry
– A Guide for General Practitioner 55

defects, difficulty in breastfeeding, or dental problems. However, controlled trials on

ankyloglossia have not been appropriately studied, and therefore indications for therapy
remain controversial. The tip of the tongue normally grows until 4 years of age, and initial
restrictions of movement may improve as the child gets older. Therefore, frenulectomy
should not be performed before 4 years of age 4.
MANAGEMENT
1. Physician education
2. Parental education and reassurance
3. Monitor for appropriate weight gain if exclusively breastfeeding
4. Complete fusion requires surgery
• Paramedian lip pits (congenital lip pits)
PITS OF THE LOWER lip (fistulas of lower lip, paramedian sinuses of lower lip, humps of
lower lip, labial cysts, etc.) is a very rare congenital malformation, first described by
Demarquay in 1845. This minimally deforming anomaly is remarkable chiefly for its
association with facial clefts. The fact that clefts that occur in families with the lip pits
anomaly have a stronger familial tendency than clefts in families without lip pits has
attracted the attention of people dealing with cleft patients.
• Bifid uvula
A bifid or bifurcated uvula is a split or cleft uvula. Newborns with cleft palate also have a
split uvula. The bifid uvula results from the incomplete fusion of the medial nasal and
maxillary processes. Bifid uvulas have less muscle in them than a normal uvula, which may
cause recurring problems with middle ear infections. While swallowing, the soft palate is
pushed backwards, preventing food and drink from entering the nasal cavity. If the soft
palate cannot touch the back of the throat while swallowing, food and drink can enter the
nasal cavity. Splitting of the uvula occurs infrequently but is the most common form of
mouth and nose area cleavage among newborns. Bifid uvula occurs in about 2% of the
general population, although some populations may have a high incidence, such as Native
Americans who have a 10% rate. Bifid uvula is a common symptom of the rare genetic
syndrome Loeys-Dietz syndrome, which is associated with an increased risk of aortic
aneurysm.
• Hyperplastic labial frenum
• White Sponge Nevus
White sponge nevus (WSN), also known as Cannon's disease, hereditary leukokeratosis of
mucosa and White sponge nevus of Cannon, is an autosomal dominant skin condition.
Although congenital in most cases, it can first occur in childhood or adolescence. It presents
in the mouth, most frequently as a thick bilateral white plaque with a spongy texture,
usually on the buccal mucosa, but sometimes on the labial mucosa, alveolar ridge or floor
of the mouth. The gingival margin and dorsum of the tongue are almost never affected.
Although this condition is perfectly benign, it is often mistaken for leukoplakia. There is
no treatment, but because there are no serious clinical complications, the prognosis is
excellent.

5. Normal teething and conditions associated with eruption of teeth

Teething is the process by which an infant's teeth erupt, or break through, the gums.
Teething is also referred to as "cutting" of the teeth. Teething is medically termed odontiasis.
56 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

The onset of teething symptoms typically precedes the eruption of a tooth by several days.
While a baby's first tooth can present between 4 and 10 months of age, the first tooth usually
erupts at approximately 6 months of age. Some dentists have noted a family pattern of
"early," "average," or "late" teethers.
A relatively rare condition, "natal" teeth, describes the presence of a tooth on the day of birth
7. The incidence of such an event is one per 2,000-3,000 live births. Usually, this single and

often somewhat malformed tooth is a unique event in an otherwise normal child. Rarely,
the presence of a natal tooth is just one of several unusual physical findings which make
up a syndrome. If the possibility of a syndrome exists, consultation with a pediatric
dentist and/or geneticist can be helpful. The natal tooth is often loose and is commonly
removed prior to the newborn's hospital discharge to lessen the risk of aspiration into the
lungs.
Teething is generally associated with gum and jaw discomfort as the infant's tooth prepares
to erupt through the gum surface. As the tooth moves beneath the surface of the gum tissue,
the area may appear slightly red or swollen. Sometimes a fluid-filled area similar to a "blood
blister" or eruption hematoma may be seen over the erupting tooth. Some teeth may be
more sensitive than others when they erupt. The larger molars may cause more discomfort
due to their larger surface area that can't "slice" through the gum tissue as an erupting
incisor is capable of doing. With the exception of the eruption of the third molars (wisdom
teeth), eruption of permanent teeth rarely cause the discomfort associated with eruption of
"baby" (primary or deciduous) teeth.
Teething may cause the following symptoms:
• increased drooling, restless or decreased sleeping due to gum discomfort, refusal of
food due to soreness of the gum region, fussiness that comes and goes, bringing hands
to the mouth, mild rash around the mouth due to skin irritation secondary to excessive
drooling, and rubbing the cheek or ear region as a consequence of referred pain during
the eruption of the molars.
Importantly, teething is not associated with the following symptoms: fever (especially
over 101 F), diarrhea, runny nose and cough, prolonged fussiness, or rashes over the
body.
Sometime minimal intervention may be required during teething in the form of certain over-
the-counter medicines can be placed directly on the gums to help relieve pain. They contain
medications that temporarily numb the gum tissue. They may help for brief periods of time
but have a taste and sensation that many children do not like. It is important not to let the
medicine numb the throat because that may interfere with the normal gag reflex and may
make it possible for food to enter the lungs. Medicines that are taken by mouth to help
reduce the pain.
Acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) can also help with pain. Ibuprofen
should not be administered to infants younger than 6 months of age. Medications should be
used only for the few times when other home-care methods do not help. Caution should be
taken not to overmedicate for teething. The medicine may mask significant symptoms that
could be important to know about.
Infant gums often feel better when gentle pressure is placed on the gums. For this reason,
gently rubbing of the gums with a clean finger or having the child bite down on a clean
washcloth. If the pain seems to be causing feeding problems, sometimes a different shaped
Pediatric Dentistry
– A Guide for General Practitioner 57

nipple or use of a cup may reduce discomfort and improve feeding. Cold objects many help
reduce inflammation as well, never put anything in a child's mouth that might enable the
child to choke.

6. The primary dentition years

The first primary tooth emerges at around six months of age and by three years
root development is complete. This is the preschool years and children are called pre
schoolers and they are increasing their cognitive abilities but still in the preconceptual
stage and should be considered unsophisticated in thinking. This sophistication only
develops during the period of intuitive thought where in the child learns the skills of
writing and classification after four years of age and can follow dental instructions given
to him.
Another difference observed three years onwards is the development of self control where
in these children can distract themselves for example when receiving anesthesia and can be
tought to monitor there behavior and they may feel guilty if they are not following the
expected norms. In clinical management terms the child is not emotionally mature but
surely emotionally complex and will respond to praise and will hurt and respond to
aggression and hostility.

6.1 Managing the developing occlusion

Guidance of eruption and development of the primary, mixed, and permanent dentitions
is an integral component of comprehensive oral health care for all pediatric dental
patients. Such guidance should contribute to the development of a permanent dentition
that is in a stable, functional, and esthetically acceptable occlusion. Early diagnosis and
successful treatment of developing malocclusions can have both short-term and long term
benefits while achieving the goals of occlusal harmony and function and dentofacial
esthetics.
Many factors can affect the management of the developing dental arches and minimize the
overall success of any treatment. The variables associated with the treatment of the
developing dentition that will affect the degree to which treatment is successful include, but
are not limited to: chronological/mental/emotional age of the patient andthe patient’s
ability to understand and cooperate in the treatment; intensity, frequency, and duration of
an oral habit; parental support for the treatment; compliance with clinician’s instructions;
craniofacial configuration; craniofacial growth; concomitant systemic disease or condition;
accuracy of diagnosis; appropriateness of treatment.
Anomalies of primary teeth and eruption may not be evident/diagnosable prior to eruption,
due to the child’s not presenting for dental examination or to a radiographic examination
not being possible in a young child. Evaluation, however, should be accomplished when
feasible. The objectives of evaluation include identification of: all anomalies of tooth number
and size (as previously noted); anterior and posterior crossbites; presence of habits along
with their dental and skeletal sequelae.
Oral Habits and posterior crossbites should be diagnosed and addressed as early as
feasible8. Parents should be informed about findings of adverse growth and developing
malocclusions. Interventions/treatment can be recommended if diagnosis can be made,
58 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

treatment is appropriate and possible, and parentsare supportive and desire to have
treatment done.
Oral habits may apply forces to the teeth and dentoalveolar structures. The relationship
between oral habits and unfavorable dental and facial development is associational rather
than cause and effect. Habits of sufficient frequency, duration, and intensity may be
associated with dentoalveolar or skeletal deformations such as increased overjet, reduced
overbite, posterior crossbite, or long facial height. As preliminary evidence indicates that
some changes resulting from sucking habits persist past the cessation of the habit, it has
been suggested that early dental visits provide parents with anticipatory guidance to help
their children stop sucking habits by age 36 months or younger.

6.2 Managing developing malocclusion in primary dentition

Anterior and posterior cross bites are malocclusions which involve one or more teeth in
which the maxillary teeth occlude lingually with the antagonistic mandibular teeth. Dental
crossbites result from the tipping or rotation of a tooth or teeth. The condition is localized
and does not involve the basal bone. Skeletal cross bites involve disharmony of the
craniofacial skeleton.
A simple anterior cross bite can be aligned as soon as the condition is noted, if there is
sufficient space; otherwise, space needs to be created first. Such appliances as acrylic
incline planes, acrylic retainers with lingual springs, or fixed appliances all have been
effective. If space is needed, an expansion appliance also is required. Early correction of
unilateral posterior crossbites has been shown to improve functional conditions
significantly and largely eliminate morphological and positional asymmetries of the
mandible.
Class II malocclusion (distocclusion) may be unilateral or bilateral and involves a distal
relationship of the mandible to the maxilla or the mandibular teeth to maxillary teeth. This
relationship may result from dental (malposition of the teeth in the arches), skeletal
(mandibular retrusion and/or maxillary protrusion), or a combination of dental and skeletal
factors. Early Class II treatment improves self-esteem and decreases negative social
experiences. Incisor injury that is more severe than simple enamel fractures has been
associated positively with increased overjet and prognathic position of the maxilla. Early
treatment for Class II malocclusions can be initiated, depending upon patient cooperation
and management this will result in an improved overbite, overjet, and intercuspation of
posterior teeth and an esthetic appearance and profile compatible with the patient’s skeletal
morphology.
Class III malocclusion may be unilateral or bilateral and involves a mesial relationship of the
mandible to the maxilla or mandibular teeth to maxillary teeth. This relationship may result
from dental factors (malposition of the teeth in the arches), skeletal factors (asymmetry,
mandibular prognathism, and/or maxillary retrognathism), or a combination of these
factors. Treatment of Class III malocclusions is indicated to provide psychosocial benefits
for the child patient by reducing or eliminating facial disfigurement and to reduce the
severity of malocclusion by promoting compensating growth. Early Class III treatment in
a growing patient will result in improved overbite, overjet, and intercuspation of
posterior teeth and an esthetic appearance and profile compatible with the patient’s
skeletal morphology.
Pediatric Dentistry
– A Guide for General Practitioner 59

6.3 Local anesthesia for children

Local anesthetic administration is an important consideration in the behavior guidance of a
pediatric patient9. Age-appropriate “nonthreatening” terminology, distraction, topical
anesthetics, proper injection technique, can help the patient have a positive experience
during administration of local anesthesia. In pediatric dentistry, the dental professional
should be aware of proper dosage (based on weight) to minimize the chance of toxicity and
the prolonged duration of anesthesia, which can lead to accidental lip or tongue trauma.
Knowledge of the gross and neuroanatomy of the head and neck allows for proper
placement of the anesthetic solution and helps minimize complications (eg, hematoma,
trismus, intravascular injection). Familiarity with the patient’s medical history is essential to
decrease the risk of aggravating a medical condition while rendering dental care.
Appropriate medical consultation should be obtained when needed.
The application of topical anesthetic may help minimize discomfort caused during
administration of local anesthesia. Topical anesthetic is effective on surface tissues (2-3 mm
in depth) to reduce painful needle penetration of the oral mucosa A variety of topical
anesthetic agents are available in gel, liquid, ointment, patch, and aerosol forms.
Injectable anesthetic available for dental usage include lidocaine, mepivacaine, articaine,
prilocaine, and bupivacaine. Absolute contraindications for local anesthetics include a
documented local anesthetic allergy. Local anesthetics without vasoconstrictors should be
used with caution due to rapid systemic absorption which may result in overdose.
Epinephrine decreases bleeding in the area of injection. Epinephrine concentrations of
1:50,000 may be indicated for infiltration in small doses into a surgical site to achieve
hemostasis but are not indicated in children to control pain.

6.4 Dental diseases in primary dentition years

6.4.1 Dental caries
Dental caries, also known as tooth decay or a cavity, is a disease where bacterial processes
damage hard tooth structure (enamel, dentin, and cementum). These tissues progressively
break down, producing dental caries (cavities, holes in the teeth). Two groups of bacteria
are responsible for initiating caries: Streptococcus mutans and Lactobacillus. If left
untreated, the disease can lead to pain, tooth loss, infection, and, in severe cases, even
death. Today, caries remains one of the most common diseases throughout the world.
Cariology is the study of dental caries. One particular condition that is seen in this age
group is the Early Child hood Caries (ECC). The disease of early childhood caries (ECC) is
the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to
caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or
younger. In children younger than 3 years of age, any sign of smooth-surface caries is
indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more
cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior
teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces
constitutes S-ECC10.
The recommended method of preventing such a condition include
Reducing the mother’s/primary caregiver’s/sibling(s) MS levels (ideally during the
prenatal period) to decrease transmission of cariogenic bacteria. Minimizing saliva-
sharing activities (eg, sharing utensils) between an infant or toddler and his
family/cohorts. Implementing oral hygiene measures no later than the time of eruption
60 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

of the first primary tooth. If an infant falls asleep while feeding, the teeth should be
cleaned before placing the child in bed. Tooth brushing of all dentate children should be
performed twice daily with a fluoridated toothpaste and a soft, age-appropriate sized
toothbrush. Parents should use a ‘smear’ of toothpaste to brush the teeth of a childless
than 2 years of age. For the 2-5 year old, parents should dispense a ‘pea-size’ amount of
toothpaste and perform or assist with their child’s tooth brushing. Flossing should be
initiated when adjacent tooth surfaces can not be cleansed by a toothbrush. Establishing
a dental home within 6 months of eruption of the first tooth and no later than 12
months of age to conduct a caries risk assessment and provide parental education
including anticipatory guidance for prevention of oral diseases. Avoiding caries-
promoting feeding behaviors. In particular: Infants should not be put to sleep with a
bottle containing fermentable carbohydrates. Ad labium breast-feeding should be
avoided after the first primary tooth begins to erupt and other dietary carbohydrates
are introduced. Parents should be encouraged to have infants drink from a cup as they
approach their first birthday. Infants should be weaned from the bottle at 12 to 14
months of age. Repetitive consumption of any liquid containing fermentable
carbohydrates from a bottle or no-spill training cup should be avoided. Between-meal
snacks and prolonged exposures to foods and juice or other beverages containing
fermentable carbohydrates should be avoided.

6.4.2 Behaviour management in dental clinic

Safe and effective treatment of dental diseases often requires modifying the child’s behavior.
Behavior guidance is a continuum of interaction involving the dentist and dental team, the
patient, and the parent directed toward communication and education. Its goal is to ease
fear and anxiety while promoting an understanding of the need for good oral health and the
process by which that is achieved. For treating children a variety of behavior guidance
approaches are used it is important to, assess accurately the child’s developmental level,
dental attitudes, and temperament and to predict the child’s reaction to treatment. The child
who presents with oral/dental pathology and noncompliance makes the management more
challenging. The pediatric dental staff can play an important role in behavior guidance.
Communication may be accomplished by a number of means but, in the dental setting, it is
affected primarily through dialogue, tone of voice, facial expression, and body language.
One should communicate with the child patient briefly at the beginning of a dental
appointment to establish rapport and trust. However, once a procedure begins, the dentist’s
ability to control and shape behavior becomes paramount, and information sharing becomes
secondary11.
Various behavior management techniques such as Tell-show-do is used by many pediatric
professionals. The technique involves verbal explanations of procedures in phrases
appropriate to the developmental level of the patient (tell); demonstrations for the patient
of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully
defined, nonthreatening setting (show); and then, without deviating from the explanation
and demonstration, completion of the procedure (do). The tell-show-do technique is used
with communication skills (verbal and nonverbal) and positive reinforcement. Voice
control is a controlled alteration of voice volume, tone, or pace to influence and direct the
patient’s behavior. Parents unfamiliar with this technique may benefit from an
Pediatric Dentistry
– A Guide for General Practitioner 61

explanation prior to its use to prevent misunderstanding. Distraction is another technique

involving diverting the patient’s attention from what may be perceived as an unpleasant
procedure. Giving the patient a short break during a stressful procedure can be an
effective use of distraction prior to considering more advanced behavior guidance
techniques.
Some children may require a more advanced behavior management techniques using
pharmacological agents such as conscious sedation, deep sedation or general anesthesia.
Nitrous oxide/oxygen inhalation is a safe and effective technique of giving conscious
sedation to reduce anxiety and enhance effective communication. Its onset of action is rapid,
the effects easily are titrated and reversible, and recovery is rapid and complete.
Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia,
amnesia, and gag reflex reduction.
Some children and developmentally disabled patients require general anesthesia to receive
comprehensive dental care in a safe and humane fashion. Many pediatric dentists (and
others who treat children) have sought to provide for the administration of general
anesthesia by properly-trained individuals in their offices or other facilities (eg,
outpatient care clinics) outside of the traditional hospital setting. The Elective Use of
Minimal, Moderate, and Deep Sedation and General Anesthesia in Pediatric Dental
Patients practiced.

6.4.3 Preventing dental caries

Pit and fissure sealants has been described as a material placed into the pits and fissures of
caries-susceptible teeth that micromechanically bonds to the tooth preventing access by
cariogenic bacteria to their source of nutrients12.
Fluoride application
Systemically-administered fluoride supplements
Fluoride supplements should be considered for all children drinking fluoride-deficient
(<0.6 ppm) water. After determining the fluoride level of the water supply or supplies
(either through contacting public health officials or water analysis), evaluating other
dietary sources of fluoride, and assessing the child’s caries risk, the daily fluoride
supplement dosage can be determined using the Dietary Fluoride Supplementation
Schedule.
Professionally-applied topical fluoride treatment
Professional topical fluoride treatments should be based on caries-risk assessment. A
pumice prophylaxis is not an essential prerequisite to this treatment. Appropriate
precautionary measures should be taken to prevent swallowing of any professionally-
applied topical fluoride. Children at moderate caries risk should receive a professional
fluoride treatment at least every 6 months; those with high caries risk should receive greater
frequency of professional fluoride applications (ie, every 3-6 months). Ideally, this would
occur as part of a comprehensive preventive program in a dental home.
Fluoride-containing products for home use
Therapeutic use of fluoride for children should focus on regimens that maximize topical
contact, preferably in lower-dose, higher-frequency approaches. Fluoridated toothpaste
should be used twice daily as a primary preventive procedure. Twice daily use has benefits
greater than once daily brushing.
62 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

Additional at-home topical fluoride regimens utilizing increased concentrations of

fluoride should be considered for children at high risk for caries.These may include
overthe-counter or prescription strength formulations. Fluoride mouth rinses or brush-on
gels may be incorporated into a caries-prevention program for a school-aged child at high
risk.

6.4.4 Management of dental caries

Restorative treatment is based upon the results of an appropriate clinical examination and is
ideally part of a comprehensive treatment plan. The treatment plan should take into
consideration: developmental status of the dentition; caries-risk assessment, patient’s oral
hygiene, anticipated parental compliance and likelihood of timely recall,patient’s ability to
cooperate for treatment. The restorative treatment plan must be prepared in conjunction
with an individually-tailored preventive program. Caries risk is greater for children who are
poor, rural, or minority or who have limited access to care. Factors for high caries risk
include decayed/missing/filled surfaces greater than the child’s age, numerous white spot
lesions, high levels of mutans streptococci, low socioeconomic status, high caries rate in
siblings/parents, diet high in sugar, and/or presence of dental appliances. Studies have
reported that maxillary primary anterior caries has a direct relationship with caries in
primary molars, and caries in the primary dentition is highly predictive of caries occurring
in the permanent dentition.

6.5 Pulp therapy for primary teeth

The primary objective of pulp therapy is to maintain the integrity and health of the teeth
and their supporting tissues. It is a treatment objective to maintain the vitality of the pulp of
a tooth affected by caries, traumatic injury, or other causes.
Vital pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis
includes placement of a protective liner wich is a thinly-applied liquid placed on the pulpal
surface of a deep cavity preparation, covering exposed dentin tubules, to act as a protective
barrier between the restorative material or cement and the pulp. Placement of a thin
protective liner such as calcium hydroxide, dentin bonding agent, or glass ionomer cement
is at the discretion of the clinician. This placement in the deep area of the preparation is
utilized to preserve the tooth’s vitality, promote pulp tissue healing and tertiary dentin
formation, and minimize bacterial microleakage.Adverse post-treatment clinical signs or
symptoms such as sensitivity, pain, or swelling should not occur.
Indirect pulp treatment is a procedure performed in a tooth with a deep carious lesion
approximating the pulp but without signs or symptoms of pulp degeneration. The caries
surrounding the pulp is left in place to avoid pulp exposure and is covered with a
biocompatible material. A radiopaque liner such as a dentin bonding agent, resin modified
glass ionomer,calcium hydroxide, zinc oxide/eugenol,or glass ionomer cement is placed
over the remaining carious dentin to stimulate healing and repair. Indirect pulp capping has
been shown to have a higher success rate than pulpotomy in long term studies.It also allows
for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a
pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.
Direct pulp cap can be done When a pinpoint mechanical exposure of the pulp is
encountered during cavity preparation or following a traumatic injury, a biocompatible
Pediatric Dentistry
– A Guide for General Practitioner 63

radiopaque base such as mineral trioxide aggregate (MTA)or calcium hydroxidemay be

placed in contact with the exposed pulp tissue. The tooth is restored with a material that
seals the tooth from microleakage.
A pulpotomy is performed in a primary tooth with extensive caries but without evidence of
radicular pathology when caries removal results in a carious or mechanical pulp exposure.
Thecoronal pulp is amputated, and the remaining vital radicularpulp tissue surface is
treated with a long-term clinically successful medicament such as Buckley’s Solution of
formocresol or ferric sulfate. Electrosurgery also has demonstrated success. Gluteraldehyde
and calcium hydroxide have been used but with less long-term success. MTA is a more
recent material used for pulpotomies with a high rate of success.
Nonvital pulp treatment for primary teeth diagnosed with irreversible pulpitis or necrotic
pulp include Pulpectomy Pulpectomy is a root canal procedure for pulp tissue that is
irreversibly infected or necrotic due to caries or trauma. The root canals are debrided and
shaped with hand or rotary files. Followed by obturation bye resorbable material such as
nonreinforced zinc/oxideeugenol, iodoform-based paste (KRI), or a combination paste of
iodoform and calcium hydroxide. The tooth then is restored with a restoration that seals the
tooth from microleakage.

6.5.1 Expected outcome of pulp therapy

No post-treatment signs or symptoms such as sensitivity, pain, or swelling should
be evident. There should be no radiographic evidence of pathologic external or
internal root resorption or other pathologic changes. There should be no harm to the
succedaneous tooth. A smooth transition from primary to permanent dentition should be
afforded13.

6.5.2 Acute dental trauma to primary teeth and management

The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when
motor coordination is developing. Dental injuries can have improved outcomes if the public
is made aware of first-aid measures and the need to seek immediate treatment. Because
optimal treatment results follow immediate assessment and care, dentists have an ethical
obligation to ensure that reasonable arrangements for emergency dental care are available.
The history, circumstances of the injury, pattern of trauma, and behavior of the child and/or
caregiver are important in distinguishing nonabusive injuries from abuse.
After a primary tooth has been injured, the treatment strategy is dictated by the concern for
the safety of the permanent dentition. If determined that the displaced primary tooth has
encroached upon the developing permanent tooth germ, removal is indicated. In the
primary dentition, the maxillary anterior region is at low risk for space loss unless the
avulsion occurs prior to canine eruption or the dentition is crowded. Fixed or removable
appliances, while not always necessary, can be fabricated to satisfy parental concerns for
esthetics or to return a loss of oral or phonetic function.
When an injury to a primary tooth occurs, informing parents about possible pulpal
complications, appearance of a vestibular sinus tract, or color change of the crown
associated with a sinus tract can help assure timely intervention, minimizing complications
for the developing succedaneous teeth. Also, it is important to caution parents that the
primary tooth’s displacement may result in any of several permanent tooth complications,
including enamel hypoplasia, hypo calcification, crown/root dilacerations, or disruptions
64 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

in eruption patterns or sequence. The risk of trauma-induced developmental disturbances

in the permanent successors is greater in children whose enamel calcification is
incomplete.

6.5.3 Managing premature loss of primary tooth

The premature loss of primary teeth due to caries, trauma, ectopic eruption, or other causes
may lead to undesirable tooth movements of primary and/or permanent teeth including
loss of arch length. Arch length deficiency can produce or increase the severity of
malocclusions with crowding, rotations, ectopic eruption, crossbite, excessive overjet,
excessive overbite, and unfavorable molar relationships. It is recommended that space
maintainers be used to reduce the prevalence and severity of malocclusion following
premature loss of primary teeth. Space maintenance may be a consideration in the primary
dentition after early loss of a maxillary incisor when the child has an active digit habit. An
intense habit may reduce the space for the erupting permanent incisor.

7. The transition from primary dentition to permanent dentition

This period is characterized by having distinctive need due to: a potentially high caries rate;
increased risk for traumatic injury and periodontal disease; a tendency for poor nutritional
habits; an increased esthetic desire and awareness; complexity of combined orthodontic and
restorative care (eg, congenitally missing teeth); dental phobia; potential use of tobacco,
alcohol, and other drugs; (8) pregnancy; (9) eating disorders; and (10) unique social and
psychological needs.
The management of these patients can be multifaceted and complex. An accurate,
comprehensive, and up-to-date medical history is necessary for correct diagnosis
and effective treatment planning. Familiarity with the patient’s medical history is
essential to decreasing the risk of aggravating a medical condition while rendering dental
care. If the parent is unable to provide adequate details regarding a patient’s medical
history, consultation with the medical health care provider may be indicated. The
practitioner also may need to obtain additional information confidentially from an
adolescent patient.

7.1 Management of dental caries during mixed dentition period

Immature permanent tooth enamel,a total increase in susceptible tooth surfaces, and
environmental factors such as diet, independence to seek care or avoid it, a low priority for
oral hygiene, and additional social factors also may contribute to the upward slope of caries
during this period. It is important to emphasize the positive effects that fluoridation, routine
professional care, patient education, and personal hygiene can have in counteracting the
changing pattern of caries this population.
Fluoridation has proven to be the most economical and effective caries prevention measure.
Both systemic benefit of fluoride incorporation into developing enamel and, topical benefits
can be obtained through optimally-fluoridated water, professionally-applied and prescribed
compounds, and fluoridated dentifrices.
Oral Hygine with a fluoridated dentifrice and flossing can provide benefit through the
topical effect of the fluoride and plaque removal from tooth surfaces.This time of heightened
Pediatric Dentistry
– A Guide for General Practitioner 65

caries activity and periodontal disease due to an increased intake of cariogenic substances
and inattention to oral hygiene procedures warrant a good oral hygiene through daily
plaque removal, including flossing, with the frequency and pattern based on the
individual’s disease pattern and oral hygiene needs
Diet management including diet analysis and modification can be very helpful to reduce the
effect of carbohydrates, foods rich in sucrose and beverages with acidic Ph. A diet analysis
should result in overall nutrient and energy needs calculation, psychosocial aspects of
adolescent nutrition; dietary carbohydrate intake and frequency; intake and frequency of
acid-containing beverages and wellness considerations.
Sealant placement is an effective caries-preventive technique that should be considered on
an individual basis. Sealants have been recommended for any tooth, primary or permanent,
that is judged to be at risk for pit and fissure caries. Caries risk may increase due to changes
in patient habits, oral microflora, or physical condition, and unsealed teeth subsequently
might benefit from sealant applications. Children at risk for caries should have sealants
placed. An individual’s caries risk may change over time; periodic reassessment for sealant
need is indicated throughout this phase.

8. Restorative dentistry
In cases where remineralization of noncavitated, demineralized tooth surfaces is not
successful, as demonstrated by progression of carious lesions, dental restorations are
necessary. Preservation of tooth structure, esthetics, and each individual patient’s needs
must be considered when selecting a restorative material. Molars with extensive caries or
malformed, hypoplastic enamel—for which traditional amalgam or composite resin
restorations are not feasible—may require full coverage restorations. Each restoration
must be evaluated on an individual basis. Preservation of noncarious tooth structure is
desirable.

8.1 Periodontal disease

Gingivitis characterized by the presence of gingival inflammation without detectable loss of
bone or clinical attachment is common in children. Normal and abnormal fluctuation in
hormone levels, including changes in gonadotrophic hormone levels during the onset of
puberty, can modify the gingival inflammatory response to dental plaque. Similarly,
alterations in insulin levels in patients with diabetes can affect gingival health. In both
situations, there is an increased inflammatory response to plaque. However, the gingival
condition usually responds to thorough removal of bacterial deposits and improved daily
oral hygiene.
Periodontitis aggressive periodontitis is more common in children and adolescents.
Aggressive periodontitis can be localized or generalized. Localized aggressive periodontitis
(LAgP) patients have interproximal attachment loss on at least two permanent first molars
and incisors, with attachment loss on no more than two teeth other than first molars and
incisors. Generalized aggressive periodontitis (GAgP) patients exhibit generalized
interproximal attachment loss including at least three teeth that are not first molars and
incisors. Successful treatment of aggressive periodontitis depends on early diagnosis,
directing therapy against the infecting microorganisms and providing an environment for
66 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

healing that is free of infection. a combination of surgical or non-surgical root debridement

in conjunction with antimicrobial (antibiotic) therapy.
Necrotizing periodontal diseases The two most significant findings used in the diagnosis of
NPD are the presence of interproximal necrosis and ulceration and the rapid onset of
gingival pain. Patients with NPD can often be febrile. Necrotizing ulcerative
gingivitis/periodontitis sites harbor high levels of spirochetes and P. intermedia, and
invasion of the tissues by spirochetes has been shown to occur. Factors that predispose
children to NPD include viral infections (including HIV), malnutrition, emotional stress,
lack of sleep, and a variety of systemic diseases. Treatment involves mechanical
debridement, oral hygiene instruction, and careful follow-up.Debridement with ultrasonics
has been shown to be particularly effective and results in a rapid decrease in symptoms. If
the patient is febrile, antibiotics may be an important adjunct to therapy. Metronidazole and
penicillin have been suggested as drugs of choice.

8.2 Occlusal considerations

Malocclusion can be a significant treatment need in the transition period as both
environmental and genetic factors come into play. Although the genetic basis of much
malocclusion makes it unpreventable, numerous methods exist to treat the occlusal
disharmonies, temporomandibular joint dysfunction, periodontal disease, and disfiguration
which may be associated with malocclusion. Temporomandibular disorders require
special attention to avoid long-termproblems. Congenitally missing teeth present complex
problem and often require combined orthodontic and restorative care for satisfactory
resolution.
Positional Malocclusion problems that present significant esthetic, functional, physiologic,
or emotional dysfunction are potential difficulties in mixed dentition. These can include
single or multiple tooth malpositions, tooth/jaw size discrepancies, and craniofacial
disfigurements. Treatment of malocclusion should be based on professional diagnosis,
available treatment options, patient motivation and readiness, and other factors to maximize
progress. If need be an orthodontist should be included for treatment.
Congenitally missing permanent teeth can have a major impact on the developing dentition.
When treating patients with congenitally missing teeth, many factors must be taken into
consideration including, but not limited to, esthetics, patient age, and growth potential, as
well as periodontal and oral surgical needs. Evaluation of congenitally missing permanent
teeth should include both immediate and long-term management.
Abnormal or ectopic eruption patterns of the permanent teeth can contribute to root
resorption, bone loss, gingival defects, space loss, and esthetic concerns. Early diagnosis and
treatment of ectopically erupting teeth can result in a healthier and more esthetic dentition.
Prevention and treatment may include extraction of deciduous teeth, surgical intervention,
and/or endodontic, orthodontic, periodontal, and/or restorative care.

8.3 Traumatic injuries

The most common injuries to permanent teeth occur secondary to falls, followed by traffic
accidents, violence, and sports. All sporting activities have an associated risk of orofacial
injuries due to falls, collisions, and contact with hard surfaces. It has been demonstrated
that dental and facial injuries can be reduced significantly by introducing mandatory
Pediatric Dentistry
– A Guide for General Practitioner 67

protective equipment such as face guards and mouthguards. Additionally, participation in

leisure activities such as skateboarding, rollerskating, and bicycling also benefit from
appropriate protective equipment.
To efficiently determine the extent of injury and correctly diagnose injuries to the teeth,
periodontium, and associated structures, a systematic approach to the traumatized child is
essential. Assessment includes a thoroughmedical and dental history, clinical and
radiographic examination, and additional tests such as palpation, percussion, sensitivity,
and mobility evaluation. Intraoral radiography is useful for the evaluation of dentoalveolar
trauma. If the area of concern extends beyond the dentoalveolar complex, extra oral imaging
may be indicated. Treatment planning takes into consideration the patient’s health status
and developmental status, as well as extent of injuries. Advanced behavior guidance
techniques or an appropriate referral may be necessary to ensure that proper diagnosis and
care are given.
Management of traumatized tooth can vary from simple restoration or re attachment of a
broken fragment in a tooth that does not involve pulp to advanced pulpal and periodontal
management where these are involved.The objective of such management should be to
maintain pulp vitality and restore normal esthetics and function.
Avulsion is the complete displacement of tooth out of socket. The periodontal ligament is
severed and fracture of the alveolus may occur. The avulsed tooth should be replanted as
soon as possible and then stabilized in its anatomically correct location to optimize healing
of the periodontal ligament and neurovascular supply while maintaining esthetic and
functional integrity. The tooth has the best prognosis if replanted immediately. If the tooth
cannot be replanted within 5 minutes, it should be stored in a medium that will help
maintain vitality of the periodontal ligament fibers. The best (ie, physiologic) transportation
media for avulsed teeth include (in order of preference) Viaspan™, Hank’s Balanced Salt
Solution (tissue culture medium), and cold milk. Next best would be a non-physiologic
medium such as saliva (buccal vestibule), physiologic saline, or water.

9. References
[1] American Dental Association Commission on Dental Accreditation. Accreditation
standards for advanced specialty education programs in pediatric dentistry.
Chicago, Ill; 2000
[2] Kim A. Boggess and Burton L. Edelstein. Oral Health in Women During Preconception
and Pregnancy: Implications for Birth Outcomes and Infant Oral Health. Matern
Child Health J. 2006 September; 10(Suppl 1): 169–174.
[3] Increased prevalence of developmental dental defects in low birth-weight, prematurely
born children: a controlled study. W. Kim Seow, BDS, MDSc, FRACDS Carolyn
Humphrys, BDSc David I. Tudehope, MBBS, FRACP. The American Academy of
Pediatric Dentistry Volume 9 Number 3
[4] Levy, Paul Tongue-tie, Management of Short SubLingual Frenulum. Pediatrics in
Review September 1995
[5] Shu, M.D., Jennifer (April 12, 2010). "Will a bifid uvula cause any problems?". CNN.
Retrieved 2010-08-07
[6] Terrinoni A, Rugg EL, Lane EB, et al (Mar 2001). "A novel mutation in the keratin 13
gene causing oral white sponge nevus". J. Dent. Res. 80 (3): 919–923.
 68 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

[7] Natal and neonatal teeth: a review.Adekoya-Sofowora CA.Niger Postgrad Med J. 2008
Mar;15(1):38-41
[8] Guideline on Management of the Developing Dentition and Occlusion in Pediatric
Dentistry. Originating Committee Clinical Affairs Committee – Developing
Dentition Subcommittee Review Council Council on Clinical Affairs Adopted
1990Revised 1991, 1998, 2001, 2005, 2009
[9] Malamed SF. Basic injection technique in local anesthesia. In: Handbook of Local
Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004:159-69.
[10] Definition of Early Childhood Caries (ECC) Originating council on clinical affairs
Review Adopted2003 AAPD Revised 2007, 2008
[11] American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations.
Pediatric Dent 2009;31 (special issue):38-9.
[12] Simonsen RJ. Chapter 2: Pit and fissure sealants. In: Clinical Applications of the Acid
Etch Technique. 1st ed.Chicago, IL:Quint essence Publishing Co , Inc ;1978:19-
42
[13] Guideline on Pulp Therapy for Primary and Immature Permanent Teeth, AAPD
REFERENCE MANUAL V 3 3 /NO 611/12

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