Treat individual child not child’s tooth
- counting child’s teeth is an efficient method of distraction, helping to make child familiar with dental surgery and staff
- good bahaviour should be rewarded, bad behaviour ignored without judgement
- treatment targets should be realistic, including preventative measures with topical fluoride
- be always positive but also firm and decisive, by creating a good ‘athmosphere’ in clinic
- treating children often like “driving on the edge” – we never know what is going to happen next
Keep dental treatment course as short as possible, as child has short attention and can get quickly impatient
- esasy, non-invasive procedures always first, eg. OHI, TB demonstration, fluoride preventative measures
- to recommend ‘brushing timer’ and ‘small brushing pack’ to encourage child keep brushing at school (images below)
- step-wise technique with long term GIC can be often beneficial
- do not attempt to do too much in one session
- behavioural management and CBT often works quite well !
- sometimes ‘wait and see’ approach works well during acclimatisation period
- do not assume that < 5 years old patient is not compliant with eg. extraction under LA, individual assessment as a good dental practice,
- individual assessment as crucial: 3-5 years old eg. autistic patient may be surprisingly very cooperative due to lack of fear/anxiety or can be the opposite – totally uncooperative depending on patient development
- accept alterations to original treatment plan, eg. GA ref. can be cancelled if child gets more cooperative and compliant with treatment under LA/ or IHS/LA
- operator must not give up ! even if child beheves badly, do something, even just initial dental examination without mirror
- child needs to understand that rules in dental surgery are different than at home and cannot ‘play the game’ with dentist
Stages of patient management summary:
- Acclimatisation and familiarisation with dental office
- Gradual confidence build up
- Bahavioural therapy and CBT
- “Therapeutical sealing”, step-wise technique, indirect capping, sedative measures or caries stabilization with GIC if justified
- Proper treatment under LA if coopeartive
- Inhalation sedation above 5-6 years
- Transmucosal or IV sedation above 12 years
- GA as a last resort since the age of 2-3 years
Close cooperation with dental therapist/hygienist can be invaluable
- diet sheet review as a routine procedure
- referral to Dental Therapist for OHI, TB demo and diet sheet review always advisable
- it is a good practice to reward the child after a dental treatment, ideally with: small toothpaste sample, sticker, TB timer, etc.
- So -called healthy dummy should be recommended
- Gifts for children after dental visit are always very welcome ! ideally fancy TB timer, fancy wall-mounted TB holder, pencil eraser mimicking molar tooth shape 🙂
- be aware of rapid progression of carious lesions in primary dentition – deciduous carious molars with decay within 2 surfaces (enamel margin breakage) are likely pulpally involved
- be realistic regarding fluoride preventative measures – arrested caries on occlusal surface of permanent molars can develop rapidly once undiagnosed/undiscovered and covered by fissure sealant, difficult moisture control during F/S is common
- be realistic in terms of long-term prognosis for grossly carious permanent molars and severely damaged front incisors affected by dental trauma, eg. avulsion and re-implantation of them
- remember about orthodontic considerations, eg. timing of 6’s extractions due to caries and 7’s furactions development
Hall technique with SS crowns works very well in vast majority of cases, but it has to be discussed with parents
- be aware of not excessing the recommended dose of fluoride varnish: 0.25 ml for deciduous dentition, 0.4 ml for mixed dentition and 0.75 for permanent.
- be aware of potential hypersensitivity reaction to some ingredients of fluoride varnishes, eg. adhesive resin colophony or shellac natural resin in Duraphat
- before fluoride varnish application check whether child suffers from asthma – it can be a relative contraindication for Duraphat use as it does contain colophony which may trigger an allergy reaction.
- use special LA techniques, eg. intrapapillary LA, CDA Wand, intraligamentary LA.
- attempt of routine treatment under LA is a viable option, before refering the patient for dental treatment under GA
- benefits, risk and procedural items of GA need to be thoroughly explained for parents
Promote healthy and non-cariogenic food, also by special cooking arrangements (mashroom/beans/broccoli/chicken pastry 🙂
Always check a parental responsibility, sometimes ‘double signature’ from foster and biological parents can be necessary
- to check court statement regarding parental responsibility
- gradual confidence build up over prolonged period of time
- grossly carious deciduous D’s almost always unrestorabel and unsavable
- balanced extractions of D’s and C’s
- balanced extractions of 6’s if justified, considering a proper timing
- compensating extractions of upper 6’s if clinically justified
- use a simple ‘desriptive’ communication: ” sleepy gelly”, ” cotton pellet snow ball” , “sleepy juice”, “water pistol”, “water jet”, “buzzy bee”
- squeeze or rub the lip gently while administrating local anesthesia, ask child to raise hand if he/she feels too much pressure.
- explain before what you are going to do and never try to lie. That would be a betrayal of confidence which usually you will not be able to restore.
- it is a good idea to use a ‘colour’ equipment, including handpieces and/or handpiece with reduced size and smallest working portion
‘Fancy looking’ fast handpiece with image and small head designed for children (“Koko”, KaVo Co.):
Slow handpiece with speed acceleration mode for micromotor (colour coded – red strip) very useful instead of turbine for cavity opening in phobic child:
Close cooperation with orthodontist
- interceptive orthodontic procedures possible
- refer for second orthodontic opinion in case of 6’s with poor prognosis
- extractions of any permanent teeth up to the age of 10 y.o. need orthodontic opinion
- cases of grossly pulpally involved carious first permanent molars in children and pain need urgent referral to orthodontist – urgent GA referral likely based on orthodontist opinion (balanced/compensating extractions)
- absent lower 5’s and retained E’s – potential ankylosis of E’s, not easy E’s extraction if justified (eg. ortho case)
- be aware of rare congenital syndroms affecting dentition: William’s syndrome, Angelman syndrome, G6PD disorder associated dental malformations: delayed eruption, malocclusion, hypoplasia, hypodontia, etc.
There is no strict age limit to start dental treatent for little children. However, for less than 3 years old, any invasive dental procedure may have a severe impact on child, including dental phobia in the future.
- be ‘sensible’ and realistic planning complex dental treatment under GA; mutiple extractions, 2-surfaces filling and stainless steel crown together my take a long time, exceeding limited time per anaethetised patient
- Non-individual, stainless steel crowns placed on first permanent molars can be used with caution as a temporary solution in case of eg. MIH (Molar-Incisor-Hypoplasia). Contact points and SS crown margins adjustment may be necessary
“Hall Technique” works very well, however the decision about using them has to be based on proper clinical criteria
- “caries inhibition”, “caries sealing” based on Marsh’s plaque biosystem hypothesis (1994)
- indications: primary caries on deciduous teeth, enamel margin breakage, interproximal caries on radiographs within enamel or with dentin involvement, no significant signs of pulpal involvement (clinical and radiological)
- MH, clinical examination and 2BWs rads essential
- to avoid upper D’s ! – unfavourable shape
- consent from parents, no surprise re: ‘metal coverage’ !
- explanations in simple words: ‘shiny tooth coverage’ , ‘best tooth protection’, ‘ baby tooth hat’, etc.
- warnings re: ‘metalic’ appearance, gums pressure during capping, ‘strange’ feelings while biting, unpleasant taste of material to be used (GIC)
- without any cavity preparation? or to consider even initial hand excavation? clinician decision, usually no preparation and no LA !
- technical aspect of Hall technique is important, careful SS crown size selection, appropriate GIC cement, to consider initial interprox preparation and cusps of deciduous teeth adjustement
- essential armamentarium: mirror, probe, excavator, forceps for margins adjustment, GIC either standard (Ketac Molar) or resin-modified (Fuji IX)
- airways management (always some game !) with the use eg. adhesive tape for crown transfer and to secure crown placement
- steps: size selection (the smallest possible) of PMC (preformed metal crown), contact points separation (with ortho band), individual margins adjustment (if necessary), GIC fill, excessive GIC removal, cotton roll bite (alternatively the use of biting plastic aid – same like for ortho band), marginal adaptation check, occlusion check
- if more than two SS crowns, esp. on E’s – prolonged occlusal adaptation, open bite
- placement of ortho band in between sometimes ‘risky’ – if patient FTA – risk of dislodgment down to interdental space and subgingivally
- contact points reduction by gentle separation with flame-shape high speed bur if justified
- be realistic applying “Hall technique” and long-term outcomes; minor or major failures may happen, including: SS crown detachment, local gingivae irritation, caries progression underneath particularly if carious cavity extending subgingivally (secondary caries), reversible/irreversible pulpitis, pulp necrosis, apical periodontitis, periapical, submucosal abscess, alveolar fistula
Preventive Fissures Sealans vs ‘Therapeutic F/S’
Always better to prevent and avoid fillings!
Do not put the tooth in an “restorble cycle” if not really necessary
Review ? , Seal ? or Restore ? dealing with first permanent molars? Dilema whether caries is present or not
Caries detection and diagnosis vitaly important
SIGN guidelines in US changed and now there is no need to perform caries risk assessment before decision about F/S. All 6’s – even perfectly sound and intact – ought to be potentially sealed
If not very compliant patient (special needs) who would not tolerate routine has very stained fissure on 6’s, which potentially can be a non-cavitated carious lesion or microcavity (minicavitation) – seal over the lesion. Lesion slows down and can be arrested under the sealant, will not progres further. It is likely to slow decay.
Non-invasive approach and first choice intervention!
What is better? a risky placement of destructive filling or to seal off possibly carious fissures as a minimally invasive approach?
It can be done on suboptimal conditions
Doing nothing is not the option. Anything is better than nothing!
If not sure re: fissure and or distinct cavity – PRR technique/sealant restoration
If gets worse and a bit leaky – recall and reapply sealant
Clinical judgement can be difficult
Apply so called “break on-demand” approach; if child indicates a need of break, eg. a few weeks time, to become more acclimatise with dental treatment
- distract a child as much as you can: constant talk, a bit of lough, chat about school experience, events, celebrations, school breaks activities, ask to join both the hands tightly and concentrate only on hands, then start counting 1 to 10 loudly , sufficient explainations of procedurę before starting treatment.
- the less pressure, the less pain during LA. Injection within a place with gross of subepithelial tissues. On the palatal aspect – the region with lots of small salivary glands
- take the time and administer very carefully and extremelly slowly, a little drop of the solution, then stop waiting for the effect of the anaesthesic agent.
- small size forceps (mini-forceps) are very handy and can be ‘hidden’ inside dentist hand
- Special coated/abrasive tips as working parts of sonic/ultrasonic devices are particularly useful for interproximal caries removal and can reduce anxiet/fear – much less noise production, less need for local anaesthesia, much better tolerated by children !
- Are chlorhexidine varnish/coating (Prevora) or silver diamine fluoride (SDF) efficient for caries prevention or caries arrest ?
Syringe ‘sleeve’ (autoclavable) can be extremely useful for phobic young patients !
Do not overestimate sedation techniques; gentle and compassionate individual approach, along with understanding and appication of CBT usually works very well
Behaviour management is widely agreed to be a key factor in providing dental care for children. Indeed, if a child’s behaviour in the dental surgery/office cannot be managed then it is difficult if not impossible to carry out any dental care that is needed. It is imperative that any approach to behavioural management for the dental child patient must be rooted in empathy and a concern for the well being of each child (Roberts J, EAPD, 2010). Most popular: Tell-Show-Do, positive reinforcement.
Cognitive behavioural therapy (CBT) is a talking therapy that can help patient manage his/her problems by changing the way patient think and behave (NHS choices source). It is most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems, including dental phobia. CBT cannot remove a main problems, but it can help to deal with them in a more positive way. It is based on the concept that thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap individual in a vicious cycle.
Acute dental trauma case – referr to: http://www.dentaltraumaguide.org/
Important question at first dental appointment – Who has parental responsibility towards the child ?
two or more people may hold PR for a child (shared responsibility)
- it is essential to estabilsh who has PR
- family life can be increasingly complex
- person holding PR must have the capacity to consent
- foster parents are unlikely to have PR
- adoptive parents have PR
- special guardians local authority (officer) may aquire PR under Emergency Protection Order
Health professionals, including dentists and dental professionals owe a statutory duty of care to their patients, ensuring that safeguarding arrangements are in place (eg. dental office) to promote the health of, and protect, the most vulnerable members of the society.
All staff need to be alert to the potential indicators of abuse and/or neglect, be familiar with local procedures for promoting and safeguarding the welfare of children, young people and vulnerable adults. Community dental team should understand the principles of patient confidentiality and information sharing.
Safeguarding means preventing harm and acting to protect children and vulnerable adults from actual or potential abuse, neglect or exploitation and ensuring they receive proper care that promotes health and welfare.
Safeguarding concerns can arise within almost all areas of practice. It is important that all members of staff have an appropriate level of understanding of the signs and presentations of abuse and neglect and are able to implement the Child Protection or Protection of Vulnerable Adults (PoVA) procedures.
Dental neglect can be defined as the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development. It may occur in isolation or may be an indicator of a wider picture of neglect or abuse.
When dental neglect has been recognised, a tiered response has been recommended with three stages of intervention (Harris, Sidebotham and Welbury, 2006):
- Preventive dental team management
- Preventive with the support of multi-agency management
- Child protection referral
Guidance from NICE: Clinical Guideline 89 (“When to suspect Child Maltreatment”, July 2009) includes dental disease as a possible sign of child negligence. Where dental professionals consider child neglected, they should liaise with other Health professionals involved. However, when they suspect child maltreatment; i.e. it is likely child negligence is happening they should refer the child to social services.
“To combat dental caries in children” (non-published, author: Arkadiusz Dziedzic)
“The most recent studie carried out by researchers from Public Health England (PHE) group formulate an argument for wider implementation of fluoridation programmes (1), despite the nonfluoride approaches for caries prevention, developed by ‘antifluoridationists’ (2). In 2015 PHE experts concluded that water fluoridation is a ‘safe and highly effective’ measure to reduce carious lesions caries and in prevention of dental caries in 5 years and 12 years old children (3). This is a high level of evidence based data confirming water fluoridation as a beneficial worldwide public health strategy, aimed to inhibit dental caries and subsequently pain/infections, eliminating multiple extractions in children (4). What is more, Public Health England study also demonstrated 45% fewer hospital admissions of children aged one to four for dental caries in fluoridated areas (5). This is particularly important because almost 50% of parents or guardians report previous dental treatment under general anaesthesia in their children or child’s sibling(s)(6).
Being supported by such strong evidences, is there any place for the use of non-fluoride topical measures against tooth decay ?. Currently, there are available additional non-fluoride local preventative agents which may provide the cariostatic benefits in patients at higher risk of developing caries, following initial use of primary caries prevention strategies ie. fluoride, fissures sealants. They include calcium and phosphate agents with casein derivatives (CPP-ACP), xylitol chewing gums, topical chlorhexidine varnish, chlorhexidine/thymol varnish, chlorhexidine mouthrinses and triclosan.
According to systemic review carried out by American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents (7), a sucrose-free chewing gum containing xylitol or polyol is useful adjunct method for caries prevention and a mixture of chlorhexidine-thymol varnish may be efficacious in the prevention of root caries. The addition of non-fluoride CPP-ACP to fluoride topical preparation seems to inhibit enamel demineralization and enhance remineralization of white spot lesions (8). The results of the clinical trials indicate a remineralization effect of CPP-ACP and the promising in-vivo results suggest a caries-preventing effect for long-term clinical CPP-ACP use (9,10). However, there is still insufficient evidence regarding the clinical efficacy of CPP-ACP used in combination with fluoride toothpaste to support their synergistic effect. Nowadays, two new methods: proximal sealing and infiltration with the low viscosity light-curing resin (‘infiltrants’) can be used in the micro-invasive treatment of non-cavitated proximal carious lesions, in both primary and permanent dentitions11. Further RCT based on the long-term human randomized controlled trials are needed in order to confirm promising results.
1. Public Health England. Water fluoridation: Health monitoring report for England 2014. Executive summary. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file /300201/Water_fluoridation_health_monitor_for_England_2014_executive_summary_1Apr2014.pdf
2. Peckham S., Awofeso N. Water Fluoridation: A Critical Review of the Physiological Effects of Ingested Fluoride as a Public Health Intervention. The Scientific World Journal, vol. 2014, Article ID 293019, 10 pages, 2014.
3. Young N, Newton J, Morris J, Morris J, Langford J, Iloya J, Edwards D, Makhani S, Verne J. Community water fluoridation and health outcomes in England: a cross-sectional study. Community Dent Oral Epidemiol. 2015; 43(6):550-9.
4. Olley RC, Hosey MT, Renton T, Gallagher J. Why are children still having preventable extractions under general anaesthetic? A service evaluation of the views of parents of a high caries risk group of children. Br Dent J. 2011; 23;210(8):E13.
5. Moles DR, Ashley P.. Hospital admissions for dental care in children: England 1997-2006. Br Dent J. 2009; 206, E14.
6. Aljafari AK, Scambler S, Gallagher JE, Hosey MT. Parental views on delivering preventive advice to children referred for treatment of dental caries under general anaesthesia: a qualitative investigation. Community Dent Health. 2014;31(2):75-9.
7. Rethman MP, Beltrán-Aguilar ED, Billings RJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright JT, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations. J Am Dent Assoc. 2011;142(9):1065-1071.
8. Shen P, Bagheri R, Walker GD, Yuan Y, Stanton DP, Reynolds C, Reynolds EC. Effect of calcium phosphate addition to fluoride containing dental varnishes on enamel demineralization. Aust Dent J. 2015 Nov 5. doi: 10.1111/adj.12385. [Epub ahead of print]
9. Bader JD. Casein phosphopeptide-amorphous calcium phosphate shows promise for preventing caries. Evid Based Dent. 2010;11(1):11-2
10. Yengopal V, Mickenautsch S. Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. Acta Odontol Scand. 2009; 67(6):321-32.
11. Paris S, Meyer-Lueckel H. The potential for resin infiltration technique in dental practice. Dent Update. 2012; 39(9):623-6, 628.