Lec. 1 Pedodontics د.حسن الوطيفي
Introduction:
Pediatric Dentistry: It is an age-defined specialty that provides primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.
Q/ What are the key elements of this definition that make it so unique?
Age- defined: most specialties are procedure defined (endodontics, periodontics. etc.). Pediatric dentists provide care for their specific age group of patients. There is no limitation to what type of treatment they provide.
Primary and comprehensive: There is no need for referral of patients. Parents can choose to have their children evaluated and treated by pediatric dentist just like they can choose to have their child treated by pediatrician.
Infants and children through adolescence: Pediatric dentists see patients at any age from birth up to their late teens.
Special health care needs: Pediatric dentists have the training and experience to evaluate and treat patients that are medically compromised. This includes patients with hemophilia, leukemia, congenital syndromes, etc… No other dental specialty other than OMS. Is more involved in hospital care of patients.
Examination and Treatment Plan of Pediatric Patient
Dentist is traditionally taught to perform a complete oral examination of the patient and to develop a treatment plan from the examination findings. Then the dentist makes a case presentation to the patient or parents, outlining the recommended course of treatment. This process should include the development and presentation of a prevention plan that outlines an ongoing comprehensive oral health care program for the patient and establishment of the "dental home."
The plan should include recommendations designed to correct existing oral problems (or halt their progression) and to prevent anticipated future problems.
Anticipatory guidance: is the term often used to describe the discussion and implementation of such a plan with the patient and/or parents.
The major difference between the treatment of children and adults is the relationship. Treating adults generally involves a one to one relationship (dentist- patient), while treating children relies on a one to two relationship (dentist – pediatric patient- parents).
Diagnostic Methods
Before making a diagnosis and developing a treatment plan, the dentist must collect and evaluate the facts associated with the patient's or parents' chief concern and any other identified problems that may be unknown to the patient or parents.
On the other hand, a comprehensive diagnosis of the entire patient's problems or potential problems may sometimes need to be postponed until more urgent conditions are resolved. For example, a patient with necrotizing ulcerative gingivitis or a newly fractured crown needs immediate treatment, but the treatment will likely be only palliative, and further diagnostic and treatment procedures will be required later.
Diagnostic methods include:
• Medical and dental history taking
• Inspection
• Palpation
• Auscultation
• Exploration
• Radiography
• Percussion
• Transillumination
• Vitality tests
• Study casts
• Laboratory tests
• Photography.
Early Examination:
Dental care for children has been designed primarily to:
1- Prevent oral pain and infection.
2- Prevent the occurrence and progress of dental caries.
3- Prevent the premature loss of primary teeth, the loss of arch length.
4- Prevent the development of an association between fear and dental care.
The goals of pediatric dental care therefore are primarily preventive
Preliminary dental and medical history
It is important for the dentist to be familiar with the medical and dental history of the pediatric patient. Familial history may also be relevant to the patient's oral condition and may provide important diagnostic information in some hereditary disorders.
Dental history includes:
1- Previous dental treatment.
2- Child behavior.
3- Patient current oral hygiene and habits.
4-Pevious fluoride exposure.
Medical history includes:
1-Family history from the parents or child's physician.
2-Informations regarding child's social and psychological development.
3-Previous hospitalization or general anesthetic and surgical procedures.
4-Child current physical condition, such as blood pressure, body temperature, heart sounds, height and weight, pulse and respiration.
5- Certain laboratory tests
6- Infectious conditions.
Clinical examination:
Most facts needed for a comprehensive oral diagnosis in the young patient are obtained by a thorough clinical and radiographic examination.
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Extra oral Examination includes:
1- The patient's size, stature, gait, or involuntary movements as he walks into the office.
2- Malnutrition.
3- Attention to the patient's hair, head, face, neck, and hands should be among the first observations made by the dentist after the patient is seated in the chair.
4- The patient's hands may reveal information pertinent to the comprehensive diagnosis. The dentist may first detect an elevated temperature by holding the patient's hand. Cold, clammy hands or bitten fingernails may be the first indication of abnormal anxiety in the child. A callused or unusually clean digit suggests a persistent sucking habit. Clubbing of the fingers or a bluish color in the nail beds suggests congenital heart disease that may require special precautions during dental treatment.
5- Inspection and palpation of the patient's face, head and neck are also indicated for the presence of any contagious diseases like hair lice, ring warm and impetigo. Further treatment should be postponed until the contagious condition is controlled.
6- Variations in size, shape, symmetry, or function of the head and neck structures should be recorded.
7- Temporomandibular joint (TMJ) evaluation while the mouth closed (teeth clenched), at rest, and in various open positions
8- The extraoral examination continues with palpation of the patient's neck and submandibular area.
Introral Examination:
The intraoral examination of a pediatric patient should be comprehensive. It includes:
1- The dentist should first evaluate the condition of the oral soft tissues and the status of the developing occlusion.
2- look first for obvious carious lesions.
3- Any unusual breath odors and abnormal quantity or consistency of saliva should also
be noted.
4- The bucket tissues, lips, floor of the mouth, palate, and gingivae should be carefully inspected and palpated.
5- The use of the periodontal screening and recording program (PSR) is often a helpful adjunct in children.
6- The tongue and oropharynx should be closely inspected.
7- Enlarged tonsils accompanied by purulent exudate may be the initial sign of a streptococcal infection, which can lead to rheumatic fever. When streptococcal throat infection is suspected, immediate referral to the child's physician is indicated.
8- After thoroughly examining the oral soft tissues, the dentist should inspect the occlusion and note any dental or skeletal irregularities.
9- Monitoring of the patient's facial profile and symmetry; molar, canine, and anterior segment relationships; dental midlines; and relation of arch length to tooth mass should be routinely included in the clinical examination.
10- Diagnostic cast and cephalometric analyses may be indicated relatively early in the mixed dentition stage and sometimes in the primary dentition.
11- Morphologic defects and incomplete coalescence of enamel at the base of pits and fissures in molar teeth can often be detected readily by visual and explorer examination after the teeth have been cleaned and dried.
12- Finally, the teeth should be inspected carefully for evidence of carious lesions and hereditary or acquired anomalies and supernumerary or missing teeth.
Note: Dentist may always start in the upper right quadrant, work around the maxillary arch, move down to the lower left quadrant, and end the examination in the lower right quadrant.
Identification of carious lesions is important in patients of all ages but is especially critical in young patients because the lesions may progress rapidly in early childhood caries if not controlled. Eliminating the carious activity and restoring the teeth as needed will prevent pain and the spread of infection and also contribute to the stability of the developing occlusion.
In patients with severe dental caries, caries activity tests and diet analysis may contribute to the diagnostic process by helping to define specific etiologic factors.
Radiographical examination:
When indicated, radiographic examination for children must be completed before the comprehensive oral health care plan can be developed and subsequent radiographs
are required periodically to allow detection of incipient carious lesions or other developing anomalies.
Obtaining isolated occlusal, periapical, or bite-wing films is sometimes indicated in very young children (even infants) because of trauma, toothache, suspected developmental disturbances, or proximal caries.
Carious lesions appear smaller on radiographs than they actually are.
Advantages of treatment plan:
Provide step by step guideline.
Estimate the time required.
Number of appointment required.
Treatment priorities include:
Emergency treatment.
A plague control program.
Restorative therapy.
Orthodontic and prosthodontic care.
Follow-up.
Emergency treatment:
Only do treat the urgent cases, to relive pain and infection if present because the child is under stress and of low tolerance level. If possible delay extraction or extensive pulpal therapy, provided that the pain can be relived by some other means.
Plague control program include:
Plague identification and removal.
Diet counseling.
Topical fluoride application.
Child parents education on home care oral hygiene practice.
Restorative therapy:
A procedure that is short and simple should be selected first during this initial appointment to allow the development of patient trust and confidence.
Orthodontic and prosthodontic care:
Following the completion of the restorative phase of treatment, orthodontic and prosthodontic care may be render if needed. Although minor oral surgical procedure are accomplished during the restorative phase of treatment using quadrant approach, complex surgical procedure should be delayed until this phase.
Follow-up: No treatment plan is completed until provision is made to provide a recall appointment for evaluation and necessary follow up care.
Presentations of treatment plane to the parents include:
The dental need of their child.
The restorative procedure required.
The amount of time required to perform the projected procedure.
The total cost of the services.
Preventive measure necessary to maintain the completed treatment.
Each problem should discuss in the following manner:
Point out the problem using cast, radiograph or the patient mouth.
State the probable cause of the problem such as plague or insufficient arch length.
State the out come of the problem such as its effect on function, health or appearance.
Show how the problem will be resolved.
Stress the benefit that the patient will receive from the treatment.