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2. Features are:
a. nitrous oxide flow rotameter
b. oxygen flow rotameter
c. gas mixture control
d. gas flow rate control
e. oxygen flush button
f. air entrainment value
g. common gas outlet.
Picture 2
1. These are (a) an intravenous cannula and (b) a butterfly
needle.
2. The cannula is used in preference to the butterfly. The
use of the butterfly leaves a needle in the patient’s vein.
This can cut out of the vein if the site is subject to movement. The cannula is soft, blunt ended and flexible and
so once sited will not tend to cut out. The cannula is
Teflon-coated and does not encourage the clotting of
blood, whereas cells can coagulate around the steel of
the butterfly. The cannula is more likely to give intravenous access for the duration of the appointment.
SHORT NOTE ANSWERS
1. Midazolam is water soluble and, therefore, does not cause
pain on intravascular injection, whereas propofol causes
pain on injection (particularly in small veins). Propofol
should be administered by continuous infusion using a
syringe pump, whereas midazolam is titrated to effect. The
equipment costs for the administration of propofol are
greater and a separate sedationist is required. All patients
requiring sedation with propofol must have their blood
pressure recorded every 5 minutes, which is uncomfortable and can cause patient movement, whereas fit and
healthy patients sedated with midazolam need to only
have recordings taken pre - and postsedation.
2. The disadvantages of oral sedation are:
n
prolonged latent period
n
unpredictable dose
n
unpredictable absorption
n
first-pass metabolism.
3. The signs of oversedation with nitrous oxide are:
n
persistent mouth closing
n
spontaneous mouth-breathing
n
disorientation
n
irrational or sluggish response to command
n
poor co-operation
n
unconsciousness.
The five symptoms of oversedation with nitrous oxide are:
n
loss of control
n
unpleasant sensations
n
anxiety
n
headache
n
nausea.
4. Technical causes of fall in arterial oxygen saturation
recorded by the pulse oximeter are:
n
probe loose or misplaced
n
cuff partially inflated on same limb.
Patient causes of fall in arterial oxygen saturation are:
n
obstruction owing to oversedation
n
obstruction by foreign body
6 • Conscious Sedation in Dentistry
n
obstruction because of treating dentist’s activity
n
respiratory depression caused by sedative agent
n
pre-existing respiratory or cardiovascular disease
n
collapse (e.g. faint).
167
5. The clinical effects of the benzodiazepines are:
n
anxiolysis
n
anticonvulsion
n
sedation
n
reduced attention
n
amnesia
n
muscle relaxation
n
anaesthesia
n
respiratory depression
n
fall in blood pressure (minimal)
n
increase in heart rate (slight)
n
potential sexual fantasy.
6. Factors monitored clinically during sedation:
n
level of consciousness (response to verbal command)
n
level of relaxation
n
response to treatment (effectiveness of sedation)
n
respiration
n
rate
n
depth
n
signs of obstruction
n
pulse
n
heart rate
n
rhythm
n
volume
n
colour: skin and mucosa.
VIVA ANSWERS
1. You should describe assessment in terms of:
n
medical history: any problems or contraindications
to a particular type of sedation
n
dental history: current pain, previous care, particular fears, particular wishes regarding current treatment, previous management – what was successful
and what was not
n
social history: alcohol or drug abuse; availability of
an escort
n
physical evaluation: blood pressure measurement,
assessment of the airway and assessment of potential
intravenous cannulation sites
n
dental examination
n
radiographic examination
n
explanation of the likely treatment options
n
provision of written and verbal information including pre- and postoperative instructions
n
obtaining verbal and written consent to the sedation
and dental treatment.
2. It is important in answering this type of question to use
words that a 10-year-old child would understand. Thus,
terms like ‘tingly’ should be used, not paraesthesia. In all
events, it is important to emphasise that it will feel pleasant, warm etc. but always use phrases like ‘you may feel’
as not everyone has all of the symptoms described in the
section on inhalational sedation. It is also wise to talk
about a nosepiece rather than a mask in case the child
has had a previous bad experience with general anaesthesia.
7
Paediatric Dentistry I
CHAPTER OUTLINE
Overview‚ 168
7.1 Tooth Development and
Eruption‚ 168
7.2 Management of the Child Patient‚ 168
7.3 History, Examination and Treatment
Planning‚ 170
7.4 Caries‚ 172
Overview
Successfully treating younger patients requires knowledge of normal child and adolescent development and
behaviour, as well as the technical and clinical skills necessary to work in small and changing mouths. The clinicians’ aim for this cohort of patients is to deliver them to
young adulthood with good oral health and a positive attitude towards dental care. A focus on prevention and
behaviour management is paramount if this aim is to be
achieved.
7.1 Tooth Development and Eruption
LEARNING OBJECTIVES
You should:
• know at what age primary teeth begin to mineralise, at
what age their root formation is complete and at what
age they erupt
• know at what age permanent teeth begin to mineralise,
at what age their root formation is complete and at
what age they erupt.
7.5 Tooth Discolouration‚ 176
7.6 Tooth Surface Loss (Wear)‚ 180
7.7 Endodontics‚ 182
7.8 Molar-Incisor Hypomineralisation‚ 186
Self-Assessment: Questions‚ 188
Self-Assessment: Answers‚ 190
On the lingual aspect of each primary tooth germ, the
dental lamina proliferates to produce the permanent successor tooth germ. Permanent tooth germs with no primary
precursors are produced by distal extension of the dental
lamina.
Dentine formation occurs after differentiation of dental
papilla cells into odontoblasts, which is induced by the internal enamel epithelium. Once dentine formation has begun, the adjacent cells of the internal enamel epithelium
differentiate into ameloblasts and produce enamel. The
dentine of the roots of teeth is produced in a similar fashion
by differentiation of odontoblasts induced by the internal
enamel epithelium, and root growth is controlled by the
epithelial cells at the margins of the enamel organ – the
root sheath of Hertwig. Root growth is not complete until
1–2 years in the primary dentition and 3–5 years in the
permanent dentition after eruption of the crowns of the
teeth. The beginning of mineralisation for both dentitions is
given in Tables 7.1 and 7.2.
The exact controlling mechanism of eruption has not yet
been identified. It is likely that the dental follicle has a major
part to play, as the connective tissue of the follicle is a rich
source of factors responsible for the local mediation of bone
deposition and resorption. Typical eruption times are given
in Tables 7.1 and 7.2.
Tooth germs develop from the dental lamina, and the dental
lamina develops from the primary epithelial band. The dental lamina forms a series of epithelial buds that grow into
surrounding connective tissue. The buds become associated
with a condensation of mesenchyme, and together they
represent a tooth germ at its early ‘cap’ stage of development. The epithelial bud becomes the enamel organ and the
mesenchymal cells the dental papilla and follicle. The cells
at the margin of the enamel organ grow to enclose some
mesenchymal cells, the ‘bell’ stage of development. Histodifferentiation of the enamel organ now forms the external
and internal enamel epithelia, stratum intermedium and
stellate reticulum.
7.2 Management of the Child Patient
LEARNING OBJECTIVES
You should:
• know the milestones of child development
• be able to relate milestones to what an individual child
can be expected to cope with in the dental surgery
• know the strategies that a dentist could employ to help
children to cope
• appreciate the importance of an accurate and compre-
hensive history and examination.
7 • Paediatric Dentistry I
Table 7.1 Typical Times for Calcification and Eruption
of Deciduous Teeth.
Calcification Begins
(Weeks in Utero) Eruption (Months)
Central incisor (a) 12–16 6–7
Lateral incisor (b) 13–16 7–8
Canine (c) 15–18 18–20
First molar (d) 14–17 12–15
Second molar (e) 16–23 24–36
Central incisor (a) 12–16 6–7
Lateral incisor (b) 13–16 7–8
Canine (c) 15–18 18–20
First molar (d) 14–17 12–15
Second molar (e) 16–23 24–36
Root calcification is complete 1–1.5 years after eruption.
Typical eruption sequence is a, b, d, c and e.
Table 7.2 Typical Times for Calcification and Eruption
of Permanent Teeth.
Calcification Begins
(Months) Eruption (Years)
Central incisor 3–4 7–8
Lateral incisor 10–12 8–9
Canine 4–5 11–12
First premolar 18–21 10–11
Second premolar 24–27 10–12
First molar At birth 6–7
Second molar 30–36 12–13
Third molar 84–108 17–21
Central incisor 3–4 6–7
Lateral incisor 3–4 7–8
Canine 4–5 9–10
First premolar 21–24 10–12
Second premolar 27–30 11–12
First molar At birth 5–6
Second molar 30–36 12–13
Third molar 96–120 17–21
Root calcification is complete 2–3 years after eruption.
Typical eruption sequence: upper 6 1 2 4 5 3 7 8; lower 6 1 2 3 4 5 7 8.
Development should be regarded as a continuum, as it differs from child to child. It is an uneven process and is influenced by periods of rapid bodily change. There are certain
‘psychological signposts’ that are important for the dentist
and their staff to recognise.
Motor Development
Motor development occurs in a predictable order, and identification of failure to attain ‘motor milestones’ enables remedial
intervention to help improve motor skills. The environment
can influence general motor development, and this type of
development is completed in early life. Skills or changes that
follow walking are refinements rather than new skills. Dominance of one hand emerges early. Motor retardation in a child
may be manifested by no specific handed dominance. At 6–7
years of age, a child may have sufficient co-ordination to
brush their teeth reasonably well. Below 6–7 years, many
areas of the mouth will be inaccessible without parental help.
Cognitive Development
Sensorimotor at 0–2 years. The infant can think of
things as permanent without having to see them directly.
Preoperational at 2–7 years. Thought patterns are not
well developed; the child is egocentric and inflexible.
Concrete operations at 7–11 years. The child can apply logi-
cal reasoning and consider another person’s point of view.
Formal operations at 11 years or older. Transition to
adult thinking results in the development of logical
abstract thinking and different possibilities for action can
be considered.
Perceptual Development
By age 7 years, children do develop selective attention and
can determine which advice merits attention and which
can be ignored. Concentration skills also improve. By age
9 years, children achieve adult proficiency.
Language Development
Language and thought are inter-related and lack of stimulation will delay both. Keep dental jargon to a minimum
and always assess patients before offering advice.
Social Development
Separation anxiety is high until age 5 years, and then
declines rapidly, so do not expect a child younger than this
to enter the surgery on their own.
Adolescence
Increasing independency and self-sufficiency develop in
adolescence. Young people can be moody, oversensitive to
criticism and often feel miserable for no apparent reason.
Therefore, do not criticise adolescents excessively, and try to
give them support and reassurance.
Parents are vital for positive reinforcement as regards how
a child copes with dental intervention. Parents should be
encouraged not to transfer any negative thoughts they may
have regarding dentistry to their child. Treatment plans
should be designed to accommodate the social dynamics of
the family with regard to appointment times and number.
Treatment plans should allow goals to be achieved one by
one, never overloading parent or child.
Each patient is a unique individual and should be treated as
such. Overall, it is fair to conclude that while the technical
skill of a dentist is of concern, the most important factors for
Master Dentistry
a patient are gentle, friendly manner, explanation of treatment procedures and the ability to keep pain to a minimum.
The extent of dental fear and anxiety (DFA) does not relate
to dental knowledge but is an amalgam of personal experiences, family concerns, disease levels and general personality traits. It is, therefore, not easy to pinpoint aetiological
agents and measure anxiety. While there is no standard
measure of anxiety, self-reported DFA measures such as the
Modified Child Dental Anxiety Scale, suitable for completion by children aged 8–15 years, can be useful.
Helping Anxious Patients Cope
There are a number of non-pharmacological behaviour
management approaches available which can help to reduce coping problems:
n
Reducing uncertainty – tell, show, do.
n
Pre-visit preparation, for example, send letter home explaining details of proposed visit.
n
Modelling – this can incorporate videos or a relaxed and
co-operative ‘live’ model.
n
Enhancing control – for example, introduction of an
agreed signal the child can use to indicate treatment
should stop.
n
Distraction – attempts to shift attention from dental setting towards another kind of situation (e.g. videos, headphones with music or stories). A patient can also be distracted during difficult procedures such as local
anaesthetic by firmly rubbing their cheek and talking
loudly to them, thus stimulating other senses.
n
Guided imagery – helping the patient to ‘daydream’ promoting a state of relaxation. This involves three stages:
relaxation, visualisation and positive suggestion.
n
Behaviour shaping and positive reinforcement – this involves
rewarding children when desired behaviour is displayed.
Reinforcement can be verbal, for example, ‘great mouth
opening’! or with a small present, for example, a sticker.
n
Negative reinforcement – removal of a stimulus the child
finds unpleasant when desired behaviour is displayed, for
example, a parent leaving the surgery when behaviour is
inappropriate and returning when the desired behaviour
is displayed.
n
Relaxation – this is useful for high levels of tension and
aims to bring about deep muscular relaxation; several
simple techniques are available for use by dentists.
n
Systematic desensitisation – gradually working through
various levels of feared situations from those which
cause ‘least anxiety’ to ‘most anxiety’.
n
Other options such as cognitive behavioural therapy
(CBT) or hypnosis can be considered, but these can require further training before use.
Where non-pharmacological behaviour techniques are
insufficient in allowing the child to cope with treatment, or
where the complexity of the operative procedure demands
it, pharmacological methods may need to be employed.
These include:
n
Inhalation sedation: usually for ages 5 years and over
n
Intravenous sedation: usually for ages 12 and over
n
General anaesthetic.
7.3 History, Examination and Treatment Planning
Entering the dental surgery can be a daunting experience
for any child and/or their family. The initial meeting with a
child and their family allows information to be collected
which will help direct any care required. In addition, examination visits allow the dental team to gain a rapport with the
family and set the scene for any future treatment requirements. Children should be addressed by name, and the dental staff should introduce themselves and explain who they
are. At the beginning of the appointment, it can be useful to
outline what it will involve, for example, today we are just
going to have a chat about your teeth, and then if you are
happy, we will have a look at your mouth with the mirror.
Patient/parent concerns. Depending on the age of the
child, it may be appropriate to ask either the child themselves or the accompanying adult to outline and provide
a history of any dental concerns.
Medical history. This should be updated at each examina-
tion appointment. Apart from allowing safe delivery of
dental care, two additional factors can be gleaned: children with medical conditions may have a negative attitude to treatment because of the time they have spent in
hospitals; they may also be more likely to fail dental appointments owing to the disruption in education that the
medical problem has already caused.
Dental history. Past dental experiences may give an indi-
cation of how the child will cope with proposed treatment. Parental attitude to treatment is important. A
treatment plan must be modified to accommodate this.
Establish exactly why they have come. The answers from
child and parent may be different!
Prevention. Ask about toothbrushing habits, for example,
how often and when teeth are brushed, who brushes the
child’s teeth, concentration of fluoride toothpaste used,
enrolment in school fluoride varnish programmes (e.g.
Childsmile in Scotland). Ask about dietary habits including what the child eats between meals, what drinks are
normally consumed, whether the child takes a bottle or a
drink to bed and if so what is consumed.
Social history. Information should be collected on the
school attended, who lives in the child’s household, who
has parental rights and responsibilities for the child and
whether the family has an assigned social worker. This
information can be helpful to assess social background,
knowledge of dentistry and the family’s expectations.
The clinical examination need not involve sitting in the
dental chair at the first visit, and it may take some time before a child allows the dental examination to take place. It
can be helpful to involve the child in the process and allow
them an element of control, for example, the child could
hold the dental mirror while handwashing takes place and
a hand signal could be introduced allowing the child to stop
if needed at any time. Where children attend with their
family, it can be helpful to let them watch other (relaxed and
co-operative) family members have a dental examination
before it is their turn.
Extraoral
General appearance is noted; percentile charts are a useful
way of monitoring height and weight. The head and neck
are examined, making a sketch of any lesions/marks.
7 • Paediatric Dentistry I
n
Moderate caries risk: radiographs should be repeated annually until no new or active lesions are apparent and
the individual has entered a lower risk category.
n
Low caries risk: intervals of 12–18 months (deciduous
dentition) or 24 months (permanent dentition) may be
used, although longer intervals may be appropriate
where there is continuing low caries risk.
Intraoral
Teeth must be clean and dry to allow a thorough examination. It can be helpful to carry out a toothbrushing demonstration at the beginning of the appointment so teeth are
cleaned prior to the examination.
Soft tissues. These may be an indicator of systemic disease.
Teeth. Teeth present should be confirmed to that expected
for a patient’s age. Any disturbance in the sequence of
permanent tooth eruption, for example, a lateral incisor
which erupts prior to the permanent incisor warrants
further investigation. Teeth condition, for example, presence of caries or defects such as hypomineralisation
should be recorded.
Occlusion. Assessment of incisor relationship, molar re-
lationship, overjet, overbite, crowding, crossbite, mandibular deviations and the ability to palpate unerupted
maxillary canines.
Periodontal condition. A modified Basic Periodontal
Examination (BPE) should be completed in children aged
7–17 years. This assesses six index teeth (UR6, UR1,
UL6, LL6, LL1 and LR6). BPE codes 0–2 are used for 7- to
11-year-olds (mixed dentition stage) to screen for bleeding and the presence of local plaque retentive factors.
The full range of codes, including any furcation involvement, can be used in 12- to 17-year-olds (permanent
teeth erupted).
Periodontal condition not consistent with oral hygiene
may indicate an underlying condition and warrant further
investigation.
If extraction of permanent teeth is considered owing to
caries, an OPT should be taken to assess the presence of dental anomalies (e.g. hypodontia), which may influence treatment decisions and also allow assessment of the stage of
development of surrounding teeth, which can influence the
timing of permanent tooth removal. For example, the ideal
time to remove poor prognosis first permanent molars
(FPMs), in the absence of orthodontic requirements, is when
the furcation of the second permanent molar is developing.
Abnormalities in Dental Development
OPT views can be used to identify disturbances in development of the dentition in terms of the number, position and
form of the teeth. Precise location of maxillary canines, if
required, can then be achieved by intraoral parallax technique.
Detection of Bony or Dental Pathology
Periapical radiographs for individual teeth; OPT views for
larger pathology or bony trauma.
Cone Beam Computed Tomography (CBCT)
CBCT has been available since the early 2000s and can
provide three-dimensional imaging. This may be helpful, in
selected cases. Evidence-based guidelines produced by the
SEDENTEXCT project in 2012 outline justification, optimisation, referral criteria and training requirements for users
of dental CBCT.
Radiation doses to patients from CBCT, although lower
than from medical computed tomography (CT) equipment,
can be significantly higher than those from conventional
dental X-ray equipment.
There are three general indications for taking radiographs
in children:
Caries Diagnosis
At least 50% more approximal lesions can be diagnosed by
bitewing radiographs than with clinical examination. Highresolution digital orthopantomogram (OPT) films at the appropriate setting (that which will separate the interproximal
contacts) are efficient at diagnosing occlusal and approximal
caries. Many standard OPT films are, however, still inadequate for caries diagnosis and, in this case, intraoral bitewing
radiographs remain the method of choice. Intervals for bitewing radiographs depend on caries risk. Intervals suggested
by the European guideline on radiation protection in dental
radiology 2004 are outlined as follows:
n
High caries risk: radiographs should be repeated at
6 monthly intervals until no new or active lesions are
apparent and the individual has entered a lower risk
category.
Other Investigations
There are a number of other special tests that may be indictated:
n
Sensitivity/sensibility testing: tests the nerve supply to a
tooth. Hot and cold stimuli can be evoked using hot
gutta-percha or ethyl chloride and electrical stimulation
can be applied using an electric pulp tester. These tests
are not suitable for the primary dentition, however, and
are not completely reliable in the permanent dentition.
n
Culture and sensitivity: bacterial, fungal and viral infections.
n
Blood tests: haematological, biochemical, bacteriological
and virological examination.
n
Salivary flow rate tests are rarely required in children.
Planning should incorporate:
n
management of pain: consider all teeth of poor prognosis
n
long-term treatment planning: to include attitudes and
motivation
Master Dentistry
n
consideration of required behaviour management techniques
n
preventive care: tailored to each individual
n
restorative care: realistic aims are important
n
aesthetic considerations: children can be under considerable peer pressure over their appearance Orthodontic
needs.
7.4 Caries
LEARNING OBJECTIVES
You should:
• be able to explain the development of caries to any
patient/parent
• know how to carry out a caries risk assessment
• know how to tailor a preventive plan in accordance
with a child’s caries risk
• know the current materials in use for the restoration
of primary and permanent teeth and their respective
advantages and disadvantages.
Fermentation of dietary sugars by micro-organisms in plaque
on the tooth surface produces organic acids. This rapid acid
formation lowers the pH at the enamel surface below the level
(critical pH 5.5) at which enamel will dissolve, a process
known as demineralisation. When sugar is no longer available to the plaque micro-organisms, the pH within plaque will
rise through the outward diffusion of acids and their metabolites. As a result, remineralisation of enamel can occur.
Dental caries progresses only when demineralisation is
greater than remineralisation. The early caries lesion is subsurface with white surface demineralisation (precavitation).
This may be because a layer of dental plaque on the tooth
acts as a partial barrier to diffusion. Plaque forms on tooth
surfaces that are not cleaned and is visually obvious within
2–3 days of ceasing toothbrushing. Plaque composition is
70% micro-organisms. Diet influences plaque flora composition; in diets rich in carbohydrate, Streptococcus mutans pre-
dominates and is very efficient at metabolising sugars to acids. Precavitated carious lesions can be reversed by
remineralisation if the plaque pH is high (alkaline). This can
occur during the periods where there is no sugar intake. The
concentrations of calcium, phosphate and fluoride in plaque
are very important in the remineralisation process.
Once cavitation has occurred and the thin white surface
layer has collapsed, it is necessary to restore the tooth surface
with a restoration, treat with biological methods or pragmatically via enhanced prevention depending on individual patient assessment. It is not possible to reverse a cavitated lesion.
The size of the problem of caries in the population has
changed over time. Prevalence and extent have fallen markedly since the late 1970s in many countries, and this fall can
largely be attributed to fluoridated toothpaste. The 2013
Child Dental Health Survey in England, Wales and Northern
Ireland found that 34% of 12-year-olds and 46% of
15-years-olds had obvious decay experience in the permanent dentition, while 31% of 5-year-olds and 46% of 8-yearolds had obvious decay experience in the primary dentition.
In the permanent dentition, there had been a continued
improvement in dental health compared to results from
1993 and 2003. Results in the primary dentition could not
be directly compared to previous years given a change in
methodology. In Scotland, the National Dental Inspection
Program found 20% of 12-year-old children had caries in
the permanent dentition (2019 data), and that 29% of
5-year-old children had obvious decay experience in the
primary dentition (2018 data). Results for both dentitions
revealed a continuing improvement in dental health.
The best method to assess caries is visual inspection on
clean, dry teeth with good lighting. This can be supplemented by radiographs as outlined in section 7.3. The use
of orthodontic separators to separate teeth and allow visual
assessment of cavitation can be considered if enamel-only
proximal lesions are identified radiographically.
Each child should undergo a caries risk assessment which
will assist in future planning, particularly in relation to the
preventive regime offered.
An effective caries risk assessment comprises seven
elements:
1. Clinical evidence: this takes account of the past and present caries experience and the rate at which new lesions
are developing. A child may be caries free at the time of
examination, but if they have recently had carious teeth
removed or repaired, they would remain as high risk.
Other areas of clinical evidence adding to a child’s risk
include the wearing of orthodontic appliances.
2. Dietary habits: especially frequency of sugar intake is
important in the development of caries.
3. Social history: main factors to look at are socioeconomic
status and parental attitudes to oral health. Cost and
availability of toothpaste and toothbrushes should also
be explored as well as access to and cost of fresh fruit
and vegetables. Children from more deprived areas or
who have eligibility for free school meals are more likely
to have obvious decay experience in both the primary
and permanent dentition.
4. Fluoride use: ask about toothbrushing habits and toothpaste strength and as to whether or not any other
sources of fluoride are used.
5. Plaque control: amounts of plaque in the mouth are dependent on oral hygiene practices and sugars in the diet.
6. Saliva: some children may have specific problems in relation to the amount or composition of their saliva,
making them at higher risk of developing caries.
7. Medical history: some children are at greater risk of developing caries due to their medications, prescribed diet
or ability to practise oral hygiene effectively. Other children are classified as high risk if poor oral health could
have a considerable detrimental effect on their current
medical condition, for example, patients with cardiac
conditions or who are immunocompromised.
7 • Paediatric Dentistry I
There is no consensus on which factors are more effective
in determining caries risk, although previous caries experience appears to be the more reliable predictor of caries risk.
The preventive regime offered will relate directly to the
child’s caries risk assessment. A full preventive plan contains eight elements:
1. Regular dental visits: parents/carers should be encour-
aged to register their child with a dentist as soon as the
first tooth erupts or by the age of 1 year at the latest and
to visit regularly.
2. Toothbrushing instruction: brushing should commence
as soon as the first primary tooth erupts. Teeth should be
brushed at least twice daily with a fluoridated toothpaste.
After brushing, excess toothpaste should be spit out rather
than rinsed out. It is important to offer child and/or their
parent a lesson on effective toothbrushing, as many will
never have been shown how to brush their teeth properly.
Children should be assisted with toothbrushing until they
have the manual dexterity and motivation to brush well
themselves. Disclosing solution or tablets can be useful in
showing the child areas that they have missed. It is important to emphasise a systematic approach so that no surfaces are left unclean. Powered toothbrushes, timers
toothbrushing apps and/or sticker charts can all be good
motivational tools. Caries reduction cannot be achieved by
toothbrushing alone. However, brushing will control gingivitis and periodontal disease and is an important way of
conveying fluoride to the tooth surface.
3. Toothpaste strength advice: fluoride has the ability to
increase enamel resistance to demineralisation as well
as decreasing acid production in plaque and increasing
remineralisation. Although it has a pre-eruptive effect,
its major role is post-eruptive.
All children should use a toothpaste containing fluoride
between 1000 and 1500 ppm. Children at increased risk
of developing dental caries should use a higher strength
of toothpaste when compared with those aged 101 prescribed 2800 ppm fluoride toothpaste.
Toothpaste amount should be restricted to a smear under
the age of 2 and a small pea size for 2–6 years. In this
younger age group, supervision and assistance during
brushing are needed for efficiency and to prevent excess
swallowing of paste as this may lead to fluorosis.
4. Fluoride varnish frequency: professionally applied fluoride
varnishes have been shown to be very effective. For children at high risk of caries, 22,600 ppm fluoride varnish
can be placed 3 monthly from the age of 2 years. Care
should be taken to follow manufacturers guidance for use
of the varnish. Varnishes containing Colophony are not
suitable for children with severe asthma or allergies.
5. Supplemental fluoride: fluoride mouthrinses for chil-
dren over the age of 6 years could be considered. Fluoride drops and tablets for systemic use are now increasingly difficult to source and have been largely superseded
by increased toothpaste strengths and regular professional application of fluoride varnish. Although each
individual method of fluoride application is effective, a
combination of methods may achieve greater benefit.
6. Dietary advice: non-milk extrinsic sugars (NME) are
most cariogenic – sucrose, glucose, fructose maltose.
While Intrinsic sugars (lactose in milk and sugars in
fruit and vegetables) are generally less harmful, this depends on the form and timing of their consumption e.g.
fruit becomes cariogenic if dried or pureed/juiced.
A 3- or 4-day diet diary is more effective than simply asking
a child and parent about their diet. The diet diary, if filled
out correctly, will provide information about frequency
and time of day with regard to sugar intake. It is also
good practice for the diary to include toothbrushing
times and bedtime, which will increase the accuracy of
your dietary analysis.
The general advice is to restrict foods and drinks to meal-
times and not to consume them within 20 minutes of
bedtime. Dietary counselling should be personal, practical and positive and realistic targets for change/improvement should be agreed. Where complete restriction of cariogenic food/drink is not realistic focus should
be on appropriate times for their intake. Suitable alternatives to cariogenic food/drinks should be suggested.
Diet advice should focus on overall health of the child.
Suggested diet advice is outlined below:
Drinks:
n
Plain water or plain milk are safe choices to drink.
n
If a drink is taken at bedtime, it must only be water.
While milk is a safe drink during the day, it can cause
decay if taken during the night.
n
Tea and coffee are not suitable drinks for young
children.
n
All other drinks contain sugar and/or acid and should
be avoided in between meals.
n
Use of a feeder cup or bottle overnight with milk or
juice should be strongly discouraged. If a child wants
to drink throughout the night, the only safe liquid is
plain water. In general, bottle-fed babies should not
require overnight milk after 4–6 months old, and
on-demand breastfeeding overnight should also be
discouraged from this time.
Foods:
n
Foods that contain sugar should be avoided in between meals. If taken at all, they should be re-
stricted to a mealtime. Examples of tooth-friendly
snacks are provided in Box 7.1.
n
Many foods including those aimed at children and
babies contain sugar. Be aware that statements on
food packaging such as ‘organic’, ‘no added sugar’,
‘natural ingredients’ or ‘no junk promise’ DO NOT
mean the food is sugar free.
n
Checking the list of ingredients on food packaging
can help to identify whether a food contains sugar.
There are many different names for sugar which are
listed in Box 7.2.
Non-sugar sweeteners allowed for use in food and drinks
can be considered for practical purposes as non-cariogenic. There are two groups of non-sugar sweeteners:
1. Bulk: sorbitol, mannitol, isomalt, xylitol, lactitol
and hydrogenated glucose syrup.
2. Intense: saccharin, acesulphame K, aspartame,
thaumatin.
Bulk sweeteners have a laxative effect and should not
be given to children under the age of 3 years.
Master Dentistry
Box 7.1 Examples of Tooth-Friendly Snacks. Box 7.3 Technique for Placement of a Resin
n
Whole fruit (not juiced or dried)
n
Vegetables
n
Reduced fat cheese
n
Unsweetened natural yoghurt/plain fromage frais (could add
fruit to these)
n
Plain bread, for example, wholemeal, brown, granary, white,
high fibre and rye bread, pitta, chapatti, rolls, baguettes and
bagels
n
Sandwiches fillings such as salad, fish, banana, oily fish (fresh
or canned in water), egg
n
Soft cheese
n
Cheese spread
n
Unsweetened breakfast cereals – plain unflavoured Ready
Brek, porridge and Shredded Wheat have no added sugar
n
Small portions of plain breadsticks
n
Plain rice cakes
n
Oatcakes occasionally (check labels as some contain added
sugars)
n
Savoury scones, for example, potato scone
n
Homemade soup.
1. Clean, wash and dry the tooth surface.
2. Etch with gel or liquid as per the manufacturer’s instructions.
3. Apply thin coat of sealant to the pits and fissures, making sure
to include the buccal extension in lower molars and the
palatal groove in upper molars.
4. Light polymerise for 20 seconds.
5. Check occlusion.
Box 7.4 Technique for Placement of a GIC
1. Clean, wash and dry the tooth surface.
2. Run/flow GIC into the fissures.
3. Compress using a gloved finger for 3 minutes.
4. Remove excess GIC with excavator.
5. Cover with petroleum jelly.
GIC, Glass ionomer cement.
Box 7.2 Dietary Sugars.
If any of the following types of sugar are on the list of ingredients,
the food is harmful for teeth and should be avoided in between
meals:
n
Sugar
n
Dextrose
n
Fruit juice concentrate
n
Fructose
n
Glucose
n
Syrup
n
Hydrolysed starch
n
Isoglucose
n
Levulose
n
Maltose
n
Molasses
n
Sucrose
n
Honey
n
Treacle
n
Dried fruit
n
Corn sweetener
7. Fissure sealants: the most effective sealant is bisphenola-glycidyl methacrylate (bis-GMA) resin. At least 50%
of sealants are retained for 5 years, and their effectiveness in reducing and delaying the onset of caries is not
in doubt. Both unfilled and filled resins and clear and
opaque resins have been used to equal effect. Isolation
after etching and drying is essential to success (Box 7.3).
Indications or patient and tooth selection include: high car-
ies risk; special needs (medical, physical, intellectual,
social disability); occlusal surfaces of permanent molars, cingulum pits of upper incisors; seal as soon as
moisture control permits; continue to monitor sealed
teeth clinically and radiographically.
Glass ionomer fissure sealants may be used as a temporary
measure in high-risk children when the tooth is
partially erupted or in nervous children who cannot
tolerate the acid-etch procedure. Use of glass ionomer
fissure sealant may also be useful for its fluoride leaching
properties and can be very useful for sensitive hypomineralised molars; however, they have poor bonding properties and require regular replacement (Box 7.4).
8. Sugar-free medicines: many children are on long-term
medication, which is often supplied to them in a sweetened elixir form. Where sugar-free formulations of the
medicine are available, it is important to liaise with the
patient’s general medical practitioner to ensure the child
is prescribed the sugar-free version. In some cases, it is
not possible to have a sugar-free alternative, such as
lactulose, which is prescribed to many children for constipation. If sugared medicine is required, it is prudent to
explore whether the child can take their medications at
mealtimes to lessen its cariogenic effect. If this is not
possible, it can be helpful for the child to rinse their
mouth with water after taking their medication.
The treatment of carious teeth should be based on the
needs of the child; the long-term objective should be to help
the child to reach adulthood with an intact permanent dentition, no active caries, as few teeth restored as possible and
a positive attitude towards their future dental health.
Restorative Materials
Amalgam. In July 2018, new environmental restrictions
on dental amalgam use became applicable by law in the
United Kingdom. Since then, the use of dental amalgam
for treatment in patients under 15 years old, in pregnant
or breastfeeding patients or for primary teeth in any patient is only allowed where deemed strictly necessary by
the dental practitioner. These restrictions specified in Article 10(2) of Regulation (EU) 2017/852 on mercury
were introduced to fulfil the requirements of the global
Minamata Convention, which aims to phase-down the
use of mercury on environmental grounds. The Scottish
Dental Clinical Effectiveness Programme (SDCEP) has
7 • Paediatric Dentistry I
provided advice to support professionals in implementing
these restrictions.
Glass ionomer cements (GIC). These consist of basic glass
and acidic water-soluble powder; they set by an acid–
base reaction between the two components. The cement
bonds to enamel and dentine and releases fluoride to the
surrounding tissues. This should be used as a temporary
filling material only or for stabilisation of caries.
Resin-modified GIC. A hybrid of GIC/resin retains signifi-
cant acid–base reaction in its overall curing process to set
in the dark. There are two setting reactions: the acid–
base reaction between glass and polyacid and a lightactivated, free radical polymerisation of methacrylate
groups of the polymer. This material has some physical
advantages over conventional GIC, together with its ability to ‘command set’. Again, this should be considered as
a temporary or intermediate restorative material.
Polyacid-modified composite resin (compomer). This
contains either or both essential components of a resinmodified GIC, but it is not water based and, therefore, no
acid–base reaction can occur. It will not set in the dark.
This technique is very sensitive to moisture contamination and should be placed under rubber dam isolation.
Resin-based composite. Their introduction revolution-
ised clinical dentistry, and their aesthetic benefits especially for the anterior teeth are unquestioned. Posterior
resin-based composites have overcome initial problems
of wear resistance, water absorption and polymerisation
contraction. This technique is very sensitive to moisture
contamination and should be placed under rubber dam
isolation.
Preformed crowns. These preformed extra-coronal resto-
rations are invaluable for in the restoration primary molars that have undergone pulp therapy, hypoplastic primary and permanent teeth and teeth in those children at
high risk of caries, particularly those having treatment
under general anaesthesia. The Hall technique of sealing
caries into primary molars with a preformed metal crown
has rapidly gained popularity.
Isolation
Adequate isolation is necessary for any restorative material to
have a chance of success. Rubber dam isolation is the optimum but may necessitate local anaesthesia for the gingival
tissues. Clamps should be secured individually with floss ligatures. Additional advantages of the rubber dam include airway protection, soft tissue protection and increased patient
comfort. In the absence of rubber dam, good moisture control
can be achieved with cotton wool rolls, dry tips and saliva
ejector. When placing a preformed metal crown without the
aid of rubber dam, it is prudent to have the child in an upright
position using a sponge or gauze for airway protection and a
pick-up stick or other sticky device to ensure you do not drop
the crown once it has been delivered to the mouth.
Management of Caries affecting Primary Teeth
The first decision to be made is whether teeth can be retained or should be extracted. In general, teeth which have
caused spontaneous or prolonged pain or where there are
clinical or radiographic signs of infection require removal.
Recent developments in the restorative management of
primary caries have moved away from traditional tech-
niques of caries removal and restoration towards more
conservative techniques which aim to seal caries from the
oral environment. These techniques can be advantageous,
given that these reduce the risk of pulpal exposure and
normally avoid the use of local anaesthetic. They are currently described as the preferred option for the management of teeth with no clinical or radiographic signs of
pulpal involvement and in the absence of medical complications.
SDCEP guidance suggests that the principle strategies for
managing caries in the primary dentition are:
n
No caries removal, seal with a crown (The Hall
technique)
n
No caries removal and fissure seal
n
Selective caries removal and restoration (i.e. walls prepared to hard dentine with adequate depth for restorative
material, previously known as partial caries removal)
n
Pulpotomy
In addition to these techniques, other options for manag-
ing caries in the primary dentition include:
n
Site-specific prevention (no caries removal, active prevention)
n
Non-restorative cavity control (i.e. no caries removal,
make cavity and lesion cleansable and apply fluoride)
n
Complete caries removal and restoration
n
Extraction, or review with extraction if pain or infection
develops
In addition to techniques described above other new
emerging techniques including the use of Silver Diamine
Fluoride (SDF), which aims to arrest carious lesions may be
of increasing use in practice.
Management options should be discussed with the parent/
carer and child. It is important that all carious lesions are
actively managed.
SDCEP guidelines suggest that:
“For a child with a carious lesion in a primary tooth, choose
the least invasive, feasible caries management strategy, taking
into account: the time to exfoliation, the site and extent of the
lesion, the risk of pain or infection, the absence or presence of
infection, preservation of tooth structure, the number of teeth
affected, avoidance of treatment-induced anxiety”
The above techniques and their indications are described
in detail in the SDCEP guideline ‘Prevention and Management of Dental Caries in Primary Teeth Children’.
Management of Caries affecting Permanent Teeth
There is increasing evidence that less invasive approaches
to caries management in permanent teeth (as in the primary dentition) are effective in reducing pulpal exposure
and maintaining tooth structure. However, in the developing dentition, there can be advantages in conventional restoration techniques which can allow the extent of caries
and therefore the prognosis of the tooth to be more fully
assessed. This allows consideration to be given to removing
teeth of guarded long-term prognosis either when there still
exists potential for movement of unerupted adjacent teeth
into the resultant space or to recommend removal of teeth
for orthodontic purposes.
Master Dentistry
A thorough clinical and radiographic examination
should be completed prior to any instrumentation of a
tooth surface.
occlusal caries. A stained but non-cavitated fissure in a
molar with no radiographic evidence of caries, a fissure
sealant is the treatment of choice.
Where clinical or radiographic examination reveals dentinal caries, then a restoration will be required. Composite
resin is the material of choice, and any remaining fissure
pattern should also be sealed with fissure sealant.
Where caries is deep, and the tooth is to be retained, consideration should be given to using a step-wise technique.
This involves a two-step process. Step 1 involves access to
caries and removal of enough caries to allow an effective
marginal seal. Caries should be removed to leave firm dentine on the cavity walls, while softer dentine can be left on
the base. A bonded restoration, for example, GIC is placed.
The provisional restoration is removed 6–12 months later.
Any remaining soft dentine is removed until hard dentine is
reached. A definitive restoration with resin-based composite can then be placed.
approximal caries. Early, non-cavitated lesions with po-
tential to remineralise can be initially managed with sitespecific prevention and careful monitoring. Once cavitation
occurs, the potential to remineralise is lost, and the tooth
needs to be managed in an alternative way.
Composite resin is the material of choice for approximal
caries in children under 15 years old following recent enforced restrictions upon the use of amalgam. It should be
placed under rubber dam isolation. Dental amalgam can
still be considered, however, where the dental practitioner
deems this strictly necessary. This decision needs to be justified, communicated to the patient/parent and valid consent
obtained. The justification should be recorded in the patient’s dental record.
Anterior Teeth
Composite resin is the material of choice. Incisal edge restorations require careful design to maximise the surface area
of normal enamel for bonding.
Table 7.3 The Aetiology of Tooth Discolouration.
Staining Type Cause
Extrinsic staining Beverages/food
Smoking
Poor oral hygiene (chromogenic bacteria
give a green/orange stain)
Drugs: iron supplements (black stain),
minocycline (black stain), chlorhexidine
(brown/black stain)
Local causes Caries
Idiopathic
Injury/infection of primary predecessor
Internal resorption
Systemic causes Amelogenesis imperfecta
Drugs (e.g. tetracyclines)
Fluorosis
Idiopathic
Systemic illness during tooth formation
Local causes Caries
Internal resorption
Metallic restorative materials
Necrotic pulp tissue
Root canal filling materials
Systemic causes Bilirubin (haemolytic disease of newborn)
Congenital porphyria
Dentinogenesis imperfecta
Drugs (e.g. tetracyclines)
Once the aetiology of the discolouration has been identified, the most appropriate method(s) of treatment can be
chosen. Treatment emphasis should be on minimal tooth
preparation.
Treatments for discoloured anterior teeth are listed as
follows:
7.5 Tooth Discolouration
LEARNING OBJECTIVES
You should:
• know which treatments are appropriate for each type of
discolouration.
The colour of a young person’s teeth is of great importance.
Peer group pressure can be significant, and teasing about
size, position and colour of teeth can be distressing.
Options to manage discolouration should be considered if/
when the child (rather than the family) becomes concerned
about their appearance.
Causes of intrinsic and extrinsic tooth discolouration are
outlined in Table 7.3. Molar-incisor hypomineralisation
(MIH) is covered in more detail in Section 7.8. Amelogenesis
imperfecta, fluorosis, chronological disturbances, dentinogenesis imperfecta, dentine dysplasia and environmentally
determined defects are considered further in Chapter 8.
1. Microabrasion
2. Tooth whitening
3. Resin infiltration
4. Direct composite restoration
5. Veneer
6. Full coverage restoration
Microabrasion is a controlled removal of surface enamel in
order to improve discolourations that are limited to the
outer enamel layer.
As hypomineralised enamel can appear whiter than surrounding teeth, the patient should understand that teeth
may look slightly darker following treatment.
The technique is described in Box 7.5. It is achieved by a
combination of abrasion and erosion, and the term ‘abrosion’ is sometimes used. Normally, no more than 100 mm of
enamel is removed, although care should be taken when
preforming the technique on larger hypomineralised areas
which may be more susceptible to wear.