Pediatric Dentistry

Chapter 1 Introduction

1 Definition What is Pediatric Dentistry

Definition 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 needs

Who ? infants and children through adolescence including those with special health care needs

What? provides both primary and comprehensive preventive oral health care provides both primary and comprehensive therapeutic oral health care

2 key elements “age-defined” “primary and comprehensive...care” "infants and children through adolescence" "special health care needs"

age-defined Most specialties: procedure defined treatment they provide PD: no limitation to treatment they provide

Pediatric dentists are primary providers Pediatric dentists are primary providers. There is no need for a referral of patients

Pediatric dentists see patients at any age from birth up to their late teens

Pediatric dentists have the training and experience to evaluate and treat patients being medically compromised.

key elements “age-defined” “primary and comprehensive...care” "infants and children through adolescence" "special health care needs"

3 Structure of the dental consultation

Greeting Preliminary chat Examination Preliminary explanation Business Health education Dismissal

Don’t proceed too quickly 3.1 Greeting 3.1.1 in a friendly way 3.1.2 by name Don’t proceed too quickly

3.2 Preliminary chat Begin with non-dental topics Ask an open qustion Listen to the answer

3.3 Examination Should be pain-free Should be adequate Should not be totally tooth-centered

3.4 Preliminary explanation The aim: to explain what the clinical or preventive objectives are

In terms parents and children will understand. This is a vital part of any visit

3.5 Business 3.5.1 Remain in verbal contact 3.5.2 Check the patient not in pain

a) Discuss what you are doing b) Use the patient’s name to show a personal interest c) Clarify misunderstandings

3.5.3 Summarize what has been done at the end 3.5.4 Offer aftercare advice

3.6 Health education Give advice on maintaining a healthy mouth The final part is goal setting Goal setting must be used sensibly.

3.7 Dismissal The final part of a visit Should be clearly signposted Should be ensured the patient and parents leave with a sense of goodwill.

Structure of the dental consultation Greeting Preliminary chat Examination Preliminary explanation Business Health education Dismissal

4 Anxious and uncooperative children

4.1 Dental anxiety is a common problem all over the world, especially in pediatric dentistry

It not only prevents patients from seeking care but also cause stress to the dentists

Dental anxiety is a problem that we as a profession must take seriously

4.2 How does the dental anxiety develop?

4.2.1 Be afraid of pain or imaginary pain

4.2.2 Uncertainty about what is to happen is certainly a factor

4.2.3 A poor past experience with a dentist could upset a patient

4.2.4 Learn anxiety response from parents, relations, friends, or books,TV show

4.3 The extent of dental anxiety

it is no easy task to measure dental anxiety and pinpoint aetiological agents

5 Helping anxious patients to copy with dental care

Establish an effective preventive programme Establish good dentist-patient relationship

Ensure any treatment is pain-free Manage time effectively Behavior Management

Behavior Management Adversive Techniques Traditional Techniques Physical restraint Hand over mouth Pharmacologic Techniques Sedation General Anesthesia Traditional Techniques Tell-show-do Distraction Modeling Positive Reinforcement Voice control

Behavior Management Pharmacological agents Pharmacological-alternatives

Behavior Management Adversive Techniques Traditional Techniques Physical restraint Hand over mouth Pharmacologic Techniques Sedation General Anesthesia Traditional Techniques Tell-show-do Distraction Modeling Positive Reinforcement Voice control

TSD Technique T: Tell S: Show D: Do

A: Tell: Explanation of procedures at the right age/educational level

CHOOSE WORDS CAREFULLY For Most Children: CHOOSE WORDS CAREFULLY AVOID Shot Needle Hurt Pull Etc.

B: Show: demonstrate the procedure C: Do: following on to undertake the task.

Positive reinforcement Find something to praise Anything Stress accomplishments Prizes at end of visit

Adaptive method

Modeling Modeling could be used to alleviate anxiety due to ‘fear of the unknown’

Live modeling Next patient watches

It’s not necessary to use a live model, videos of co-operative patients are of value.

Cognitive approaches Asking patients to identify their negative thoughts

helping patients to recognize their negative thoughts and suggesting more positive alternatives ‘reality based’;

Distraction: Shift attention from the dental setting towards some other kind of situation.

Distraction Conversation Mirror Book Electronics Whatever…

Voice control Tone or inflection Volume Use to hold child’s attention Soft and even Loud and abrupt Use to hold child’s attention Do not telegraph frustration

Parental presence? Supportive for very young patients Instructive for parents Parent is silent partner Never interpreter of same language Don’t threaten departure

Parental interactions Parents should be told where they should stand (sit), what they can say, and how they should react; without threats or condescension.

Uncooperative Patient Explanation maintain confidence Direct attention to child Speak directly Parental presence Silent assurance Positive reinforcement Persist

Time Out Pause for reflection May assist the dentist Test of stamina Economically difficult

Restraints Mouth Prop Parental security Wraps or Papoose Board Hand over mouth

Mouth prop Support oral access Apply with care Treatment aid Apply with care Not to impinge on lips Not to subluxate mandible May be interpreted as restraint Assure ratchet works Open slowly Don’t impinge on lips Do not use as a crow-bar

Physical restraint Parent may be more supportive than wrap Wraps/Boards Pediwrap®, Papoose Board® Supports physically challenged patients Necessity during sedation Downside Sense of helplessness, loss of control Avoid injury Assure parental informed consent Meet community standards

When to consider pharmacologic management...

Nitrous Oxide Analgesia Adjunct to non-pharmacological management Assumes a minimal level of cooperation Child must be capable of following instruction Capable of sitting alone in chair Capable of breathing through the nose Nasal inhaler hood must fit properly

Sedation Definition of Conscious Sedation Minimally depressed level of consciousness that retains the patient’s ability to maintain a patent airway independently and continuously and to respond appropriately to physical stimulation and/or verbal command

Sedation Strict guidelines requiring Monitoring & recording Recovery area Additional personnel

Functional Levels of Sedation Conscious Sedation I Anxiolysis II Interactive III Non-interactive, arousable with mild/moderate stimuli IV Non-interative, non-arousable except with intensive stimulus V General Anesthesia Deep Sedation General Anesthesia

Conscious sedation (I,II,III)

General Anesthesia Last resort Indications Immaturity Extensive caries Physical or mental challenge Definition Induced state of unconsciousness accompanied by loss of protective reflexes, including the ability to maintain an airway independently and respond appropriately to physical stimulation and/or verbal command

Management entree´ selection Most patients require simple management techniques A small cohort require the more aggressive management techniques Advance preparation further minimizes necessity for aversive techniques

Number of children who actually present as management problem??? Estimated that 22% actually present moderate - severe management challenges

Management Technique Utilization Curve moves left with increasing age General anesthesia more likely to be utilized below the age of 2.5 yrs

Successful Patient Management Goal: Safe, effective and quality dental care Significant resources are required

Successful Patient Management Good communication with patients and parents to establish expectations and mitigate misunderstanding Patient’s recognition of their own accomplishment, without dreading the next visit Parent’s recognition of the dentist’s accomplishment and an understanding of what will be necessary to complete future visits

6 First dental visit There seems to be a lot of confusion about the correct timing for the first dental visit.

6.1 The correct time The AAPD recommends : within 6 months of the eruption of the first primary tooth and no later than 12 months of age

A child should have his or her first dental visit at the first birthday!

6.2 Medical and dental record The dentist should record a thorough medical and dental history.

6.3 oral examination Usually be accomplished with the parent present in the office. The child patient may be sitting in knee-to-knee position

6.4 Assess 6.4.1 Assess the risk of oral and dental disease 6.4.2 Evaluate the child's oral and dental development

6.4.3 Evaluate the need for fluoride supplemen-tation.

6.4.4 It may be important to discuss non-nutritive habits, injury prevention, oral hygiene, and effects of diet on the dentition.

6.5 Treatment If treatment is indicated the dentist should be prepared to provide therapy or he needs to refer the patient.

第二章 生长发育

生长发育的概念：指机体组织形态机能中所显示的生物肉体、 心理、 生理、 情绪等变化过程的综合，可受遗传、 性别、 营养、 疾病、 锻炼等内外因素影响而存在个体差异。它是一个连续不断的发展过程，时间即年龄在儿童生长发育中是一个十分重要的因素。它包括两方面： 生长：指机体增殖的过程，是量的增加 发育：指机能和成熟的程度，是质的变化

第一节 生长发育分期及各期特点

一 按年龄阶段分期 二 按牙列分期 三 咬合发育阶段分期

一 按年龄阶段分期 生长期 年龄阶段 特 点 危险因素 胚芽期 0~8周 1 胚胎第4周，牙板出现 2 胚胎第8周， 1)初步形成人的面型， 特 点 危险因素 胚芽期 0~8周 1 胚胎第4周，牙板出现 2 胚胎第8周， 1)初步形成人的面型， 2)腭的发育才开始； 3)乳牙胚已经发生 基因突变 环境有害因素

生长期 阶段 特 点 危险因素 胎儿期 8周~出生（40周） 1 组织器官迅速生长 和功能渐趋出现 2 胎龄14周 1）通过胎盘与母体 特 点 危险因素 胎儿期 8周~出生（40周） 1 组织器官迅速生长 和功能渐趋出现 2 胎龄14周 1）通过胎盘与母体 进行物质交换 2）腭盖形成 3）乳牙开始钙化 母体营养不良 母体疾病

生长期 阶段 特 点 危险因素 新生儿期 出生~4周 1 胎儿在母体内寄生的结束 2 乳牙冠部出现新生线 3 唾液腺不发达，唾液分泌量少 唾液腺不发达，唾液分泌少

生长期 阶段 特 点 危险因素 婴儿期 4周~出生后1年 1 生长快，代谢率高 2 消化功能未发育完善 3 被动免疫消失，获得 性免疫尚未完全建立 4 乳牙开始萌出，恒牙 的钙化期 营养紊乱和疾病

生长期 阶段 特 点 危险因素 幼儿期 1~6岁 1 神经系统发育 仍然很快， 2 3岁时乳牙全部 出齐，钙化低 3 活动多 进食次数多，糖类食品多 乳牙外伤多 感染后的变态反应性疾病开始出现

生长期 阶段 特 点 危险因素 学龄期 6岁到12~13岁 淋巴系统的发育处于高峰期，颈部和腹股沟处的淋巴结可以触及。 扁桃腺肥大或咽部腺样体增生常常影响儿童呼吸道的通畅，患儿张口呼吸，久之容易形成开唇露齿的颌面畸形。 恒磨牙萌出，窝沟复杂

生长期 年龄阶段 特点 危险因素 青春发育期 女孩11~12岁到17~18岁 男孩13~14岁到18~20岁 身体骨骼出现第2次快速生长 恒磨牙龋病发病率高，病损严重

二 牙列的临床分期 （一）牙列分期 1 无牙期： 2 乳牙列形成期： 3 乳牙列期： 4 混合牙列期： 5 恒牙列期：

二 儿童时期的3个牙列阶段 1 乳牙列阶段 2 混合牙列阶段 3 年轻恒牙列阶段

3个牙列阶段的特点 牙列阶段 特点 主要任务 1乳牙列阶段 1 口腔内全部为乳牙 2 乳牙龋患开始和逐年增多 维护乳牙的健康完好 1 加强口腔卫生宣教 2 早发现，早治疗 2 混合牙列 1儿童颌骨和牙弓主要生长发育期，也是恒牙合建立的关键时期 2 恒牙龋患开始 1 预防错合畸形 2 防治恒牙龋病 3 年轻恒牙列 口腔内全部都是恒牙 恒牙龋病患病率高，病损严重 第一，二恒磨牙的保存

三咬合发育阶段的分期 A Ⅰ C 乳牙萌出前 乳牙咬合完成前 无牙期 乳牙萌出期 Ⅱ 乳牙咬合完成期 第一恒磨牙及恒前牙萌出开始期 （前牙替换期） 乳牙列期 混合牙列期 Ⅲ B 第一恒磨牙萌出完成期 （恒前牙部分或全部萌出完成） 侧方牙群替换期 第二恒磨牙萌出开始期 恒牙列期 Ⅳ 第二恒磨牙萌出完成期 第三恒磨牙萌出开始期 Ⅴ A 第三恒磨牙萌出完成期

第二节 颅面骨骼和牙列的生长

一 颅面骨骼的生长 （一）概论 1 出生前 1）起源：原始胚胎的支持性结缔组织 2） 化骨方式：膜内化骨 软骨内化骨

2 出生时 颅面骨骼：面骨=8：1 原因：咀嚼器官的发育落后 于脑和感觉器官发育

3 出生后 颅部生长： 1~2岁，增长最快 5岁后，增长减少 6岁，已达成人90% 10岁后，变化甚少

面部生长 高度 宽度 深度 高度>深度>宽度

3 生长曲线： 1） 颅骨：与神经系统的生长曲线相一致 2 ）面骨：一般躯体骨骼系统的生长曲线

（二）颅骨的生长 颅骨体积的增长： 1）骨的表面增生 2）骨缝间质增生 3）软骨的间质及表面增生

（三）面骨的生长 1 上颌骨 1）体积增长依赖于： 骨的表面增生 骨缝间质增生 上颌窦的发育

2）途径：长度： A ：骨缝间质增生(额颌 颧颌 颧颞 翼腭) B：上颌骨唇侧骨增生，舌侧骨吸收 C：上颌结节区增长 D：腭骨后缘的增长 长度增加最明显的为上颌磨牙区

宽度： A：腭突及腭中缝的生长 B：颧骨的宽度增加 C：上颌骨前部 上颌骨宽度增长较慢

高度 A：牙齿的萌出和牙槽骨的表面增生 B：骨缝间质增生 C：上颌窦的发育

2 下颌骨 1）下颌骨的发育：由下颌突深部组织发 育而来。 2)发育方式： 骨的表面增生 下颌髁突软骨生长 无骨缝间质增生

长度： A：骨板外新骨沉积，内侧陈骨吸收 B：下颌支前缘陈骨吸收，后缘新骨 增生

高度： A：下颌髁突新骨增生 B：牙槽突的增高及下颌骨下缘少量新骨增生

宽度 A：外侧骨增生，内侧骨吸收 B：髁突向侧方生长

二 牙齿的发育 （一）牙齿发育的时间 1 牙齿发育的三个阶段：生长期，钙化期和萌出期 2 观察牙齿发育的方法：X-线片观察牙齿钙化的不同阶段 3 恒牙发育时间表 4 恒牙钙化的10个阶段

（二） 牙齿萌出 1 牙齿萌出的概念：一般指牙齿突破口腔粘膜的现象 2 组织学：包括一系列的变化 3 牙齿萌出规律 ：1）一定的时间 2）一定的顺序 3）左右对称 4 牙齿萌出的变异

生理性流涎：乳牙萌出时，对三叉神经产生刺激，引起唾液分泌量的增加，但由于小儿还没有吞咽大量唾液的习惯，口腔又浅，唾液往往流到口外来，形成“生理性流涎”

三 咬合发育阶段的分期

乳牙列的生理间隙 1 灵长间隙：存在于上颌乳侧切牙和乳尖牙之间，下颌乳尖牙与第一乳磨牙之间的间隙 2 发育间隙：灵长间隙以外的生理间隙

恒前牙萌出期 正中分开 丑小鸭阶段 下切牙拥挤现象

侧方牙群替换期 1 侧方牙群 2 剩余间隙

第三节 生长发育的评价

常用评价方法 1 实际年龄 2 生理年龄 3 骨龄 4 牙龄