Chapter 1
Introduction to pediatric dentistry
1 Definition of pediatric dentistry
According to AAPD(America Academy of Pediatric Dentistry), Pediatric
dentistry is 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.
The definition gives us answers for the following questions:
a. Who are the objects of Pediatric dentistry?
 Infants and children through adolescence
 including those with special health care needs
b. What does the Pediatric dentistry provide?
 Provides both primary and comprehensive preventive oral health care
 Provides both primary and comprehensive therapeutic oral health care
c. 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...care”: Pediatric dentists are primary providers.
There is no need for a referral of patients. Parents can choose to have their
children evaluated and treated by a pediatric dentist just like they can choose
to have their child treated by a 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.
We’ve talked about the four key elements in the definition that make the
Pedodontics so unique, now if you find the Pedodontics has its sunshinning future,
and welcome you join us and become one of pediatric dentist.
2.Structure of the dental consultation
The way a dentist interacts with patients will have a major influence on the
success of any clinical or preventive care. It is particularly important for pediatric
dentists to learn how to communicate with children, and how to help anxious and
uncooperative children relax, as communicating effectively is of great value to
reduce the stress involved when offering clinical care, and failure to communicate
will result in disappointed children and an unsuccessful practice. So, the training of
pediatric dentistry should include a thorough understanding of how the dental visit
should be structured, and what strategies are available to help children cope with
their apprehension about dental procedures.
Each patient is a unique individuals with different needs and aspirations, this is
especially so in pediatric dentistry where a clinician may have to treat a frightened
3-year-old child at one appointment and an hour and a half later be faced with the
problem of offering preventive advice on oral health to a 15 year old. So, only an
outline structure is given to a successful dental consultation.
2.1 Greeting. First, as a pediatric dentist, you should greet the child in a
friendly way, smiling and looking steadily at him/her. Second, it is better for you to
greet the child by name, especially when he/she is recalled . It’s an honor for a
person whose name is born in mind by another person. Third, you should remember
that proceeding too quickly to an instruction could spoil a greeting. For example,
‘Hello, qing, jump in the chair‘ is rather abrupt and may prejudice an interactive
relationship. The greeting should be used to put the children and parents at ease
before proceeding to the next stage.
2.2 Preliminary chat. This phase has three objectives, to assess whether the
patients have any particular worries or concerns, to settle the patient into the clinical
environment, and to assess the patient’s emotional state. The following sequence
represents one way of maximizing the effect of the ‘preliminary chat’:
(a) Begin with non-dental topics. For child who never comes before, you may
express your praise to him/her. For example, you may say‘ oh, your eyes so
beautiful’ or ‘ you are so clever’ and so on. For children who have been before, it is
helpful to record useful information such as toys, school and hobbies.
(b) Ask an open question such as ‘How are you/are you having any problems
with your teeth?’
(c) Listen to the answer. It is important to listen to the answer and probe further
if necessary. All too often dentists ask questions and then ignore the answer.
By talking generally and taking note of what the child is saying you are offering a
degree of control and reducing anxiety.
2.3 Preliminary explanation In this stage the aim is to explain what the clinical
or preventive objectives are in terms that parents and children will understand. This
is a vital part of any visit as it establishes the credibility of the dentist as someone
who knows what the ultimate goal for the treatment is, and is prepared to take the
time and trouble to discuss it in non-technical language.
It must be stressed that sensible information cannot be offered to the patient or
parents until the clinician has a full history and a treatment plan based on adequate
information. This requires a broad view of the patient and should not be totally
tooth-centered. It is all too easy to lose the confidence of parents and children if you
find yourself making excuses for clinical decision taken in a hurried and unscientific
manner.
2.4 Business. The patient is now worked on. Many jokes are made about dentists
who ask questions of patients who are unable to reply because of a mouthful
instruments! This does not mean that the visit should enter a silent phase. It is
important to remain in verbal contact. Check the patient not in pain, discuss what
you are doing, use the patient’s name to show a personal interest, and clarify any
misunderstandings.
At the end of the business stage it is helpful to summarize what has been done and
offer aftercare advice. If the parent is not present in the surgery, the treatment
summary is particularly important, as it is useful way of maintaining contact with
the parents.
2.5 Health education. To a large extent, oral health id dependent upon personal
behavior and as such it would be unethical for dentists not to include advice on
maintaining a healthy mouth. The final part of the health education activity is goal
setting. The dentist sets out in simple terms what the patient should try and achieve
by the next visit. It implies a form of contract and as such helps both children and
parents to gain a clearer insight into how they all can help to improve the child’s
oral health. Goal setting must be used sensibly.
2.6 Dismissal. This is the final part of a visit and should be clearly signposted
so that everyone knows that the appointment is over. The patient should be
addressed by name and a definite farewell offered. The objectives should be ensured
that wherever possible the patient and parents leave with a sense of goodwill.
Clearly, not all appointment sessions can be dissected into these six stages.
However, the basic element of according the patient the maximum attention and
personalizing your comments should never be forgotten.
3 Anxious and uncooperative children
3.1 Dental anxiety is a common problem all over the world, especially in pediatric
dentistry.
Dental anxiety is a common problem all over the world, and it not only prevents
many patients from seeking care but it also cause stress to the dentists undertaking
dental treatment. Indeed one of the major sources of stress for general dental
practitioners is ‘coping with difficult patients’. So dental anxiety is a problem that
we as a profession must take seriously, especially as children remember pain and
stress suffered at the dentist and carry the emotional scars into adult life. Some
people may develop such a fear of dentistry that they are termed phobics. A phobia
is an intense fear, which is out of all proportion to the actual threat.
3.2 How does the dental anxiety develop?
Dental anxiety should be seen as a multi-factorial problem, and must also be seen
as a continuum with fear—it is almost impossible to separate the two in much of the
research undertaken in the field of dentistry, where the two words are used
interchangeably. A number of theories have been suggested in an effort to explain
the development of anxiety.
(a) Uncertainty about what is to happen is certainly a factor,
(b) A poor past experience with a dentist could upset a patient,
© While others may learn anxiety response from parents, relations, or friends.
3.3 The extent of dental anxiety
Research in this area suggests that the extent of anxiety a person experiences does
not relate directly to dental knowledge, but is an amalgamation of personal
experiences, family concerns, disease levels, and general personality traits. Such a
complex situation means that it is no easy task to measure dental anxiety and
pinpoint aetiological agents.
4 Helping anxious patients to copy with dental care
4.1 Establish an effective preventive programme
Clearly, the easiest way to control anxiety is to establish an effective preventive
programme so that children do not require any treatment.
4.2 Establish good dentist-patient relationship
4.3 Ensure any treatment is pain-free
4.4 Manage time effectively
4.5 Behavior Management
A. Traditional Techniques
a. Tell-show-do: to Reducing uncertainty
The majority of young children have very little idea of what dental treatment
involves and this will raise anxiety levels. Most children will copy if given friendly
reassurance from the dentist, but some patients will need a more structured
programme.
One such structured method is the tell-show-do technique. As its name implies it
centers on three phases:
Tell: explanation of procedures at the right age/educational level.
Show: demonstrate the procedure.
Do: following on to undertake the task. Praise being an essential part of the
exercise.
b. Positive Reinforcement: During the treatment, first, you may find something
to praise, it may be anything. Second, you should stress accomplishments and
prizes at end of visit.
c. Adaptive method
d. Modeling: This makes use of the fact that individuals learn much about
their environment from observing the consequences of other people’s behavior. You
might repeat an action if we see others being rewarded, or if someone is punished
we might decide not to follow that behavior. Modeling could be used to alleviate
anxiety. If a child could be shown that it is possible to visit the dentist, have
treatment, and then leave in a happy frame of mind, this could reduce anxiety due to
‘fear of the unknown’.
It’s not necessary to use a live model, videos of co-operative patients are of value.
e.Cognitive approaches Modeling helps people learn about dental treatment
from watching others, but it does not take account of an individual’s ‘cognitions’ or
thoughts. People may heighten their anxiety by worrying more and more about a
dental problem so creating a vicious reinforcing circle. Thus there has been great
interest in trying to get individuals to identify and then alter their dysfunctional
beliefs. A number of cognitive modification techniques have been suggested, the
most common ones including:
*asking patients to identify their negative thoughts
*helping patients to recognize their negative thoughts and suggesting more positive
alternatives
‘reality based’;
f. Distraction: This technique attempts to shift attention from the dental setting
towards some other kind of situation. Distracters such as videotaped cartoons and
stories have been used to help children cope with dental treatment.
g. Voice control: Use the change of tone or inflection, volume to hold child’s
attention, but do not telegraph frustration
B. Adversive Techniques
a. Physical restraint:
Mouth Prop:
Support oral access: Treatment aid
Apply with care:
Not to impinge on lips
Not to subluxate mandible
Assure ratchet works
Open slowly
Do not use as a crow-bar
Wraps or Papoose Board
Supports physically challenged patients, and it’s necessary during sedation,
Downside : sense of helplessness, loss of control
Pay attention to:
Avoid injury
Assure parental informed consent
Meet community standards
Hand over mouth
C. Pharmacologic Techniques
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.
Pay attention to:
Strict guidelines requiring
Monitoring & recording
Recovery area
Additional personnel
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
First dental visit There seems to be a lot of confusion amongst parents, pediatricians,
and dentists about the correct timing for the first dental visit. Many “family” dentists
may tell parents not to bring children to their practice before they have all their primary
teeth (age two or three), sometimes they even recommend to wait until age 6. The
parent of a fearful or uncooperative child may be told “we have to wait until your child
is old enough to sit still”. Under unfavorable circumstances delay of dental care can
lead to catastrophic disease progression that is not in the best interest of the child.
The AAPD recommends an initial postnatal oral evaluation within six months of
the eruption of the first primary tooth and no later than twelve months of age.
This means a child should have his or her first dental visit at the first birthday!
At this examination visit the dentist should record a thorough medical and dental
history. Parents should be prepared to review the prenatal, perinatal, and postnatal
period of their child’s development.
The oral examination at this early age is usually accomplished with the parent
present in the office. It is most often only a visual exam. The child patient may be
sitting in the parent’s lap with the head in the dentist’s lap (knee-to-knee position).
One important aspect of this visit is to discuss the child’s risk of developing oral
and dental disease. Based on this assessment the dentist will determine the appropriate
recall interval for the next dental visit. In high risk cases this may be as early as three
months. Dental decay in children can progress very rapidly.
The dentist will also evaluate the child’s oral and dental development. The
common question about “how many teeth at what age ?” will be addressed. The dentist
will also evaluate the need for fluoride supplementation. It may be important to discuss
non-nutritive habits (finger sucking, pacifier), injury prevention, oral hygiene, and
effects of diet on the dentition.
If treatment is indicated the dentist should be prepared to provide therapy or he
needs to refer the patient.