3 Paediatric dentistry

Treat the patient not the tooth.

Dental caries is often a rapidly progressing condition in children. It is essential to secure an accurate ∆ before making a Rx plan. This is achieved by taking a history, doing an examination, and, where appropriate, taking bitewing radiographs.

Bitewings are important for an accurate ∆ unless approximal surfaces of the primary molars can be visualized (i.e. the dentition is spaced).

The ultimate aim in dentistry for children is for the child to reach adulthood with good dental status and a positive attitude towards dental health and dental Rx. The final Rx plan will take into account the following considerations:

Remember to consider the developing occlusion:

The Rx plan is drawn up visit by visit. Each visit has both preventive and operative components (optimally aiming to deliver only one key preventive message per visit).

As it is considered to be easier to administer LA for maxillary teeth, these teeth are usually treated before mandibular teeth.

Restorative care (i.e. repair) without prevention is of limited value. Dental caries is treated by ‘preventive’ measures; ‘restoration’ primarily repairs the damage caused by the carious process.

Children with caries in primary molars treated by prevention alone are likely to experience toothache/infection, especially if the child is young when the caries is first diagnosed. Therefore a combination of prevention and restorative/surgical treatment is usually indicated for most children with caries in the 1° dentition.

Pain or evidence of infection may influence the order of the Rx plan.

Temporization (i.e. hand excavation and dressing) of open cavities at the start of Rx:

Once the Rx needs have been decided upon:

Look out for any signs of underlying medical or social problems which may modify the Rx plan:

Most of these are fancy terms to describe techniques that come with experience of treating children over a period of time.

Self-explanatory, but use language the child will understand.

Aim to guide and modify the child’s responses, selectively reinforcing appropriate behaviour, whilst discouraging/ignoring inappropriate behaviour.

This is the strengthening of patterns of behaviour, usually by rewarding good behaviour with approval and praise. If a child protests and is uncooperative during Rx, do not immediately abandon session and return them to the consolation of their parent, as this could inadvertently reinforce the undesirable behaviour. Try to ensure that something is completed, (e.g. placing a dressing or even an examination) and focus on the successful completion of this, rather than the failure to complete what might have been originally planned.

Useful for children with little previous dental experience who are apprehensive. Encourage child to watch other children of similar age or siblings receiving dental Rx happily.

Used for child with pre-existing fears or phobias. Involves helping patient to relax in dental environment, then constructing a hierarchy of fearful stimuli for that patient. These are introduced to the child gradually, with progression on to the next stimulus only when the child is able to cope with previous situation.

Essential on first visit, thereafter depends upon child’s age and clinician’s preference. If in doubt ask child’s preference. However, if parent is dental phobic, their anxiety in the dental environment can be detrimental, so in these cases it is worth considering leaving the parent in the waiting room. Younger children are more likely to suffer ‘separation anxiety’, and many parents nowadays wish to be involved in, and informed about, their child’s Rx. In the event of anxiety-related behaviour being encountered, parental presence in the surgery does enable consent for any adjustment in treatment to be easily maintained. Ideally parents should be motivated positively and instructed implicitly to act in the role of the ‘silent helper’.

Sometimes indicated for the genuinely anxious child who wishes to cooperate and also may help children with over-active gag reflexes and those where analgesia additional to LA may be needed (e.g. for difficult extractions such as 6s).

Drugs such as midazolam and chloral hydrate have been advocated, although specialized knowledge and skills are required.

Rarely used in children.

Rarely used in children >12yrs of age.

Popular in some Scandinavian countries.

Uses nitrous oxide/oxygen mixture to produce RA and is most popular technique for use with children. Effective for ↓ anxiety and ↑ tolerance of invasive procedures in children who wish to cooperate but are too anxious to do so without help. It is a good idea not to carry out any Rx during the visit when the child is introduced to ‘happy air’. Let child position nose-piece themselves. See also Chapter 14.

Produces a state of altered consciousness and relaxation, though it cannot be used to make subjects do anything that they do not wish to do.¹ Appropriate training is necessary for those wishing to practise hypnosis. It can be described as either a way of helping the child to relax, or as a special kind of sleep.

Allows dental rehabilitation &/or dental extractions to be achieved at one visit. GA should only be used for dental Rx when absolutely necessary (i.e. when other methods of management, e.g. LA or sedation, are deemed unsuitable). Alternative strategies and the risks of GA must be discussed to enable parents to make an informed decision. The risk of unexpected death of a healthy person:

When faced with a child with toothache, pulpal or periodontal pathology are the commonest causes. The dentist has to use clinical acumen to try and determine the state of the affected tooth/teeth, as this will decide the Rx required (Table 3.1). To that end the following investigations may be employed:

Take a pain history (see Dental pain, p. 222) from the child and parent. Beware of variations in accuracy; anxious children may deny being in pain when faced with an eager dentist, whereas parents who feel guilty for delaying seeking dental Rx may exaggerate pain. Remember some pathology is painless, e.g. chronic periradicular periodontitis.

Swelling, temperature, lymphadenopathy? Intraorally look for caries, abscesses, chronic buccal sinuses, mobile teeth (? due to exfoliation or apical infection), and erupting teeth.

Can be unreliable in children. Gentle finger pressure first. Care needed to establish a consistent response and compare with unaffected ‘control’ teeth.

Using thermal (e.g. ethyl chloride on cotton wool) or electrical stimulation. Again, establish a consistent, reliable response on a ‘control’ tooth before testing the tooth/teeth in question. Check for false-positives, by altering the intensity of stimulus (e.g. cotton ball with ethyl chloride, followed by a dry cotton ball). Less reliable in primary teeth.

Bitewing X-rays may be useful. Not only are they less uncomfortable for small mouths than periapicals, but they also often show the bifurcation area where radiolucency secondary to periodontitis is often first apparent.

Fleeting pain on hot/cold/sweet stimuli = reversible pulpitis. Longer-lasting pain on hot/cold/sweet stimuli &/or spontaneous pain with no initiating factor (? child kept awake) but no mobility, not TTP = irreversible pulpitis. Pain on biting and pressure &/or swelling and tenderness of adjacent tissues, mobility = acute periradicular periodontitis. Remember, the only 100% accurate diagnostic method is histological!

With a fractious child keep examination and operative intervention to a minimum, doing only what is necessary to alleviate pain and win child’s trust.

If extractions under a GA are required consider carefully the long-term prognosis of remaining teeth to try and avoid a repeat of the anaesthetic in the foreseeable future.

Other common potential causes of toothache:

are usually members of the 1° dentition, not supernumerary teeth, and so should be retained if possible. Most frequently occur in lower incisor region and because of limited root development at that age, are often mobile. If in danger of being inhaled or causing problems with breast-feeding, they can be removed under LA.

As eruption of the 1° dentition coincides with a diminution in circulating maternal antibodies, teething is often blamed for systemic symptoms. However, local discomfort, and so disturbed sleep, may accompany the actual process of eruption. A number of proprietary ‘teething’ preparations are available, which usually contain a combination of an analgesic, an antiseptic, and anti-inflammatory agents for topical use. Having something hard to chew may help, e.g. teething ring. Some are designed to be cooled in the fridge, which can enhance their soothing ability.

is caused by an accumulation of fluid or blood in the follicular space overlying an erupting tooth. The presence of blood gives a bluish hue. Most rupture spontaneously, allowing eruption to proceed. Rarely, it may be necessary to marsupialize the cyst.

Disruption of normal eruption sequence (see Fig. 3.1) and asymmetry in eruption times of contralateral teeth >6 months warrants further investigation.

It must be remembered that there is a wide range of individual variation in eruption times. Developmental age is of more importance in assessing delayed eruption than chronological age.

Hereditary gingival fibromatosis, Down syndrome, Gardner syndrome, hypothyroidism, cleidocranial dysostosis, rickets.

Occur where the 1° molar has failed to maintain its position relevant to the adjacent teeth in the developing dentition and is therefore below the occlusal level of adjacent teeth. Often due to ankylosis secondary to disruption in normal resorptive/repair cycle of exfoliation. This is usually self-correcting (if the permanent successor is present and not ectopic) and the affected tooth is exfoliated at the normal time. However, where the premolar is missing or where the infraoccluded molar appears in danger of disappearing below the gingival level, extraction may be indicated (monitor carefully—if in doubt get a specialist opinion).

against the occurs in 2–5% of children. It is an indication of crowding. In younger patients (<8yrs) many self-correct (‘jump’). If still present after 4–6 months (‘hold’) or in older children, insertion of an orthodontic separating spring may allow the 6 to jump free. More severe impactions should be kept under observation. If the becomes abscessed or the 6 is in danger of becoming carious then the 1° tooth should be extracted. The resulting space loss can be dealt with later as part of the overall orthodontic Rx plan.

Most common reason for early tooth loss is extraction for caries. Traumatic avulsion is less common. More rarely, systemic disease such as neutropenia or leukaemia may result in an abnormal periodontal attachment and thus premature tooth loss. Alveolar bone loss in a young child is a serious finding and warrants referral.

Means complete absence of all teeth. Rare. Partial anodontia is a misnomer.

Developmental absence of one or more teeth.

1° dentition: 0.1–0.9%, 2° dentition: 3.5–6.5%.² In Caucasians most commonly affected teeth are 8 (25–35%), 2 (2%), lower 5 (3%). Affects F > M and is often associated with smaller than average tooth size in remainder of dentition. Peg-shaped 2 often occurs in conjunction with absence of contralateral 2  NB  3 migrates down guided by the distal aspect of 2. When 2 is absent, peg-shaped, or small-rooted, it is important to monitor the maxillary canine for signs of ectopic eruption.

Often familial—polygenic inheritance. Also associated with ectodermal dysplasia and Down syndrome.

Better known as supernumerary teeth.

1° dentition 0.8%, 2° dentition 2%.¹ Occurs most frequently in premaxillary region. Affects M > F. Associated with cleidocranial dysostosis and CLP. If $ in 1° dentition is followed in about 50% cases by $ in 2° dentition, so warn mum!

Theories include: offshoot of dental lamina, third dentition.

either by shape or position (Table 3.2) and orientation (e.g. ‘upright, ‘inverted’, etc.).

Enamel usually develops in two phases, first an organic matrix and second mineralization. Disruption of enamel formation can therefore manifest as:

Caused by disturbance in matrix formation and is characterized by pitted, grooved, or thinned enamel.

Hypocalcification is a disturbance of calcification. Affected enamel appears white, yellow, or brown and opaque. May become more discoloured post-eruptively. Affected enamel may be weak and prone to breakdown. Most disturbances of enamel formation will produce both hypoplasia and hypomineralization, but clinically one type usually predominates.

(not an exhaustive list)

Infection (‘Turner tooth’), trauma, irradiation, idiopathic (see Enamel opacities, p. 74).

So called because the hypoplastic enamel occurs in a distribution related to the extent of tooth formation at the time of the insult. Characteristically, due to its later formation, 2 is affected nearer to the incisal edge than 1 or 3.

Fluorosis See Fluoride, p. 28.

Small areas of hypoplasia can be fissure-sealed or restored conventionally, but more severely affected teeth will require crowning. SS crowns ( Stainless steel crowns, p. 86) can be used in children as a semi-permanent measure.

Small areas of hypoplasia can be restored using composites, but larger areas may require veneers ( Veneers, p. 250) or crowns.

Rx options include intracoronal restoration, SS crowns, or extraction ( Extraction of poor quality first permanent molars, p. 138). Consider partial composite veneering for incisors.

Many classifications exist, but generally these are classified by the type of enamel defect &/or the mode of inheritance. There are now known to be >25 mutations in four different genes (AMELX, ENAM, KLK4, MMP20) that are associated with AI).⁴

Usually both 1° and 2° dentitions and all the teeth are affected. The different subgroups give rise to a wide variation in clinical presentation, ranging from discoloration to soft &/or deficient enamel. It is therefore difficult to make general recommendations, but it is wise to seek specialist advice for all but the mildest forms. Rx: in more severe cases, SS crowns and composite resin can be used to maintain molars and 2° inc, prior to more permanent restorations when child is older.

Include dentinogenesis imperfecta, dentinal dysplasias (types I and II), regional odontodysplasia, vitamin D-resistant rickets, and Ehlers–Danlos syndrome—all of which are rare.

Is more common affecting 1 in 8000. Both 1° and 2° dentitions are involved, although later-formed teeth may be less so. Main types:

Affected teeth have an opalescent brown or blue hue, bulbous crowns, short roots, and narrow flame-shaped pulps. The ADJ is abnormal, which results in the enamel flaking off, leading to rapid wear of the soft dentine. Rx: along similar lines as for severe amelogenesis.

Early recognition and Rx of amelogenesis and dentinogenesis imperfecta important to prevent rapid tooth wear.

Hypoplasia and aplasia of cementum are uncommon. The latter occurs in hypophosphatasia and results in premature exfoliation. Hypercementosis is relatively common and may occur in response to inflammation, mechanical stimulation, or Paget’s disease, or be idiopathic. Concrescence is the uniting of the roots of two teeth by cementum.

Prevalence.⁵Normal width 1 = 8.5mm, 2 = 6.5mm.

occurs by partial splitting of a tooth germ.

occurs as a result of the fusion of two tooth germs. As fusion can take place between either two teeth of the normal series or, less commonly, with a $ tooth, then counting the number of teeth will not always give the correct aetiology.

As the distinction is really only of academic interest, the term ‘double teeth’ is to be preferred. Both 1° and 2° teeth may be affected and a wide variation in presentation is seen. The prevalence in the 2° dentition is 0.1–0.2%.

for aesthetics should be delayed to allow pulpal recession. If the tooth has separate pulp chambers and root canals, separation can be considered. If due to fusion with a $ tooth, the $ portion can be extracted. Where a single pulp chamber exists sometimes the tooth can be contoured to resemble two separate teeth or the bulk of the crown reduced.

Generalized macrodontia is rare, but is unilaterally associated with hemifacial hypertrophy. Isolated megadont teeth are seen in 1% of 2° dentitions.

1° dentition <0.5%. In 2° dentition overall prevalence is 2.5%. Of this figure 1–2% is accounted for by diminutive 2. Peg-shaped 2 often have short roots and are thought to be a possible factor in the palatal displacement of 3 ( Palatally displaced maxillary canines, p. 142). 8 also commonly affected.

This is really a marked palatal invagination, which gives the appearance of a tooth within a tooth. Usually affects 2, but can also affect premolars. Where the invagination is in close proximity to the pulp, early pulp death may ensue. Fissure sealing of the invagination as soon as possible after eruption may prevent this, but is often too late. Conventional RCT is difficult and extraction is usually required.

Describes a tooth with a distorted crown or root. Usually affects 1. Two types seen, dependent upon aetiology (Table 3.3).

The traumatically induced type is caused by intrusion of the 1° incisor, resulting in displacement of the developing 2° incisor tooth germ. The effects depend upon the developmental stage at the time of injury.

Rx: depends upon severity and patient cooperation. If mild it may be possible to expose crown and align orthodontically provided the apex will not be positioned against the labial plate of bone at the end of the Rx, otherwise extraction indicated.

Term used to describe the effect of a disturbance of enamel and dentine formation by infection from an overlying 1° tooth therefore usually affects premolar teeth. Rx: as for hypoplasia Hypoplasia, p. 68.

Of academic interest only, but seems to crop up on X-rays in exams much more frequently than in clinical practice. Means bull-like, and radiographically an elongation of the pulp chamber is seen. Rx: none required.

By definition this is caused by extrinsic agents and can be removed by prophylaxis. Green, black, orange, or brown stains are seen, and may be formed by chromogenic bacteria or be dietary in origin. Chlorhexidine mouthwash causes a brown stain by combining with dietary tannin. Where the staining is associated with poor oral hygiene, demineralization and roughening of the underlying enamel may make removal difficult. Rx: a mixture of pumice powder and toothpaste or an abrasive prophylaxis paste together with a bristle brush should remove the stain. Give OHI to prevent recurrence.

This can be caused by:

Are localized areas of hypomineralized (or hypoplastic) enamel. Fluoride ( Fluoride, p. 28) is only one of a considerable number of possible aetiological agents.

Four possible approaches:

Acid pumice abrasion technique is effective for some types of diffuse (surface) enamel defects. Two methods (take pre-op photos to monitor improvement):

(quicker, but great care needed)

A mixture of 18% hydrochloric acid and pumice is applied to the affected area using a wooden stick. Careful isolation with rubber dam, use of a neutralizing agent (e.g. sodium bicarbonate) and protection of the soft tissues/patient is essential. The mixture is rubbed into the surface for 5sec and then rinsed away. These two steps are repeated (max. 10 times—removing <0.1mm enamel) until the desired colour change is achieved. The enamel is then polished and a fluoride solution applied.⁶

(slower but potentially safer)

A number of variations of this technique are in use. A commonly used method is to etch with 30–50% orthophosphoric acid for 1–2min, wash, then use pumice and water slurry with rubber prophy cup for 1min (take care not to overheat the tooth). Wash. Repeat etch and pumice stage ×2, washing between. Dry tooth and apply topical fluoride solution (avoid pigmented varnishes). May be repeated up to ×2, but leave at least 6 weeks before each repeat to check for improvement.

Bleaching Tooth whitening, p. 248.

Veneers Veneers, p. 250.

Crowns Anterior crowns for vital teeth, p. 252.

Primary teeth differ in several respects from permanent teeth, affecting both the sequelae of dental disease and its management (Fig. 3.3).

(1) Enamel in 1° teeth is ~1mm thick, which is 1/2 that of 2° teeth.

(2) The pulp chamber in 1° teeth is proportionately larger, with more accentuated pulp horns. DE—3 pulp horns MB, DB, and palatal. Lower DE—4 pulp horns MB, ML, DB, and DL. These features mean that caries will affect the pulp sooner and there is a greater likelihood of pulp exposure during cavity preparation. Aim for 0.5–1.0mm penetration dentine only, except where caries determines deeper preparation.

(3) follows the amelo-dentinal junction more closely in 1° teeth, therefore cavity floor should follow external contour of tooth sinuously to avoid exposure.

Greater convergence of the buccal and lingual walls results in a proportionately narrower occlusal table. This is more pronounced in D than E therefore, over-extension of an occlusal cavity or lock can lead to weakening of the cusps.

(4) This makes detection of interproximal caries more difficult, and means that in 1° molars divergence of the buccal and lingual walls towards the approximal surface is necessary to ensure cavity margins are self-cleansing. Isthmus should not extend >1/2 intercuspal distance.

(5) 1° molars have a more bulbous crown form than 2°, molars, making matrix placement more difficult.

(6) In the cervical 1/3 of 1° molars the enamel prisms are inclined in an occlusal direction so there is no need to bevel the gingival floor of a proximal box.

(7) is more marked in 1° molars, therefore if the base of the proximal box is extended too far gingivally it will be difficult to cut an adequate floor without encroaching on the pulp.

This is ↑ in younger children, thus it is usually possible to achieve local anaesthesia of 1° mandibular molars by infiltration alone, up to 6yrs of age.

(8) may explain the greater incidence of inter-radicular involvement following pulp death.

(9) 1° molars have proportionately longer roots than their permanent counterparts. They are also more flared to straddle the developing premolar tooth. The roots are flattened mesio-distally, as are canals within.

(10) follows a tortuous and branching path, making complete cleansing and preparation of the root canal system almost impossible, although instrumenting canals is often easier than suggested in some texts. In addition, as the roots resorb, a different approach to RCT is needed for the 1° dentition, pure zinc oxide and eugenol being the obturation material of choice.

Despite a welcome reduction in the prevalence of dental decay, the dilemma of whether to restore or extract a 1° tooth is still all too familiar. In making a decision a number of factors should be considered:

This will influence the likely cooperation for restorative procedures, the expected remaining length of service of the affected tooth, and the severity of sequelae following early tooth loss (as the earlier the tooth is lost, the greater the potential for space loss).

For patients where recurrent bacteraemia carries ↑ risks (e.g. immunocompromised, risk of endocarditis) it is generally considered that 1° tooth pulp therapy should be avoided, with extraction (taking appropriate precautions where necessary) often being more appropriate. Conversely, in haemophiliacs, extractions should be avoided and 1° teeth preserved, if possible, until their exfoliation. Prevention is particularly important in all such patients.

As it is the parents that bring the child to the surgery, we must explain to them the benefits of maintaining the 1° dentition. Unfortunately, a small proportion of the population may regard a dentist that fills 1° teeth with suspicion—after all, everyone knows that baby teeth fall out!

In a child with an otherwise caries-free mouth every attempt should be made to preserve an intact dentition. Where there is extensive caries, restoration of Es and loss of Ds can be an acceptable compromise.

If a child is suffering pain from one or more teeth, this needs to be alleviated as soon as possible. If symptom-free, then the dentist will have more time to explore the extent of the lesion(s) and the child’s cooperation.

In 1° molars destruction of the marginal ridge indicates a high probability of pulpal involvement.⁷ If several 1° molars require pulp therapy, and cooperation/motivation is poor, serious thought should be given to extraction rather than restoration.

Although early loss of 1° incisors will have little effect, extraction of C, D, or E will, in a crowded patient, lead to localization of the crowding. Extraction of Es, particularly in the upper arch, should be deferred, if possible, until the 6 has erupted.

Bear in mind the amount of crowding present and the likelihood of spontaneous space closure.

If still undecided, it is worth considering the occlusion. In a particularly crowded case, restoration of a decayed tooth may be indicated if further space loss would mean that extraction of more than one premolar per quadrant would be required. Much has been written about compensating (same tooth in opposing arch) and balancing (contralateral tooth) extractions, although this is still an area of some controversy.⁸ The rationale is that a symmetrical problem is easier to deal with later but if taken to its logical conclusion, gross caries of D| and ⎡E will result in a clearance! In general, loss of Cs in a crowded patient should be balanced to prevent a centre-line shift. Balancing Ds in a child with ↑ risk of caries also has the advantage of removing very caries prone contacts (i.e. E–D and D–C).

So much for the theory; in practice, it should be remembered that a happy and cooperative patient is more important long term. When treating a child under local analgesia leaving extractions unbalanced and monitoring for centreline shift may be preferable to prolonging intervention in the dental chair.

Although there is no scientific evidence to suggest that 1° teeth are less sensitive than 2° teeth, clinically it is sometimes possible to complete cavity preparation of minimal cavities without LA, especially on 1° anterior teeth. However, Walls et al. found that restorations placed without LA did not survive as long as those where LA was used.⁹ Adequate management of approximal caries in 1° molars usually requires LA.

Lidocaine 2% with 1:80 000 adrenaline. Maximum dose = 4.4mg/kg.

Prilocaine 3% with felypressin (0.03IU/mL)—may give slightly less profound anaesthesia. Maximum dose = 6.6mg/kg.

In both lidocaine and articaine maximum dosage equates to (i) 2.2mL for a healthy 10kg 1.5yr-old child and (ii) 4.4mL for a healthy 20kg 5yr-old (i.e. 1 × 2.2mL cartridge per 10kg). This may need to be reduced for children with certain medical conditions.

Articaine 4% with adrenaline may be used (maximum dose 7mg/kg) and there is some evidence that 1° molar teeth can be more reliably anaesthetized by infiltration alone. However, articaine is not licensed for children <4yrs of age and greater care needed to avoid exceeding maximum dose. Some evidence suggests greater risk of prolonged anaesthesia/paraesthesia when articaine used for ID blocks, so some suggest avoiding the use of articaine for blocks.

Used for maxillary teeth, mandibular incisors and lower 1° molars before lower 6 has erupted. After 6yrs of age bone permeability is reduced and an IDB is required (infiltration with articaine may be an alternative). Infiltration technique as for adults ( Local analgesia—techniques, p. 608). In children, the malar buttress overlies 6, so it is often advisable to deposit some solution over the more permeable bone mesial and distal to this tooth.

Using thumb and forefinger, find the shortest width of ramus. Penetrate about 1cm into lingual tissues from internal oblique ridge, on a line between thumb and finger. An aspirating syringe is essential. Note: mandibular foramen is lower on ramus in young children (about same level as occlusal plane).

is rarely required in children and carries a significant risk of post-injection haematoma. If necessary due to failure of infiltration for 6, the technique should be modified by depositing solution distal to the zygomatic buttress and massaging it backwards towards the posterior superior alveolar foramen (maxillary molar block).¹⁰

These purpose-designed syringes have an ultra-short needle and a ‘gun’ or ‘pen’ appearance. This makes it helpful for children with a needle phobia, or as a more acceptable alternative or adjunct to an IDB. In addition, as the lips and tongue are not anaesthetized it is useful for young or disabled children, in whom there is a greater risk of post-operative soft-tissue trauma.

In this technique a jet syringe (e.g. Syrijet^® or Injex^®) is used to inject LA solution under pressure through mucosa and bone to a depth of about 1cm. Useful for producing soft-tissue analgesia prior to conventional LA injection or for infiltration analgesia, and for some patients who will not contemplate LA using a needle, but not widely used.

Allows carefully controlled slow delivery via a line and needle resembling an IV giving set. Especially useful for direct palatal analgesia and for anxious patients.

Making an accurate pre-operative ∆ (including appropriate radiographs) and Rx plan is essential. This will enable Rx to be provided as efficiently as possible ( Treatment planning for children, p. 58).

See Local analgesia for children, p. 80.

Ideally, rubber dam should be used routinely for all restorative procedures. It not only protects the airway, but also improves moisture control and visibility, and aids in patient management. It is essential for all root canal and pulp therapy for permanent teeth, and advisable for restoration of primary teeth. If placement of rubber dam is not possible, plastic disposable salivary ejectors are better tolerated than the metal flange type.

High-speed; pear-shaped bur numbers 330 and 525, and short fissure bur number 541. Slow-speed: a selection of pear-shaped and round burs are most useful. For access use a small bur and for caries removal use the largest round bur which fits into the cavity.

A miniature-head handpiece is invaluable. Some children are apprehensive of the aspirator tip, making use of a high-speed, water-cooled handpiece difficult; others find the vibration of the slow-speed handpiece distressing, and may confuse it with pain. In these cases distraction or counting (i.e. ‘I will count to thee each time, then I will stop’) can help. Occasionally it is possible, but time-consuming, to complete cavity preparation with hand instruments.

Because of concerns about toxicity and environmental pollution, plus the availability of alternative materials, amalgam is less frequently used. However, it still remains an acceptable and durable material for class I and II restorations in 1° molars.

Has advantages of adhesion and fluoride release, but is more technique sensitive and less wear resistant than amalgam. Useful in non-load bearing class III and V cavities, temporization of 1° teeth in young, pre-cooperative children, or teeth near to exfoliation.

Has been demonstrated to have excellent performance in 1° teeth.

A modified composite-type material with some of the properties of GI cement. More technique and moisture sensitive than amalgam, but studies suggest similar longevity.

Early studies suggested poor performance in 1° teeth, but modern materials placed with good isolation (i.e. rubber dam) perform as well, or better than amalgam, but take longer to place.

Plastic, intracoronal restorations perform best in 1° molars with small class I and II cavities. SS crowns ( Stainless steel crowns, p. 86) give superior longevity where lesions are more extensive.

Should include any undermined enamel. Extension for prevention is now outmoded, but any suspect adjacent fissures should be included. Do not cross transverse marginal ridges unless they are undermined.

Caries should be excavated from the ADJ first. If necessary, you may need to re-establish outline form to improve access to ensure ADJ is caries free. Then progress to carefully removing caries from floor.

Whilst not as crucial with adhesive materials, ensuring reasonable resistance form is of value in load bearing situations.

Many others, but these are the most common.

It is important to explain to the child what you are doing, and why, in terms they can understand.

It may be helpful to describe some of the instruments we use in ways that can make them seem less threatening to a child (‘childrenese’) (e.g. see Table 3.4).

See Anatomy of primary teeth (& relevance to cavity design), p. 76 for anatomy of 1° molars and effect upon cavity design. Have all necessary instruments and filling materials ready so that appointment is kept as short as possible.

Reinforce good aspects of child’s behaviour with praise and possibly sticker/badge/toothbrush.

SS crowns are the most durable restoration for 1° molars with extensive caries and those where pulp Rx has been performed.

SS crowns do contain small traces of nickel and are therefore not suitable for patients with a known nickel allergy.

High-speed tapered diamond bur (e.g. 582) and diamond occlusal wheel. Straight handpiece and a stone. Slow-speed handpiece and burs as required. Crown scissors, dividers, selection of suitable crowns and Adam’s pliers. Johnstone contouring pliers (no. 114) and Abel pliers (no. 112) can also be useful, but are not essential.

There are two principal methods for placement:

SS crowns rely for retention only on a tight adaptation at the gingival margin of the preparation, therefore taper of preparation walls is not critical (Fig. 3.5).

Technique for 2° molars (Fig. 3.6) is similar but more careful adjustment is necessary.

In this relatively new technique, no conventional preparation or caries removal is normally carried out. After simply removing any loose debris, a crown is cemented over the carious, unprepared molar. LA is not usually required, with the child ‘biting’ the cement-filled crown down into place. Advocates of the technique suggest its use is restricted to asymptomatic teeth with no evidence of pulpal inflammation/necrosis/periodontal involvement.

A number of studies have demonstrated that conventionally placed SS crowns have a far superior longevity to other types of restoration in 1° molars. Initial studies of ‘Hall’ technique SS crowns have also indicated very favourable results probably due to creation of an effective pericoronal seal.¹¹

Carious 1° incisors and canines are seen less frequently than molars and are usually indicative of a high caries rate during early infanthood (see ‘Severe early childhood caries’ Severe early childhood caries, p. 90).

Objectives are relief of pain and prevention. Aesthetics are less important.

include:

Similar technique to that used for permanent incisors, but omit incisal retention groove.

If restoration is essential the greater strength of composite is required. Polycarboxylate (strip) crowns are advocated by some paedodontists, for the well-motivated child.

Remove caries with a small round bur and restore with GIC/composite.

Cellulose acetate crown forms for primary incisors. Enable restoration of primary incisors using composite resin.

Frequent ingestion of sugar &/or reduced salivary flow.

Terms used to describe patterns of ECC associated with frequent consumption of a sugar-containing drink, especially from a feeding-bottle Commonly the child falls asleep with the bottle or suckles during the night. Occasionally seen in some cases of prolonged on-demand breast-feeding, especially where children >1yr old suckle frequently during the night, possibly due to the lactose in breast milk.¹² Characteristically, starts with the maxillary 1° incisors, but in more severe cases the first 1° molars are also involved. The mandibular incisors are relatively protected by the tongue and saliva.

Severe ECC may also be associated with the prolonged and frequent intake of sugar-based medications; however, both pharmaceutical companies and doctors are more aware of the problem and the number of alternative sugar-free preparations is increasing. See Table 3.6 for list.

A term with no specific definition, but often used to describe extensive, rapidly progressing caries affecting many teeth in the primary &/or permanent dentition.

Radiation for head and neck cancer may result in fibrosis of salivary glands and salivary flow. Patients often resort to sucking sweets to alleviate their dry mouth, which exacerbates the problem. Management of radiation caries requires specialist referral.

NB Primary molar roots resorb.

Where the carious process has jeopardized pulpal sensibility there are two alternatives: (i) extraction; (ii) pulp therapy.

See Extraction versus restoration of primary teeth, p. 78.

Diagnosis of state of the pulp can be difficult, as not only is a child’s perception of pain less precise than an adult’s, but the clinical picture may also be complicated by death of one root canal whilst the other(s) remain vital.

Indicated for asymptomatic, vital 1° molars with no pulp exposure after removal of all soft caries.

Removal of all soft caries. Leaving carious, but firm, affected dentine in vital, asymptomatic 1° molars has been shown to be reasonably successful. Margins of cavities should be rendered caries free to ensure an adequate coronal seal. Works best in occlusal cavities: less likely to be successful in approximal caries due to early pulpal involvement. Setting calcium hydroxide can be used in the deepest portion, with GIC, composite or SS crown (see Stainless steel crowns, p. 86). If pulp exposure occurs, pulpotomy/pulpectomy are usually more appropriate restorative techniques.

In 1° molars the relatively larger pulps result in earlier pulpal involvement, therefore amputation of the coronal pulp leaving healthy radicular pulp in situ (pulpotomy) gives more consistent results than techniques that attempt to retain vitality of the whole pulp, e.g. indirect pulp capping.

The most commonly used medicaments are:

>90% for vital pulps.¹⁴

A pulpectomy is often considered difficult in 1° molars because of the complexity of ribbon-shaped canals (although instrumentation is often easier than some texts might suggest). The risk of damage to the permanent successor also needs to be considered, but if conditions are favourable it is the Rx of choice for non-vital pulps.¹⁵ The technique can be carried out in one or two visits.

If there is evidence of any infection a two-stage Rx is recommended, leaving non-setting calcium hydroxide in the canals for 1–2 weeks prior to filling.

>80% at 3 years has been reported.

Usual Rx is extraction, as A and B are exfoliated before patient is able to cooperate satisfactorily with more complicated Rx. However, C is exfoliated later and unilateral loss may result in centre-line shift, therefore pulp treatment is indicated for some patients. The root canal morphology is amenable to pulpectomy and the canal should be cleaned using files, with care (remember underlying successor). A resorbable filling material, e.g. calcium hydroxide or ZOE, should be used.

If evidence of head injury, transfer patient to hospital immediately.

Take a structured history as an aide-mémoire and for medico-legal purposes.

Several exist; some use roman numerals, others describe the injuries sustained (WHO system):

Be alert for evidence of NAI ( Safeguarding children, p. 96).

All professionals involved with children need to be aware of the principles of safeguarding and alert to the possibility of child abuse or neglect.

NB The term ‘child abuse’ is now favoured over NAI.

The following signs are associated with abuse:

‘Child Protection and the Dental Team’ is a detailed and practical web-based resource developed by COPDEND/DOH aimed specifically at dentists and other DCPs and can be accessed at:  http://www.cpdt.org.uk

Local guidelines are produced by Local Safeguarding Children Boards (LSCBs) or Area Child Protection Committees. To find yours type ‘LSCB’ followed by your area into an Internet search engine. A copy of the local LSCB guidance should be kept in every practice.

(tip: write the telephone numbers of the first three on your copy of the local LSCB guidance)

Referral should be made directly to Social Services and followed up in writing within 48 hours. The child’s medical practitioner should also be informed. If a child presents with serious injuries which are suspicious, they should be referred to the nearest accident and emergency department, with the department informed of the situation before the child’s arrival.

Tact and understanding is required when dealing with the patient’s family. Try to avoid making accusations and concentrate on treating the patient’s injuries, expressing the need to refer them on to experts who will be able to fully evaluate the situation and offer appropriate help.

30–40% of 5yr-olds have experienced dental trauma,¹⁷ most frequently at toddler stage. As alveolar bone is more elastic the younger the child, the most common injuries are luxation or avulsion. Crown and root # are relatively rare.

For definitions see Definitions, p. 104. If X-rays are required, you may have to get parent to hold child and film. Alternatively, try placing a periapical film between the teeth (like an occlusal view) and angle the beam at 45°.

Need to consider the effect of any proposed Rx upon permanent successor.¹⁸ Splinting of 1° incisors is exceedingly difficult and not indicated. When in doubt, extract 1° tooth!

Rx: reassurance and soft diet.

If tooth near to exfoliation, extract. Otherwise, soft diet (for about 1 week). May become non-vital, therefore keep under observation. Give appropriate advice re possible complications.

Extraction if loose and tooth in danger of being inhaled, or if tooth interferes with occlusion. If crown displaced labially, ↑ risk of damage to underlying 2° incisor.

Most common injury (>60%). If X-ray confirms that tooth has been forced into follicle of 2° tooth, extract 1° incisor. Otherwise leave tooth and wait to see if spontaneous eruption will occur (between 1 and 6 months). Unfortunately, pulpal necrosis often follows, necessitating either pulp Rx ( Pulp therapy for primary anterior teeth, p. 93) or extraction. Should the tooth fail to erupt, then extraction is indicated. It is prudent to warn parents about possible damage to underlying permanent tooth.

Replantation not recommended due to risk of damage to permanent successor.

Rare. Minimal # can be smoothed and left under observation. Larger # either restore with composite &/or RCT if pulp involved, or extract.

Provided not displaced and little mobility, advise soft diet and keep under review. If coronal fragment displaced or mobile, extract, but leave apical portion as it will usually resorb.

If tooth becomes grey/reddish in early post-trauma period, pulp may be vital and discoloration reversible.

Greying later indicates pulp necrosis. Yellowing of tooth is suggestive of calcification of pulp—no Rx required.

Rx: extraction to prevent displacement of 2° incisor.

Rx: RCT or extraction.

In >50% of children <4yrs trauma to 1° tooth affects underlying developing successor.¹⁹ Effect depends upon stage of development, type of injury and severity, Rx, and pulpal sequelae. Can cause hypomineralization, hypoplasia (likelihood ↑ if <4yrs &/or injury more severe), dilaceration, severe malformation, and arrest of development.

Prevalence: 26–76% of injuries.

For small enamel #, smooth with white stone.

Need to protect exposed dentine, preferably with a hard-setting calcium hydroxide cement and an acid-etch retained composite. If time permits, this can be done with a crown former to restore tooth contour. Keep under review. Veneer or PJC can be considered later. If # near to pulp, treat as for pulp involvement.

Rx depends upon size of exposure; state of root development (1 root radiographically complete 10–11yrs, histologically 14–15yrs); time since injury and other injuries (e.g. root #). If apex open ↑ blood supply to pulp, therefore likelihood of pulp death ↓. This is advantageous as Rx should be directed towards retaining vitality of radicular pulp to allow root closure to continue. If pulp non-vital, see Root canal treatment—rationale, p. 330. Otherwise, Rx alternatives are:

exposure <1mm; <24h; complete or incomplete root development; pulp still vital. Cover exposure with calcium hydroxide (e.g. Dycal^®), and place composite tip. Review vitality.

Indications: exposure >1mm; >24h; complete or incomplete root development, pulp still vital.

large, contaminated exposures; long duration; incomplete root development; coronal pulp demonstrates impaired vascularity.

All pulpotomized teeth should be kept under long-term review as pulp necrosis and calcification are common sequelae. Success rates of 72% for cervical pulpotomies and 96% for minimal (Cvek) pulpotomies have been reported.²⁰

<10% of injuries to permanent dentition.

Usually no Rx required unless mobility ↑ significantly. However, tooth should be kept under observation as death of coronal 2/3 of pulp may occur. Only need to prepare canal to # line as apical 1/3 usually retains vitality. Prognosis good. If extraction required, apical 1/3 can be left in situ to preserve bone.

In majority of cases tooth is loosened, therefore rigid splinting advisable to attempt to achieve hard-tissue union of # line. 12 weeks previously advocated, but recent evidence suggests flexible splinting for 4 weeks may give similar outcome.²¹ If coronal part not displaced loss of vitality unlikely. Where coronal fragment displaced, re-position, splint, and if loss of vitality occurs, RCT to # line. Calcium hydroxide should be used as an interim dressing to limit inflammation and resorption. Delay in Rx ↓ prognosis. If extraction required, consider leaving apical portion in situ.

In this group there is a high risk of direct communication with the gingival crevice, allowing ingress of bacteria into pulp. Where no obvious risk, flexible splinting for a prolonged period (up to 4 months) is advocated.²¹ Where the # line extends coronally, emergency Rx is either (i) temporary stabilization or (ii) extraction of the coronal fragment. Definitive treatment usually is extraction of both parts of tooth or, preferably, removal of the coronal fragment, and appropriate RCT of remainder, followed by placement of a dressing which will prevent gingival tissues overgrowing root surface. Can use a temporary post-retained crown, but repositioning of the coronal fragment using a dentine-bonding agent and composite has been described. Permanent Rx is post and core crown.

If # extends below alveolar crest, need improved access for crown fabrication. There are two alternatives shown in Table 3.5.

For orthodontic extrusion will need either a URA or a sectional FA with an attachment bonded on to labial surface of temporary post and core crown or any available enamel. Gentle forces of 50–100g should be used. When sufficient extrusion has been achieved, retain for at least 3–6 months before fabricating a permanent restoration.

Provided # does not extend above alveolar crest, can treat as coronal #. Otherwise, consider extraction of coronal portion only, leaving apical portion in situ to preserve bone.

Extraction is often only option.

If tooth extracted, a P/- will need to be fabricated ( Treatment planning for patients with missing teeth, p. 264).

Prevalence: 15–40% of injuries.

Injury to supporting tissues of tooth, without displacement.

Displacement of tooth (laterally, labially, or palatally).

Actually means partial displacement, but commonly used to describe loosening of a tooth without displacement.

Displacement of tooth into its socket. Often accompanied by # of alveolar bone.

Partial displacement of tooth from its socket.

Reassurance and soft diet.

Need to reposition tooth as soon as possible. Give LA and use fingers to push back into place. Then tooth should be splinted flexibly for 2–3 weeks. If there has been a delay of >24h since the injury, manual reduction is unlikely to be successful. In these cases the tooth can be repositioned orthodontically. If the displaced tooth is interfering with the occlusion an URA, with buccal capping, should be fitted as soon as possible. If root development is complete loss of vitality is a common sequelae following luxation (~70%), leading to inflammatory resorption ( Pulpal sequelae following trauma, p. 110). Teeth with immature apices have a much better chance of pulp survival. External or internal resorption and pulp canal obliteration may also occur, therefore keep under review.

If minor, no Rx other than advising a soft diet is necessary. If mobile, splint for 1–2 weeks and watch vitality.

Teeth with immature roots frequently re-erupt and therefore no immediate Rx is required. Teeth with closed apices have a limited potential for re-eruption and will need orthodontic extrusion. This should be started as soon as possible to facilitate access for RCT. However, if displacement is severe (>6mm intrusion) consider surgical repositioning (whether apex is open or closed). Surgically repositioned teeth require flexible splinting for 1–2 weeks. Pulp death &/or root resorption can ensue rapidly after injury and early pulp extirpation and placement of the calcium hydroxide dressing is advisable. Pulp death is virtually certain in teeth with closed apices, and occurs in 2/3 of immature teeth. Replacement resorption is also a common sequel.

The affected tooth should be repositioned under LA with digital pressure and splinted for 1–2 weeks. Again, loss of vitality is a common sequel, so the tooth should be observed for any signs of resorption or pulp death.

If any of these situations occur in conjunction with # of the alveolar bone, the splinting period should be ↑ to 3–4 weeks to aid bony healing. If, however, the socket is comminuted, splinting may need to be extended to 6–8 weeks.

Constructed on patient. An almost infinite variety has been described, but the following are the most popular:

This type of splint is removable, allowing an assessment of mobility or firmness, which may be of value in cases of reimplantation. The more common types are:

However, this approach requires an impression of traumatized mouth and involves some delay (few hours/days) before splint can be fitted, so in practice direct splinting is usually preferred.

Exarticulation = avulsion. Prevalence: 0–16% of injuries.

Success depends upon re-establishment of a normal periodontium.

If described procedure followed, medium-term survival is relatively good²⁴ but long-term survival is generally poor.

Long-term survival is closely related to extra-alveolar dry-storage time. Teeth stored dry for >30min have a very poor long-term prognosis, but replantation may still be worthwhile, as failure is usually by replacement resorption which is slow (i.e. tooth may last several years) and maintains bulk of alveolus (facilitates future prosthetic replacement).

Where prognosis is deemed to be poor, premolar transplant can be considered at 10–12yrs old.

occurs as a result of minor trauma to PDL cells. Usually is self-limiting and affected areas are repaired by cementum. No Rx.

(ankylosis) caused by damage to PDL cells during extra-alveolar period and promoted by prolonged splinting. It appears that the absence of vital periodontal ligament allows resorption of the root and replacement by bone. In growing child results in infra-occlusion of affected tooth. Once started is usually progressive, resulting in the eventual loss of the tooth.

Development is dependent upon the presence of both damage to the periodontal ligament and breakdown products from pulp necrosis diffusing through the dentinal tubules to the PDL. Occurs rapidly, as soon as 1–2 weeks after injury. Once evident radiographically prognosis is poor, as it is progressive and Rx is not always successful. Inflammatory resorption can be prevented by extirpation of the pulp as soon as is practicable after injury and placement of non-setting calcium hydroxide. If resorption is halted a GP root filling can be placed.

Where viability of PDL cells doubtful, Andreasen has suggested chemical Rx of the root surface with fluoride to limit resorption.²⁴ Following RCT with GP, the tooth is immersed in 2.4% sodium fluoride solution for 20min. Then tooth is replanted and splinted for 6 weeks. As some replacement resorption is inevitable, perhaps best limited to adults. If the extra-alveolar period is >24h, leave and consider instead whether the resulting space should be maintained with a P/- ( Treatment planning for patients with missing teeth, p. 264).

Damage to the pulp can occur as a result of disruption of the apical vessels or exposure of the pulp by a crown or root #, or be caused by haemorrhage and inflammation of coronal pulp, resulting in strangulation.

Remember that no response to vitality testing indicates damage to the nerve supply of a tooth, but not necessarily to the blood supply. Therefore following trauma, you should assess vitality in the light of symptoms, tooth colour, mobility, presence of buccal swelling, and radiographic evidence. Except where a tooth has been replanted, it is best to adopt a ‘wait and see’ approach if in doubt about vitality. When pulp death has occurred, subsequent Rx depends upon whether the apex is closed or open.

As achievement of an apical seal is difficult in a tooth with an open apex, Rx should aim to produce apexification (i.e. a hard-tissue barrier across the apex). Under rubber dam, the necrotic pulp should be extirpated. The working length is set 1–2mm short of the radiographic apex (unless vital pulp tissue is encountered earlier) and narrow files are used in order to negotiate any undercuts. The canal should then be filled with a radiopaque non-setting calcium hydroxide (e.g. Hypocal™ or Ultracal^®) to the apex and sealed. The calcium hydroxide should be replaced every 3 months, until a calcific apical barrier is detectable by gentle probing with a paper point. The average time for a calcific barrier to be formed is 9 months.²⁵ Then the canal can be filled. Usually, because of the width of the canal, a large GP point (a conventional point upside down) can be used. This should be warmed in a flame before pressing into place and then lots of laterally condensed points used to obtain a good seal. Alternatively, thermoplasticised GP (e.g. Obtura^®) can be used. A 5yr survival rate of 86% has been reported²⁶ but many teeth will fail eventually secondary to cervical root fracture. This probably results from weakening of the tooth due to large access cavity and brittleness of dentine which may be associated with long-term dressing with calcium hydroxide. Some now advocate MTA as an alternative to calcium hydroxide, allowing obturation to be achieved more quickly over fewer visits.

Commonly seen after avulsion, luxation, intrusion, or extrusion.

is associated with chronic pulpal inflammation, which results in resorption of dentine from the pulpal surface. Is progressive, therefore the pulp needs to be carefully extirpated. Dressing the tooth with calcium hydroxide appears to help arrest the resorption and once controlled, a GP filling may be placed. If perforation has occurred the prognosis is ↓ considerably. Raising a flap, removal of granulation tissue, and direct repair can be attempted.

Three types are seen: surface (transient), replacement, and inflammatory. Replacement resorption is usually 2° to irreversible damage to the cementum, leading to ankylosis (usually associated with a high percussion note). Replacement resorption is usually progressive, is not influenced by endodontic therapy, and eventually leads to the root being replaced by bone. Inflammatory resorption is frequently related to pulp necrosis and can often be halted by appropriate endodontic management.

Occurs in 6–35% of luxation-type injuries. Prophylactic endodontic Rx is not necessary as pulp necrosis occurs in only 13–16% of cases. A high rate of success (80%) has been reported for subsequent RCT, despite a hairline or no root-canal detectable on X-ray.

Missing upper anterior teeth are noticed by the general public before other types of malocclusion. The aim of Rx is to provide 321|123 smile. Although Cary Grant did well enough with a missing upper central incisor, symmetry is usually preferable. The management of missing incisors involves either recovery or maintenance of space for prosthetic replacement, or orthodontic space closure. Previous studies have shown that patients were more satisfied with space closure than prosthetic replacement;²⁷ however, with the introduction of implants and newer materials this may change.

For each patient a number of factors need to be considered:

In a class III case, space closure in the upper arch could compromise the incisor relationship, whereas in a class II/1 it would facilitate o/j ↓. Consider also the vertical relationship, as space closure is easier in patients with ↑ LFH and vice versa in ↓ LFH.

In a patient with no crowding, space closure is difficult and requires prolonged retention. Before opening space it is important to ensure that sufficient will be available at the end of Rx for an adequate prosthetic replacement (minimum width for implant to replace 2 is 6.5mm). A Kesling set-up may be useful.

Although much can be done with veneers, composite additions and grinding, if 3 is significantly darker &/or caniform in shape, it will be difficult to turn it into convincing 2 if space closure planned. 2 can only be used to mimic 1 if root length and circumference at gingival margin are not significantly smaller.

The final axial inclination of the teeth will determine the aesthetics of the finished result.

If a good Class I buccal interdigitation exists this may C/I bringing the posterior teeth forward to close space.

A symmetrical result is more pleasing, therefore maintenance or opening of space is preferable. If a 2 is missing and the contralateral tooth is peg-shaped, thought should be given to extracting this tooth to achieve symmetry.

If the patient has a high smile line then need to consider gingival level. In some cases may need gingival surgery.