Treatment Planning for a Child

• Differences - Child vs Adult:

  • Child is growing and has a developing dentition
  • Primary teeth versus permanent teeth - primary teeth behave in different ways in terms of the carious process and in terms of how we'd restore them
  • Behaviour management
  • Lots of children are anxious/inexperienced
  • Development of good habits/attitudes towards the dentist - give them a positive experience
  • Third party involved (parent/carer)
• Parental responsibility:

  • Birth mother: automatic
  • Birth fathers: if married at birth or afterwards or if on birth certificate
  • Others (e.g. Ineligible fathers, other relatives, adopters, local authorities (social services)) can gain parental responsibility via:
  • PR agreement with the mother
  • PR order from the court
  • Residence Order from the court
  • Become the child's guardian through a legal will
• Exam differences for children:

  • May need to be brief/limited (eg may have to forego extra-oral exam)
  • Knee to knee exam
  • Parent's knees touching dentist's knees
  • Pt is facing parent and is dropped back into dentist's lap for examination
  • Gives dentist control of head whilst they look at the teeth
  • Mixed dentition
  • Physiological (natural) vs pathological wear
  • Perio - modified BPE (index teeth)
  • Need to include ortho considerations
• Treatment plan - modifying factors for CDH:

  • Pt/parent preference in terms of treatment options
  • Caries risk status
  • Motivation
  • Co-operation
• Risk assessment:

  • When devising treatment plan, important to take into account future risk
  • Risk assessment guides what de do in terms of:
  • Dental caries
  • Dental erosion
  • Gingival/periodontal disease
  • Dental trauma
• Clinical caries risk assessment factors:

  • Decalcification
  • Plaque
  • Extractions due to caries
  • Hypomineralised/hypoplastic teeth
  • Primary dentition crowding
  • Salivary factors
• Social & behavioural caries risk assessment factors:

  • Multiple NME (non-milk extrinsic) sugars intakes
  • Irregular attendance
  • Mother with high caries rate
  • No fluoride/irregular brushing
  • Prolonged breast-feeding after tooth eruption
  • Bottle feeding during night
• Developmental caries risk assessment factors:

  • Appropriate for age
  • Symmetrical lesions
  • Teeth recently erupted
  • eg 2nd primary molars at 2.5 years old
  • eg 1st permanent molars at 6-7 years old
• Elements and ordering of treatment - basic elements:

  • Deal with acute symptoms
  • Behaviour management
  • Prevention
  • Stabilisation
  • Restorations
  • Extractions
  • Aesthetic work
  • Orthodontics
  • Review/recall
• Behaviour management:

  • Non-pharmacological
  • Distraction
  • Positive reinforcement
  • Tell-show-do
  • Modelling
  • Systematic desensitisation
  • Hypnotherapy
  • (Restraint - HoM/Full)
  • Pharmacological
  • Inhalation sedation
  • Oral sedation
  • Nasal sedation
  • IV sedation
  • General anaesthetic
• Non-pharmacological behaviour management:

  • Distraction
  • Positive reinforcement
  • E.g. If the child sits still in the chair with their mouth open then we praise them specifically for doing that action
  • Tell-show-do
  • Tell the pt about the procedure we're about to perform, show it to them in some way, and then finally do it
  • Modelling
  • Where the child sees someone else having the treatment and exhibiting good behaviours - often done with a sibling
• Non-pharmacological behaviour management:

  • Systematic desensitisation
  • If a pt has a specific anxiety about something then first teach them some relaxation techniques, and then tell them to construct a hierarchy of fear...
  • E.g. having topical anaesthetic applied, looking at a needle, having a needle cap on inside the mouth, having a needle with the cap off inside the mouth, inserting the needle into the mucosa, having the LA injected
  • In the relaxed state, the patient would then be introduced to each part of the hierarchy one at a time
• Non-pharmacological behaviour management:

  • Hypnotherapy
  • (Restraint - HoM/Full)
  • Not used a lot in the UK
  • HoM = hand over mouth
  • Full restraint = strapping pt down
• Prevention:

  • Review & recall
  • Seeing the pt more frequently allows diseases to be picked up earlier
  • Oral hygiene
  • Brushing the teeth
  • Diet
  • Avoiding sugars
  • Fluoride
  • Pt-applied fluoride, like toothpaste
  • Professionally-applied fluoride, like fluoride varnish
  • Fissure sealants
• Systematic fluorides:

  • Drinking water
  • Naturally-occurring fluoride
  • Artificially-added fluoride (less common in UK)
  • Diet
  • Naturally-occurring fluoride (fish, tea, bottled waters)
  • Artificially-added fluoride (salt, milk, fruit juices)
  • Fluoride-supplements
  • Tablets and drops
  • Toothpastes
  • Ingested portion in young children
• Topical fluorides:

  • Professional Applied Topical Fluorides (PATFs)
  • Fluoride solutions, gels and foam
  • Fluoride varnish
  • Sustained release/deposition of fluoride
  • Self-Applied Topical Fluorides (SATFs)
  • Fluoride toothpastes
  • Fluoride mouth rinses
  • Fluoridated water
• Children who have their molar teeth covered by a resin based sealant are less likely to get dental decay in their molar teeth than children without sealants. Those without sealants are ~10 times more likely to have caries at 2 years follow up (5-10 year olds).
• Balancing extractions (taking out tooth on opposite site from one that needs extracting):

  • To prevent centreline shift
  • Doesn't happen in permanent dentition but will happen in primary dentition
  • Need to balance Cs/Ds
• Compensating extractions (take out opposing tooth on opposite arch):

  • To prevent over-eruption
  • Need to consider taking upper 6 if lower extracted - opposite not true
• Common problems with extractions:

  • Early loss of Es causes forward migration of 6s (not as much problem with Ds)
  • So try to maintain Es
  • 6s often need extracting
  • If we time it right, 7 will erupt into 6 space
  • This is ideally when 7 is bifurcating (about 9.5 years)
• Review and recall:

  • One scheme does not fit all
  • NICE guidelines
  • Longest interval for child - 12 monthly
  • HIGH risk of caries - 3 monthly
  • Factors influencing timing of recalls
  • Caries risk: medical status
  • Compliance
  • Stage of dental development
  • Specific dental conditions
• Anaesthetic choice:

  • LA
  • Least complex/costly
  • Least risk
  • Most difficult for pt
  • Can build co-operation
  • GA
  • Complex/costly
  • Potential risk
  • Potentially easier for pt
  • Doesn't build co-operation
• Anaesthetic choice:

  • As GA carries (small) risk > must minimise exposure to a second GA dose
  • Avoid repeat GAs - deal with all problems at the same time
  • Minimise length of GAs (less likely to restore primary teeth, more likely to extract them)
  • So anaesthetic choice has major impact on treatment plan