Pediatric Dentistry Seminar

1. Pediatric Dentistry Seminar Dr. Christine Bell, DMD, Cert.Ped.Dent, FRCD(C) Pediatric Medical Residents Seminar Series January 2013

2. Objectives • Provide a basic overview of pediatric dentistry • Answer frequently asked questions raised by Family Medicine and Peds Medicine Residents

3. Overview • Normal Dental Development • Abnormal Dental Development • Early Childhood Caries • Common Pediatric Dentistry • Recommendations for Parents • When to Refer and For What • Special Needs Patients • Trauma

4. Education: General Dentist and Specialist • Undergraduate Training • 3-4 years • Dental School • 4 years • General Dentist • Specialty Training • 2-4 years depending on the specialty and the program

5. Dental Specialists • Endodontist • Oral and Maxillofacial Surgeon • Orthodontist • Pedodontist/Pediatric Dentist • Periodontist • Prosthodontist

6. When should the first dental check up be?

7. The American & Canadian Academy of Pediatric Dentistry recommend a dental home be established as early as 6 months of ageor6 months after the eruption of the first tooth and definitelyby 1 year of age Age One

8. First Dental Visit • Comprehensive oral examination • acute care, preventive services • assess for oral diseases and conditions • asses the need for fluoride • Anticipatory guidance • teething, digit/pacifier habits, trauma, prevention • Oral hygiene instructions • Dietary counseling • Prolonged breast/bottle feeding, sippy cup, juice • Caries- risk assessment • determine individualized dental health plan

9. Who can children see for dental exams/treatment? • Family/General Dentist • Pediatric Dentist • Typically treats children from birth to age 18 • Some offices stop seeing patients at an earlier age • Hospital Pediatric Dentist

10. Alberta Children’s Hospital

11. Alberta Children’s Hospital Pediatric Dental Clinic • Patients are seen by referral only • Referrals • Physicians/Medical Specialists • Community physicians/pediatricians • In-and Out-patient clinics/physicians • Oncology, cardiology, nephrology, hematology, GI • Perinatology, endocrinology, genetics, infectious disease • Developmental Clinic, Neuromotor Clinic • Cleft Palate & Craniofacial Clinic, ENT, Plastics • Emergency Department • Community general and pediatric dentists

12. ACH Dental Clinic Patients • Medically compromised and special needs patients from birth up to 18 years • Syndromes, autism • Immune compromised • Bleeding disorders • Oncology, transplant patients • Cardiac/vascular diseases • Uncontrolled seizure disorders, etc… • Children with craniofacial/structural anomalies • Genetic disorders, cleft lip and palate, craniofacial anomalies velopharyngeal incompetency, sleep apnea • Healthy patients under the age of 4 years with significant dental issues

13. Significant Dental Issues • Urgent, extensive or special oral needs • Early childhood caries • Dental/periodontal abscesses, facial cellulitis • Oral/dental trauma • Oral surgery needs(surgical extraction, frenectomy, gingivectomy, soft tissue biopsy) • Unusual/rare dental conditions (amelogenesis imperfecta, dentinogenisis imperfecta, ectodermal dysplasia, cleidocranial dysostosis etc)

14. Cleft Lip and Palate Infants • Cleft lip and palate infants are referred to the ACH Dental Clinic for consult by a Pediatric Dentist certified in Nasoalveolar Molding (NAM) Therapy

15. Nasoalveolar Molding Appliance • Consists of an intra-oral acrylic plate with extra-oral nasal stent. • Adjustments are made weekly to the appliance to guide tissues into a more desired position prior to initial lip closure procedure

16. NAM: Objectives • Reduce the severity of cleft deformity • Approximate alveolar and lip segments • Decrease nasal base width • Shape nasal dome and alar cartilage • Promote columella elongation • Allow one-stage lip and nose repair • No need for lip adhesion surgery

17. a c d b

18. Behavior Management Options ACH Dental Clinic • Non-pharmacologic techniques • tell-show-do • positive reinforcement • voice control • distraction • medical stabilization • Nitrous oxide inhalation sedation • Oral conscious sedation • Combination of oral and inhalation sedation • General anesthesia

19. Dental Development 2013 Pediatric Resident Seminar Series - Dr. Christine Bell

20. Basic Structure of a Tooth • Two “parts” • Crown • Root • Tooth Structure • Enamel • Dentin • Pulp • Cementum Crown Root

21. Dental Development • Two sets of teeth: • Primary Dentition • ‘baby’ or ‘milk’ teeth • 20 teeth • Secondary Dentition • ‘adult’ or ‘permanent’ teeth • 32 teeth

22. How are teeth numbered? • Different tooth numbering systems • Universal • International (FDI) • Palmer • Typically in Canada we use the International Tooth Numbering System

23. International Tooth Numbering System • Two digit numbering system • First number is the quadrant number • Second number is the position/number of teeth from the midline

24. Permanent Teeth Quadrant I Quadrant II Quadrant IV Quadrant III

25. Primary Teeth Quadrant 5 Quadrant 6 Right Left Quadrant 8 Quadrant 7

26. Typical Eruption Sequence: Primary Dentition • First tooth • lower central incisor • 6-10 months of age • General trends • right and left erupt around the same time • erupt in order from front to back except the canines • complete by 25 -33 months of age

27. Timing of Tooth Eruption Permanent Dentition Primary Dentition

28. Mixed Dentition Stage • 6 yrs – 14 yrs of age • typically initiated with eruption of the lower first permanent molar

29. What to do for teething?

30. Teething • Massage the gums, have baby chew on cold wash cloth, cold teething rings, give tylenol if necessary • We typically do not recommend oragel or baby oragel • Lidocaine or benzocaine content • Studies have not confirmed strong association between tooth eruption and a range of teething symptoms. • Study by King et.al. 1992 found HSV associated with almost 50% of infants with teething difficulties

31. Herpes Simplex Virus • Everyone is exposed to it • 1% present with primary herpetic gingivostomatitis • Typically occurs in children <4 years of age • 7-18% end up with recurrent herpes labialis (cold sores)

32. Primary Outbreak of Herpes Simplex • Primary Herpetic Gingivostomatitis • Fever • Malaise • Irritability • Not eating/drinking well • Red inflamed, possibly bleeding gingiva • Herpetic ulcerations intraorally, possibly extraorally • May not present with all signs/symptoms • Typically resolves within 14 days

33. Treatment of Primary Herpetic Gingivostomatitis • Encourage fluids • Treat fever (Tylenol) • Encourage good hand hygiene • Educate family: viral, can spread/inoculate other sites (eyes, herpetic whitlow), contagious (others can acquire) • Antiviral meds of limited value • typically prescribed if outbreak is severe or patient is immune compromised (acyclovir)

34. Dental Development Prior to Eruption

35. Dental Development • Initiation of all primary teeth occurs while IU • Initiation of most permanent teeth occurs IU (with exception of the premolars, 2nd and 3rd molars)

36. Dental Development • All primary teeth begin to calcify at 4 months IU • 1st permanent tooth to undergo calcification is the 1st permanent molar (birth) • All permanent teeth with the exception of the wisdom teeth are calcified by 6-7 years of age

37. Dental Development • Complication or interruption of any of the processes of development (initiation, histodifferentiation, calcification or maturation) could result in dental issues

38. Abnormal Dental Development 2013 ACH Pediatric Resident Seminar Series - Dr. Christine Bell

39. Dental Anomalies • Natal/Neonatal teeth • Extra/supernumerary teeth • Missing teeth • Anodontia/oligodontia • Malformed teeth • Microdont/macrodont/conical/twinning/genination • Structural/mineralization anomalies • Hypocalcification/hypoplasia/fluorisis/amelogenesis imprefecta/dentinogenesis imperfecta

40. Natal/Neonatal Teeth • Natal teeth • teeth present at birth • Neonatal teeth • Teeth/tooth erupt during 1st month following birth • Incidence 1:2500-3500 births • 85% are mandibular incisors • 90% are true primary teeth

41. Treatment • Monitor vs extraction • Indications for extraction • hyper-mobility • difficulties with breast feeding • traumatic ulcerations on tongue (Riga Fede Disease)

42. Dental Anomalies • Fused or geminated teeth • Hypoplastic tooth

43. Some dental development issues may be linked to genetics &/or medical conditions • Dentinogenesis imperfecta • Osteogenesis imperfecta • Oligodontia, conical teeth • Ectodermal dysplasia • Multiple supernumerary teeth • Cleidocranial dysostosis

44. Dentinogenesis Imperfecta Amelogenesis Imperfecta

45. Ectodermal Dysplasia Conical teeth, severe oligodontia of the upper arch Anodontia of lower arch

46. 4 year old male with Ectodermal Dysplasia and severe oligodontia

47. Dental Caries (Cavities) 2013 ACH Pediatric Resident Seminar Series - Dr. Christine Bell

48. Dental Caries/Cavities • The Centre for Disease Control & Prevention reports Dental Caries as being the ‘most prevalent infectious disease in our Nation’s children’ • 5x more common than asthma • Estimated that >40 % of children have caries by kindergarten • Preventable disease

49. Etiology of Dental Caries • Multifactorial TIME Fermentable Carbohydrate Bacteria C A R I E S Tooth

50. The Caries Process