Pediatric Dentistry

Introduction

Chapter 1

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

PD: no limitation to treatment they provide

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

3.1 Greeting

3.1.1 in a friendly way

3.1.2 by name

Don’t proceed too quickly

Begin with non-dental topics

Ask an open qustion

Listen to the answer

3.2 Preliminary chat

3.3 Examination

Should be pain-freeShould be adequateShould 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 doingb) Use the patient’s name to show a personal interestc) 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 Traditional

Techniques Tell-show-do Distraction Modeling Positive

Reinforcement Voice control

Adversive Techniques Physical restraint Hand over mouth

Pharmacologic Techniques Sedation General

Anesthesia

Pharmacological agentsPharmacological-alternatives

Behavior Management

Behavior Management Traditional

Techniques Tell-show-do Distraction Modeling Positive

Reinforcement Voice control

Adversive Techniques Physical restraint Hand over mouth

Pharmacologic Techniques Sedation General

Anesthesia

T: TellS: ShowD: Do

TSD Technique

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

CHOOSE WORDS CAREFULLY

AVOID

Shot

Needle

Hurt

Pull

Etc.

For Most Children:

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

ModelingModeling 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.

Asking patients to identify their negative

thoughts

Cognitive approaches

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

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

Distraction:

Distraction Conversation

Mirror

Book

Electronics

Whatever…

Voice control Tone or inflection

Volume

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

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

I Anxiolysis II Interactive III Non-interactive, arousable

with mild/moderate stimuli

IV Non-interative, non-arousable except with intensive stimulus

V General Anesthesia

ConsciousSedation

Deep Sedation

GeneralAnesthesia

Conscious sedation (I,II,III)Functional Level of Sedation Goal

Mild Sedation (Anxiolysis) (Level 1) Decrease anxiety; facilitate coping skills

Interactive (Level 2) Decrease or eliminate anxiety; facilitate coping skills

Non-interactive/Arousable With Mild/Moderate Stimulus (Level 3) Decrease or eliminate anxiety, faciliitate coping skills, promote non-interaction

Responsiveness Uninterrupted interactive ability; totally awake

Minimally depressed level of consciousness; eyes open or temporarily closed;resp

Moderately depressed level of consciousness;mimics physiologic sleep; eyes mostly closed, may or may not respond to verbal commands alone; responds to mild/moderate stimuli

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

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

Management Technique UtilizationManagement Technique Utilization

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 visitThere 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 recordThe 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

生长发育分期及各期特

点

第一节

一 按年龄阶段分期

二 按牙列分期

三 咬合发育阶段分期

基因突变

环境有害

因素

危险因素

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

特 点

0~8 周

年龄阶段

胚芽期

生长期

一 按年龄阶段分期

危险因素特 点阶段生长期

母体营养不

良

母体疾病

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

8 周 ~ 出生（ 40周）

胎儿期

唾液腺

不发达

，唾液

分泌少

危险因素

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

特 点

出生~4 周

阶段

新生儿期

生长期

危险因素

特 点阶段生长期

营养紊

乱和疾

病

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

4 周 ~

出生后

1 年

婴儿

期

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

危险因素

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

特 点

1~6

岁

阶段

幼儿

期

生长期

危险因素特 点阶段生长期 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

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

。

6 岁到12~13

岁

学龄期

恒磨牙龋

病发病率

高，病损

严重

危险因素

身体骨骼出现

第 2 次快速生

长

特点

女孩 11~12

岁到 17~18

岁

男孩 13~14

岁到 18~20

岁

年龄阶段

青春发

育期

生长期

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

第一，二恒磨牙的保存

口腔内全部都是恒牙

恒牙龋病患病率高，病损严重

3 年轻恒牙列

1 预防错合畸形

2 防治恒牙龋病

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

2 混合牙列

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

主要任务

1 口腔内全部为乳牙

2 乳牙龋患开始和逐年增多

特点

1 乳牙列阶段

牙列阶段

3 个牙列阶段的特点

恒牙列期

第三恒磨牙萌出完成期 Ⅴ A

第二恒磨牙萌出完成期

第三恒磨牙萌出开始期

AⅣ C

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

AⅢ B C

混合牙列期

乳牙列期

无牙期

乳牙萌出期

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）

乳牙萌出前

乳牙咬合完成前

AⅡ C

AⅠ C

三咬合发育阶段的分期

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 咬合发育阶段的分三 咬合发育阶段的分

期期

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