The term focus (region of a localized infection or disease) at the orofacial area stands for a local deviation that causes pathological changes of remote organs. It is presumed that caries products of dental foci sensitize and allergize the whole organism. Focal infections may cause a variety of diseases, such as endocarditis, myocarditis, phlebitis, nephritis, pyelonephritis, migraines, subfebrile states, eczemas and rheumatic diseases. As the foci of a dental infection, all teeth with an X-ray detectable periapical finding, devitalized and gangrenous teeth, chronic pulpitis, sinusitis, radices, retained teeth, dental cysts, dentitio difficilis, periodontal pockets and abscesses may be designated.
Detection of a dental focus is based on an anamnesis (the relationship between a basic disease and a pathological state of mouth) and on the clinical and X-ray examinations. Provocation tests are not used in these cases due to their unreliability. Dental focus therapy relies on a focus removal by conservative or surgical means. The treatment is performed under an antibiotic screen which should decrease the possibility of complications to minimum.
The scheme of antibiotic prophylaxis (Pávek 1989)
A. Patients tolerant to penicillin:
1 hour before surgery 3 grams of amoxycillin administered perorally (Amoclen 6 tablets)
B. Patients allergic to penicillin:
1 hour before surgery 1.5 grams of erythromycin administered perorally (Erythromycin 6 tablets)
plus 0.5 gram (2 tablets) of erythromycin 6 hours after surgery
2.3 Special Aspects of Children’s Treatment
Pedostomatology is a complex field that includes all branches of stomatology - restorative, prosthetic, surgical stomatology and periodontology. All these branches possess special approaches for treatment of children which are determined by a somatic and psychological development of a child. A proper treatment should always be based and respect a stage of development of little patients.
Children’s age means the period between the birth of child and finishing the elementary school attendance. It can be divided into the following periods: newborn baby (the 1st month of life), nursling (till the end of the 1st year), toddler (1 to 3 years), preschool age (3 to 6 years), school age (6 to 15 years), and youngsters (15 - 18 years). Each age has its specific diseases, and for each age group, an attention has to be paid to the stage of development of the organism, especially to that of jaws and teeth, during the therapy.
Newborn baby age. It is very rare that a dentist meets patients of this age. Typical diseases include developmental anomalies (clefts, cysts, dentes praelactei etc.).
Nursing age. Dentists seldom meet children of this age in their offices as well. Rarely, a decay may occur on freshly erupted incisor teeth. Cariousness at this age is caused by the developmental defect of hard dental tissues composition and by an inappropriate diet (sweet drinks at night, a pacifier with honey).
Toddler age. At this age, dental decay of molars and incisors may already develop more frequently. The most common reasons for visiting a dentist are, however, injuries of the milk dentition.
Preschool age. Dental caries and its complications, as well as teeth injuries are the most frequent problems. Teeth loss due to caries or injuries are treated prosthetically. Of the periodontal diseases, cheilitis or various forms of gingivitis may be encountered. Gingivostomatitis herpetica is a typical disease of this period.
School age. Children of this age already have a mixed dentition. Attention should be paid to the first permanent molars that are very susceptible to decay. Again, the most frequent stomatologic problems of this age is caries and its complications and injuries of the frontal section permanent teeth. Lost teeth are replaced by prosthetic means. The incidence of gingivitis is higher. Some anatomical deviations (attachment of the lip’s frenulum) may be corrected surgically. This age period is the most suitable one for the orthodontic therapy. The dentition changes and jaws grow at this age.
Youngsters' age. Stomatologic therapy at this age does not differ from the therapy of adults, just prosthetics and surgical therapy include some special characteristics. Cariousness gets higher incidence rate at this age, as well as inflammation of gums and oral mucous membranes. Gingivostomatitis ulcerosa is a typical disease.
The importance of the temporary teeth.
The main function of the temporary dentition is the food mastication. If the temporary teeth are destroyed, the digestive system suffers and the healthy development of an organism may be affected. Periosteal inflammation and lymph nodes possibly caused by milk teeth may be a life threatening situation for a young person. Untreated caries causes a bad breath. Temporary dentition’s periapical changes may damage the permanent dentition. Premature loss of milk teeth leads to shifts of permanent teeth and often disturbs an occlusion plane, resulting at some orthodontic anomalies. In addition, frequent painful procedures are reflected by a child’s mind and form his/her negative relation to dental therapy. Missing teeth affect a proper pronunciation, and an esthetic aspect should not be neglected, too.
2.3.1 Restorative Stomatology
During a treatment of dental caries and its consequences we should consider whether we treat a temporary or permanent tooth and what stage of development the tooth and its root are at. A degree of a root’s resorption should be evaluated on X-ray images of temporary teeth. Principles of a cavity preparation are the same for children’s temporary and permanent teeth as for adults, except the temporary frontal teeth. The same filling materials are used, just Evicrol should not be used for temporary teeth and permanent teeth with an incomplete root development. Resorbing filling materials should only be used for filling of root canals of temporary teeth. In case of permanent teeth with complete development, methods of treatment and materials for root canals filling are the same as those for adults. Endodontic treatment of teeth with incomplete development is very difficult. If a root is very short, one should not hesitate to perform an extraction, even at frontal region. In case of partial pulp inflammation, a vital pulpotomy of a crown pulp is performed. A typical method of children’s stomatology is apification that has been used successfully for the following diagnoses: pulp necrosis, gangrene, and acute periodontitis. The method decreased to a minimum the need for surgico-conservative therapy of teeth with incomplete development (so called filling under visual control). The apification method is based on high biological activity of the tissue at an open root apex (mesenchymal papilla). Teeth with the above described diagnoses are filled repeatedly with Calxyd. The root’s closure should occur at 6 to 24 months, although the root may remain shorter. Indeed, it may reach its normal length (so called apigenesis).
Prevention of dental caries.
Dental caries prevention may be either local or systemic.
Systemic prevention may be applied during the period of teeth development only. It consists in sufficient supply of proteins, minerals and vitamins, especially A and D; fat and polysaccharides must not be absent either. An enamel’s resistance against decay is significantly influenced by fluorine. For this reason, fluoridation of a drinking water at an optimal dose of 1 mg of a fluorine compound per 1 liter of water is used. Fluorine becomes introduced into hydroxyapatite crystalline structure thus forming hydroxyfluoroapatite that is more resistant to acids. Fluorine also replaces CO3 ions, binds to the organic matrix of enamel and influences to a certain extent positively formation of the teeth occlusal planes. Fluorine contained in saliva suppresses metabolism of microorganisms that contribute to formation of dental decay. It also influences tonus of capillaries thus improving the gingiva’s blood supply. Fluorine’s anti-carious properties may only be active when it is supplied to an organism for at least 300 days a year. At places where a drinking water fluoridation does not take place, fluoride tablets are administered to children. High doses of fluorine impair building of an enamel, however. Some brands of mineral water used for dilution of milk baby formulas contain high concentration of fluorine and are not suitable for babies (e.g. Mattoniho kyselka, Praga). On the other hand, “Ida” brand mineral water is suitable, it contains 0.29 mg F per 1 liter.
Local prophylaxis is applied to erupted teeth. It consists in increasing the enamel’s resistance and limiting activity of harmful substances. Enamel’s resistance is increased upon fluorine treatment of teeth surfaces. Fluorine ions penetrate 100 - 200 µm in depth, their bond is not stable, however, and fluorine supply has to be repeated. Aqueous solutions of sodium fluoride or fluorine aliphatic monoamines (Elmex) in forms of varnishes or gels are mostly used. Some brands of toothpaste contain fluorine as well. It is possible to decrease an action of harmful substances on an enamel by proper diet composition that excludes cariogenous foods, such as saccharose. Our daily diet should be complemented by solid foods with self-cleaning properties (apples, raw vegetables, hard cheese, dark bread). Proper dental hygiene plays an important role in fighting caries. Effective teeth brushing removes dental plaques and reduces number of microbes in oral cavity. Proper oral care has to start at early child’s age by learning the right brushing technique, selection of a good toothbrush and toothpaste. Toothpastes that contain fluorine and have pleasant tastes are recommended (Fluorka, Tuti Fruti, Gabi, Perlička).
2.3.2 Surgical Stomatology
The most common dental surgeries of children’s age is tooth extraction. It is performed under a surface or injection anesthesia. Temporary teeth with highly resorbed root may be extracted without an anesthesia. Among frequent surgico-conservative treatment of permanent teeth belongs root canal therapy that is practiced at teeth with radicular cysts or granuloma, eventually in case of the apification method failure. Injuries of temporary and permanent teeth represent a separate topic, described below. In case of temporary dentition, sub-luxations or luxations of teeth are quite often seen. Rather than hard teeth tissues, a tooth socket that is still highly elastic, is affected upon an impact.
Injuries of the temporary dentition periodontal ligament.
The slightest and prognosticativelly most favorable injury of the dental supporting apparatus is contusion. At this injury, a mushy food is recommended and the dental pulp vitality is checked periodically. In case of the pulp necrosis, therapy should be applied according to principles of restorative stomatology with respect to the stage of development of the root. Sub-luxation is a common temporary teeth injury. A slight sub-luxation requires the same therapy as contusion, more severe cases require repositioning of sub-luxated teeth followed by immobilization with a fixed splint. An increased care of the dental hygiene and a pulpy food are recommended. If the pulp of sub-luxated teeth looses its vitality, therapy should be applied according to principles of conserving stomatology. In case that injured teeth has to be extracted, a gap is replaced with a removable denture. Luxated temporary teeth must not be replanted. There is a danger of damaging permanent teeth germs; the younger a child, the higher the danger. A special kind of luxation is repulsion (intrusion, central luxation) which occurs after an impact at a longitudinal tooth axis and causes partial or total immersion of a tooth to the alveolar ridge. Upper incisor teeth are mostly prone to this type of injury while it is rare for teeth of the lower jaw. This condition does not require any therapy since intruded teeth usually erupt again during 2 - 4 weeks. Teeth should be extracted only if they are intruded into nasal cavity or if they could harm the permanent tooth buds. Resulting gap should be replaced removable dentures (space-maintainers). Fractures of temporary teeth crowns that do not expose the pulp chamber should be treated similarly as a corresponding injury of permanent dentition. If the pulp is exposed by an injury, a therapy is applied with respect to a stage of development of the tooth. Teeth with advanced root resorption should be extracted. In case of a fracture in the middle third of a root, teeth should be fixed by a splint. Fractures of the apical third of a root are mostly treated by grinding that just excludes an affected tooth from articulation.
Consequences of temporary teeth injuries.
A coloration may occur at affected teeth, their vitality may be preserved, however. More often, discoloration is a sign of the dental pulp necrosis. A rare consequence of an injury is the pulp chamber obliteration or internal root resorption. After heavy sub-luxations, an accelerated root resorption, a temporary tooth position change, eventually its delayed exfoliation, may often take place. Long lasting teeth mobility, post-accidental gingivitis, denudation of the cervix or root of a temporary tooth may be further consequences of an injury.
Consequences of permanent dentition injuries.
Bearing in mind that a permanent tooth development takes about ten years, during which formation and mineralization of the enamel, dentine, and cement takes place, a root is formed and teeth gradually erupt, permanent teeth change their positions relative to their temporary predecessors, we can not be surprised by a number of various possible defects of permanent dentition. Mechanism of an injury may lead to a permanent tooth crown fracture, to a tooth germ position change or its complete shattering. Permanent teeth defects are more prominent after their eruption. The crown or the root part of a tooth, its pulp, or sometimes the whole germ may be damaged. Defects of teeth eruption are not all that sporadic. Injuries of permanent teeth with completed root development should be treated the same way as in adult patients. At incompletely developed teeth, we have to consider a stage of the root development. Luxated teeth should be replanted in all cases where the gap needs to be preserved. If it would be more suitable to compensate for a lost tooth by an orthodontic movement, we do not perform replanting and the sub-luxated teeth should be extracted as well.
2.3.3 Stomatologic Prosthetics
The leading goal of children’s age prosthetic therapy is to enable a smooth development of the orofacial system after loss of a dental crown or a whole tooth. Children’s prosthetic work has mostly a temporary character. Besides the main purposes, such as rehabilitation of its function, phonation and personal appearance, dentures at children provide for additional functions: enable complete teeth development and growth of alveolar ridges of jaws, thus serving an orthodontically preventive purpose. All kinds of dentures have to be constructed in such a manner that they are easily replaceable when the growth of alveolar ridges requires it. Lost teeth are replaced so that it does not impede the growth of jaws. When reconstructing crowns of temporary or permanent teeth, aspect of a personal visage is not the most important one. The main effort should be put in preserving a tooth vitality. Hard dental tissues defects of temporary and permanent dentition are replaced with crowns made of platinum - gold alloy. Some kinds of nice looking crowns may be used for permanent dentition restoration when articulation is favorable. Finalization of permanent teeth with a composite material is possible only for some defects where a line of fracture allows it. Devitalized permanent teeth may be fitted with a root post and an esthetic crown. At temporary teeth, a denture must not obstruct the root canal and disturb the root resorption. Here, crowns made of dental precious metals are utilized. Missing permanent teeth are replaced with dentures in majority of cases; the orthodontic teeth movement is applied in indicated exceptional cases only. Dentures have to be made so that they restore teeth functions, prevent shifting or tilting of adjacent teeth into the gap, improve a patient’s look and enable for a proper pronunciation. As a rule, removable dentures (space-maintainers) are applied until the growth and development of alveolar ridges is finished. Removable dentures must not be fitted with clasps. Missing temporary teeth (mostly the frontal teeth) is also replaced with dentures without clasps. Lateral teeth are rarely replaced; if they are, a removable denture is used.
Pathological changes affecting the periodontium may occur at temporary, mixed and permanent dentition. Various forms of gingivitis or gingivostomatitis are the most common diseases. Periodontal diseases at children may be divided into three classes.
At the first group of diseases, the periodontium is damaged by a local noxa and this damage is limited to a small area. Permanent teeth are more often affected. Irritation by a incorrectly made filling, a denture, pathological tension of either upper or lower lip frenum, eventually shallow vestibulum oris are among the most typical examples. That is why such an emphasis is put not only to teeth restorative care, but also to a timely frenectomy. Surgical correction of a shallow vestibule should be practiced at the age of 14 and up.
At the second group of diseases, the periodontium is damaged by pathological processes that originate in surrounding tissues, e.g. inflammatory and necrotic states, tumorous growth etc. If the cause is removed successfully, the disease does not spread further.
At the third group there are diffuse alterations of periodontal tissues that result in a premature loss of temporary or permanent teeth. Progress of destructive changes is rapid. A systemic disease or metabolic disorder are usually the cause: Down’s syndrome, ectodermal dysplasia, skin diseases, diabetes mellitus.
2.3.5 Treatment of Non-cooperating Patients
At children’s dentistry we may encounter patients who do not cooperate well. There may be lots of reasons for this non-cooperative behavior, the most frequent one being a pathologically exaggerated fear. Some of children who have normal intellect can be treated with use of proper medication and well planned psychological approach. High doses of Oxazepam have been used successfully at our clinic. If a painful treatment has to be performed, a child prepared by medication should be treated under a local anesthesia. Oxazepam has an advantage of a good antianxiety effect and low sedative effect. If this approach does not allow for a child’s treatment, general anesthesia should be chosen in collaboration with specialists - anesthesiologists. Treatment under general anesthesia is also indicated in cases of illnesses accompanied with twitches or uncoordinated movements, or in case of low intellect of a child. This kind of treatment should be more radical: not only all carious teeth should be repaired, but extractions and other surgical interventions should be performed as well. If prosthetic treatment is to be used, prepared teeth should be abutted and impressions should be taken. Keep in mind that treatment under general anesthesia is not a common method of therapy. We should select it only after all other attempts failed.
2.3.6 Disorders of Teeth Development
Anomalies exist in number, shape, size, structure, position of teeth, as well as temporal disorders of teeth development and teething.
Orthodontics deals with teeth position anomalies.
Reduction of teeth number is called hypodontia (agenesis). Upper second incisor teeth and wisdom teeth are those teeth that are most often absent. A condition when groups of teeth are not formed is called oligodontia, if the teeth are not formed at all we call it anodontia. Increase in teeth number is called hyperodontia. Extra teeth are most often found between the central incisor teeth (mesiodens). A shape change may affect the crown, the root or the pulp chamber. The most common shape alterations are peg-shaped teeth or teeth with accessory cusps. An interesting anomaly of a crown and root is taurodontism. Proportional reduction in teeth size is called microdontia, enlargement of teeth is macrodontia. Defects of hard dental tissues formation can be divided into two groups:
the first group encompasses disorders that are caused by non-specific effects on a developing tooth
the second group includes genetically determined anomalies.
Among non-specific changes belong hypo-mineralization and the enamel hypoplasia. These disorders may be caused by common diseases of upper respiratory tract, otitis, diarrhea, deficiency (especially vitamin deficiency) states or endocrinopathies. Hypomineralization and hypoplasia are also a result of tetracycline antibiotics administration during the enamel formation and mineralization, i.e. from about the 6th week of the intrauterine life up to the 8th year of a child’s life. The first few years of life is especially risky since crowns of most permanent teeth are formed and mineralized at this age. Affected teeth have yellow-brownish colored enamel and numerous hypoplastic defects that are prone to decays and fractures. A child’s psychology is usually strongly affected by a defect of the cosmetic look. Enamel composition defects occur also as a consequence of erythroblastosis, lues congenita or as a result of fluorine overdosing (fluorosis) as well. Among genetically determined disorders there are dentinogenesis imperfecta hereditaria and amelogenesis imperfecta hereditaria. These disorders affect all teeth of both dentitions.
Teeth development and eruption may be either accelerated or, on the other hand, retarded.