Chapter 4: Pediatric Dentistry Introduction


Section C: Pediatric Diagnosis and Treatment Planning



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Section C: Pediatric Diagnosis and
Treatment Planning

Introduction


There should not be a minimum age requirement to gain access to a dental clinic. Prevention and treatment should begin as early as possible with the first oral examination at 12 to 18 months of age. Dental staff is encouraged to consider Well Child Dental Programs to ensure this.

Responsibilities


It is usually the responsibility of the general dentist to diagnose conditions and plan for their treatment in children. Treating a child requires special attention to some unique factors. This attention should begin at the child's first visit and be a major part of the treatment and prevention plan you develop for this child.

As with adults, you must begin by obtaining a history of the patient. You then perform physical and radiographic examinations. From this data you can develop a treatment or prevention plan.

Another responsibility of all health care providers is to report child abuse and neglect (CAN). Oral examinations often provide the first signs of physical abuse.

Examining the Infant

Introduction


The American Academy of Pediatric Dentistry (AAPD) recommends that all children receive an oral evaluation visit within 6 months of the eruption of the first primary tooth and no later than twelve months of age. The time required to perform an examination on an infant is minimal and the benefits can be enormous. Early intervention and prevention relies on early examination.

Stages


As with adults, the examination consists of the physical examination (both intraoral and extraoral) and the radiographic examination. If insufficient cooperation exists for radiographs this should be documented.

Natal Teeth


One of the most common consultation requests pediatric dentists receive concerns natal teeth. Less than 10 percent of natal teeth are supernumerary teeth, so the best treatment is no treatment.

Fear of exfoliation and aspiration have been exaggerated since there have been no reports of this in the literature. Severely malformed natal teeth, or those that lack the support to maintain an upright position, may need to be extracted. Occasionally, natal teeth interfere with breastfeeding and removal is considered. Usually, when the mother is informed that these are primary teeth she will attempt to continue breastfeeding and will be successful.


Preventive Services


The major purpose of examining infants and very young children is to intercept destructive habits and practices and prevent the early formation of dental caries. Recommendations on diet, bottle use, nighttime breast feeding, and preventive measures can help in the development of a healthy dentition. Preventive measures and the use of frequent recalls for observation or treatment may be indicated. Fluoride varnish application may be done at any age.

Positioning


Children less than 3 years old are often frightened by the dental chair. The knee-to-knee position provides a less threatening option. Have the parent sit in a chair at the same height as yours, face the parent, and put your knees together. Have the child lay down on this platform with his or her legs around the parent’s waist and the hands held by the parent.

Dental Radiographs

Introduction


The IHS adheres to the Food and Drug Administration (FDA) and the American Dental Association (ADA) guidelines for the use of radiographs.

Who Needs Radiographs?


Generally, all children need bite-wing radiographs at each examination appointment, unless the child is without caries and has interproximal contacts open to exploration and visualization.

Determining Which Radiographs to Take


To determine which radiographs should be taken, you must address each of the following factors:

  • Age/Maturity Factor. How old and cooperative is the child?

  • Nature. What is the nature of the pathology?

  • Approach. How should children be approached for radiographs?

Age/Maturity Factor

In very young children (less than 4 years of age) you should take--



  • two bite-wing radiographs

  • an occlusal radiograph taken with a #0 (Pedo) or #2 (adult) film (in high risk patients). The Academy of Pediatric Dentistry recommends the occlusal film at this age only if caries is suspected.

These films are excellent in demonstrating small interproximal caries and for evaluating the child for supernumerary teeth commonly found in the maxillary anterior region.

Caution: These films generally do not adequately show you the apices of the primary teeth. A #2 bite-wing (adult) should be used as soon as the child is able to tolerate it, since it will demonstrate interproximal surfaces, the root furcations, and the developing tooth buds.

Nature of the Decay

In children demonstrating large carious lesions throughout the mouth, making pulpal therapy almost a certainty, it is more appropriate to take four periapical radiographs making more diagnostic information available.



Approach

Many children who are labeled as uncooperative or frightened have had a poor introduction to the process. The use of the tell-show-do method is extremely important.



Using the Tell-Show-Do Method

Follow these steps to obtain radiographs using the tell-show-do method:



Step

Action

1

Introduce the tube-head as a camera, the lead shield as a superman cape, etc

2

Attempt to take the easier maxillary occlusals first using a #2 film turned sideways, or a #0 (Pedo) film, if necessary.

3

Attempt to take the two bite-wings. Use encouragement and patience.



Growth and Development


Periodic growth and development concerns dictate the use of a panoramic radiograph if possible. Films taken at age 9 for examination of the developing permanent dentition and at age 15 to view the developing third molars are recommended.

Radiographs With the Uncooperative Child


Many times dental radiographs are not possible due to age, maturity, or fear. Films can be exposed during a sedation visit or during general anesthesia. In an emergency situation, extraoral techniques or restraint may be required.



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