Planning treatment for children should take age and maturity into consideration. A treatment plan for preschoolers may vary significantly from that for older children. Appointment length and time of day may vary with age.
Try to limit treatment for the preschooler to 30 minutes or less. You should work hard at developing clinical speed. This will help prevent misbehavior and should still allow quadrant dentistry. More appointments are often helpful. Do not plan appointments during nap time. If emesis is a problem, meals may be delayed.
When planning treatment for the older child, give consideration to the root development of permanent teeth and the stage of root re-absorption of the primary teeth. Do not ignore caries because “they’re only baby teeth.” Plan to restore, extract, or attempt to arrest the progress of decay with fluorides or other preventive measures.
The oral environment and decay progression of the dentition is affected by the presence of active carious lesions. The outdated idea of ignoring maxillary anterior caries until exfoliation is not acceptable. These teeth should be restored, extracted, or addressed through a preventive regimen.
Having a recall program is crucial if dentistry for children is to be a pleasant experience instead of an anxiety-filled experience driven by emergency encounters. Preventive treatments often provide the children with these more pleasant experiences.
Use of fluorides and sealants needs to be individualized for the pediatric patient based on the following factors:
Examples of Individualized Prevention Planning
The following are examples of individualized treatment planning designed to address the above planning factors:
Example 1. A young child with incipient lesions in the maxillary incisor region might benefit from a twice daily application by an adult a pea sized portion of fluoridated toothpaste with a toothbrush, and periodic fluoride varnish applications.
Example 2. An anxious patient might not be able to tolerate an operative procedure for an incipient lesion but could tolerate a sealant.
Example 3.Caries in an anxious child could be treated with the Alternative Restorative Technique (ART). Using appropriate behavior management techniques and hand instrumentation only, as much decay is removed as cooperation allows. The teeth are restored with a light cured glass isonomer material. These teeth can be considered temporized or filled depending on decay removal success. N2O-O2 may be helpful with this technique.
Fluoride varnish is an invaluable aid in caries prevention, particularly in young children. Traditional topical fluorides for children less than six years of age may contribute to fluorosis or acute toxic episodes. Fluoride varnish offers fluoride uptake with reduced risk to toxicity. It is appropriate for ECC prevention programs. Application frequency should be based on caries risk assessment protocols.
The following dietary fluoride supplement dosage schedule has recently been adopted by the ADA and AAPD. Increased levels of fluoride in processed foods and concerns about fluorosis led to these changes.
Supplemental Fluoride Dosage Schedule
Fluoride in Drinking Water (ppm)
Less than 0.3
Between 0.3 to 0.6
More than 0.6
Birth to 6 mo
6 mo to 3 yrs
3 yrs to 6 yrs
6 yrs to 16 yrs
*milligrams of fluoride per day
Treating Early Childhood Caries/Baby Bottle Tooth Decay (ECC/BBTD)
Increasing community awareness and the awareness of other health professionals may lead to more children being treated during the early stages of caries. Prevention efforts can focus on preventing further destruction, pain, or infection.
Ignoring the caries and waiting for a toothache should not be an option. Failing to prevent the progression of caries is likely to lead to the development of symptoms and an emergency dental encounter.
The dentist’s skill and program demands and resources will dictate what services can be provided for young children with decayed incisors. The preferred way to arrest the progression of these lesions is to restore the teeth with the ART and the use of topical fluorides.
If more invasive treatment is necessary, restraint or sedation may be required. Under these conditions a full coverage restoration is the best choice.
Extracting Primary Incisors
When primary incisors need to be extracted, the dentist should show compassion and do everything possible to make this unpleasant experience more easily tolerated. Often in the cases of ECC/BBTD this may be the patient’s first visit. The following tips may help:
Do not extract one carious incisor and leave three carious incisors unless you plan to restore them soon. Usually, it is better to subject the child to this experience only once; therefore, treat all carious incisors at the same time.
During any childhood extraction procedure, use a gauze drape to prevent inadvertent aspiration of the tooth.
After curettage of the extraction socket, a hemostatic dressing (e.g., Gelfoam) may help make the postoperative management less messy.
Consider dispensing analgesics, especially with multiple extractions