Paediatric Dentistry At a Glance: Part 1

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Paediatric Dentistry at a Glance http://dentalebooks.com
Titles in the dentistry At a Glance series Orthodontics at a Glance Daljit S. Gill 978-1-4051-2788-2 Periodontology at a Glance Valerie Clerehugh, Aradhna Tugnait, Robert J. Genco 978-1-4051-2383-9 Dental Materials at a Glance J. A. von Fraunhofer 978-0-8138-1614-2 Oral Microbiology at a Glance Richard J. Lamont, Howard F. Jenkinson 978-0-8138-2892-3 Implant Dentistry at a Glance Jacques Malet, Francis Mora, Philippe Bouchard 978-1-4443-3744-0 Prosthodontics at a Glance Irfan Ahmad 978-1-4051-7691-0 Paediatric Dentistry at a Glance Monty Duggal, Angus Cameron, Jack Toumba 978-1-4443-3676-4 http://dentalebooks.com
Paediatric Dentistry at a Glance Monty Duggal BDS, MDS, FDS (Paeds), RCS (Eng), PhD Professor and Head of Paediatric Dentistry Department of Paediatric Dentistry Leeds Dental Institute Leeds UK Angus Cameron BDS, MDSc, FDSRCS (Eng), FRACDS, FICD Head of Department, Paediatric Dentistry and Orthodontics Westmead Hospital and Clinical Associate Professor and Head, Paediatric Dentistry The University of Sydney NSW Australia Jack Toumba BSc (Hons), BChD, MSc, FDS (Paeds), RCS (Eng), PhD Professor of Paediatric and Preventive Dentistry Department of Paediatric Dentistry Leeds Dental Institute Leeds UK A John Wiley & Sons, Ltd., Publication http://dentalebooks.com
This edition first published 2013 © 2013 by John Wiley & Sons Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www. wiley.com/wiley-blackwell. The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Duggal, Monty S. Paediatric dentistry at a glance / Monty Duggal, Angus Cameron, Jack Toumba. p. ; cm. – (At a glance series) Includes bibliographical references and index. ISBN 978-1-4443-3676-4 (pbk. : alk. paper) I. Cameron, Angus C. II. Toumba, Jack. III. Title. IV. Series: At a glance series (Oxford, England) [DNLM: 1. Dental Care for Children–Handbooks. 2. Child–Handbooks. 3. Tooth Diseases– Handbooks. WU 49] 617.6'45–dc23 2012015790 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Cover image: courtesy of the authors Cover design by Meaden Creative Set in 9/11.5 pt Times by Toppan Best-set Premedia Limited 1 2013 http://dentalebooks.com
Contents Treatment planning, growth and development Dento-alveolar trauma 1 Planning treatment for children 6 27 Assessment of trauma in children 58 2 Growth and development 8 28 Trauma to primary teeth 60 3 Child cognitive and psychological development 10 29 Crown fractures in permanent teeth 62 30 Complicated crown and crown/root fractures 64 Strategies for management of the child patient 31 Non-vital immature teeth 66 4 Behaviour management 12 32 Root fractures 68 5 Aversive conditioning and management of phobia 14 33 Luxations and avulsion 70 6 Local analgesia 16 7 Conscious sedation 18 Paediatric oral medicine and pathology 8 General anaesthesia 20 34 Diagnosis, biopsy and investigation of pathology in children 72 9 Rubber dam 22 35 Differential diagnosis of pathology of the jaws 74 10 Dental radiography 24 36 Management of odontogenic infections in children 76 37 Ulcers and vesiculobullous lesions in children 78 Prevention of caries and erosion 38 Swellings and enlargements of the gingiva 80 11 Preventive care for children 26 39 Oral pathology in the newborn 82 12 Topical fluorides I 28 13 Topical fluorides II 30 Dental and oro-facial anomalies 14 Systemic fluoridation and fluoride toxicity 32 40 Premature loss of primary teeth 84 15 Cariology 34 41 Missing teeth and extra teeth 86 16 Caries risk assessment and detection 36 42 Disorders of tooth shape and size 88 17 Dental erosion 38 43 Enamel disorders 90 44 Disorders of dentine and eruptive defects 92 Restorative management in the primary dentition Management of children with special needs 18 Early childhood caries 40 45 Physical and learning disabilities I 94 19 Strip crowns for primary incisors 42 46 Physical and learning disabilities II 96 20 Plastic restorations in primary molars 44 47 Bleeding disorders 98 21 Pulp therapy 46 48 Thalassaemia and other blood dyscrasias 100 22 Crowns for primary molars 48 49 Children with congenital heart defects 102 23 Management of extensive caries 50 50 Children with cancer 104 51 The diabetic child 106 Management of first permanent molars 52 Kidney and liver disease and organ transplantation 108 24 Preservation of the first permanent molar 52 53 Prescribing drugs for children 110 25 Molar incisor hypomineralisation 54 References 113 Space management Index 115 26 Space maintenance 56 Contents 5 http://dentalebooks.com
1 Planning treatment for children (a) (a) (a) (b) (b) Figure 1.2 Bitewing radiographs showing extent of caries. (b) Figure 1.1 Intra-oral view showing the carious upper (a) and lower (b) primary molars. Figure 1.3 Intra-oral view showing upper (a) and lower (b) arches at the end of treatment. Table 1.1 Step-by-step plan of the proposed treatment where prevention is carried out alongside restorative care. Visit Treatment Preventative One Examination and treatment Oral hygiene instructions plan Use of adult tooth paste Correspondence with Diet sheet was given (a) (b) paediatrician Figure 1.4 Postoperative radiographs of the treated case. Two Full mouth prophylaxis Reinforce oral hygiene 55 – Fissure sealant instructions 65 – Fissure sealant Collect diet sheet 75 – Fissure sealant Duraphat™ (22 600 ppm F) 85 – Fissure sealant Plaque score Temporisation of 54 and 64 Three 64 – Composite restoration Reinforce oral hygiene measures Diet counselling Duraphat™ (22 600 ppm F) Four 54 – Stainless steel crown Reinforce diet advice Plaque score (a) (b) Duraphat™ (22 600 ppm F) Figure 1.5 Follow-up visit revealed that first permanent molars had erupted Five 74 – Composite restoration Reinforce oral hygiene measures and these were fissure sealed. Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 6 Chapter 1 Planning treatment for children http://dentalebooks.com
General philosophy of the authors Diagnosis should be specific. For example, a diagnosis “dental caries” Dentists who treat children are in a unique position not only to provide in itself is incomplete as it does not specify the reason the child has dental treatment when required, but to influence the future behaviour, dental caries. The root cause of the problem cannot be addressed attitudes to oral health and attitude towards dentistry in general. Chil- unless a specific diagnosis is made. dren deserve the highest quality care and highest quality restorative dentistry should be provided to them, supplemented with rigorous pre Formulating treatment plan vention. Prevention of dental caries in children should be a priority An example of a treated case and the step-by-step treatment plan is but sadly nearly half of 5-year-olds, even in developed countries, still shown is Figs. 1.1–1.5 and Table 1.1 respectively. When managing develop dental caries. A non-interventionist approach, as has been caries in children this should relate to: advocated in some countries such as the UK, or poor restorative • prognosis of the affected teeth; patchwork dentistry, is doomed to failure and only leads to pain, infec- • child’s behaviour and likely acceptance of the treatment. tion and suffering in children, requiring more invasive interventions. These are traumatic and expensive and negatively influence the child’s Restore or extract future behaviour and attitudes to dentistry. Good restorative and pre- • Extent of caries. Are the teeth restorable? ventive care obviates the need for extraction of primary teeth under • Impact that either option will have not only on developing dentition general anaesthesia, a practice which should have only a small place but child’s long-term well-being. in the dental care of young children. In addition, in a developing child, • When all primary molars are involved, give consideration to restor- the dentist has the task of monitoring the dentition, diagnosis and ing the second and extraction of the first primary molars. management of anomalies as well as having a knowledge of medical Each treatment plan should be tailor-made for the child. For some conditions and the provision of safe restorative care for children. children, comprehensive restorative care using one of the behavioural approaches is appropriate. For others extraction of some primary teeth Philosophy of treatment planning and restoration of the others with local analgesia (LA) or general • Gain the trust and cooperation of the child. anaesthesia (GA) is more appropriate. • Make an accurate diagnosis and devise a treatment plan appropriate to the child’s need. Management strategy – LA, LA with sedation or GA? • Comprehensive preventive care. Most children are amenable to behaviour guidance. However, when • Deliver care in a manner the child finds acceptable. planning treatment, the child’s well-being, and also the impact that • Use materials and techniques which provide effective and long- multiple visits of invasive treatment under local analgesia might have lasting results. on the child’s future behaviour and attitude towards dental treatment should be considered. Access to good GA facilities is essential. History This should include medical history, social history, history of the Preventive strategy present complaint and the past dental history. What were the Depending on the caries risk, a preventive strategy is devised. “likes” and “dislikes” of the child at previous dental visits? In addition, parents’ assessment of the previous and expected child’s behaviour Choice of materials is useful. This depends on tooth to be restored, past caries history and coopera- tion of the child. An important consideration in children is that the Examination tooth should only need restoring once. In very young children where • A good examination using tell–show–do, including charting for a restoration is required to last 4–5 years, due consideration should be teeth present and caries, including areas of early decalcification. given to the use of stainless steel crowns. • Any missing teeth. • Gingival health. Developmental anomalies • Developmental defects. Formulate a short-, medium- and long-term plan. • Tooth surface loss. • Initial occlusal assessment. Medical history and treatment planning • Liaise with medical practitioner. Radiographs and other investigations • Understand the impact of the medical condition on the provision of Appropriate radiographs such as bitewings or OPG (Chapter 10) or treatment. any other special tests such as pulp sensibility tests. In the following chapters all the aspects that play a role in the manage- ment of children’s oral and dental health are discussed. Diagnosis In children the diagnosis needs to encompass two aspects: • diagnosis of the dental/oral condition; • the child’s behaviour and the behavioural approach likely to succeed in provision of the treatment. Planning treatment for children Chapter 1 7 http://dentalebooks.com
2 Growth and development Table 2.1 Growth period. Lowrey’s classification (1973). Growth period Chronological age Prenatal Conception to birth (40 weeks) Infancy Birth to 2 years Early childhood (preschool) 3–6 years Toddlers – second and third year Play stage – 4–6 years Late childhood (prepubertal) 7–12 years Puberty age range for girls 10–14 years, puberty age range for boys 12–16 years Adolescence 13–20 years Table 2.2 Disturbances in prenatal development. Genetic disturbances Environmental disturbances Chromosomal: Down syndrome, chromosome 18 Medication: thalidomide Polygenic (several genes), e.g. cleft lip/palate Maternal infections: rubella, toxoplasmosis Monogenic (single gene), e.g. enzyme deficiencies, X-ray radiation amelogenesis imperfecta, chondrodysplasia, some Anorexia craniofacial syndromes Maternal malnutrition Maternal alcoholism Table 2.3 Disturbances in postnatal development. Primary Secondary Skeletal dysplasias – 100 disorders where genetic damage or Malnutrition: if prolonged and severe. Poverty and poor nutrition. Emotional and physical defect to skeletal system abuse Chromosomal aberrations/disorders, e.g. Down syndrome, Systemic and metabolic disorders, e.g. coeliac disease, cystic fibrosis, chronic renal Turner’s syndrome disease Congenital errors of metabolism, e.g. mucopolysaccharidoses Deprivation dwarfism (psychosocial growth retardation), caused by disturbances in (genetic conditioned failures in the intercellular substance in emotional contact between child, parents and environment the connective tissues), Hunter syndrome, Hurler syndrome Endocrine disorders: growth, sex or thyroid hormone deficiency, hypothyroidism Miscellaneous syndromes. Unknown aetiology but seen at birth Constitutional growth delay and puberty (normal variant): children with delayed skeletal Genetic short stature (familial) maturity. They tend to have delayed growth and sexual maturation but their final height will be normal Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 8 Chapter 2 Growth and development http://dentalebooks.com
Development of the nasomaxillary • Chronological age. complex • Neurological age. • Grows downwards and forwards relative to the cranial base and • Morphological age. greatest during pubertal growth spurt. • Skeletal age. • Areas near sutures found at maxilla and cranial base have bone • Mental age. deposition as brain grows and soft tissue of face forms. • Secondary sex characteristics. • During pubertal growth spurt, facial skeleton growth starts and is • Dental age. almost completed at age 15.5 years in girls and later in boys. Methods of monitoring somatic growth Mandibular growth • Length/height. • Greatest during pubertal growth spurt. • Weight. • Growth of mandible coordinates with growth of maxilla and cranial • Head circumference. base in forward and downward direction (translation of the mandible). • Behavioural milestones. • Bony deposition at ramus and in condyles allows mandible to grow • Dental age. downwards and forward. Height and weight are usually monitored using standard growth charts. • Mandibular condylar cartilage (reactive growth site) is involved in For height the most common one used is height velocity chart and for bone formation with cartilage proliferation and its replacement by weight the BMI-for-age chart. bone. Dental age – why is it important? Tooth development Dental age correlates well with chronological age. It is important for Teeth start to form very early on, around the 5th week of the embryo. dentists to have a knowledge of growth and development, especially The dental lamina gives rise to epithelial buds that then differentiate of the dentition, for the following reasons: into the tooth germ, within which reside the cells for the development • tooth eruption sequence is important – if any problems with the of the various tooth structures. The odontoblasts form dentine and occlusion occur, it is important to check whether the eruption sequence ameloblasts form the enamel. The epithelial structure known as the is correct, especially in cases where teeth might be developmentally root sheath of Hertwig arises from an apical migration of the epithelial absent; cells at the cervical loop of the enamel organ and is responsible for • tooth emergence dates are used in orthodontics for timing of the development of the roots of the teeth. treatment; • timing of fluoride supplements (systemic fluoride) depends on the Tooth eruption dental age (prevention advice); Eruption times for the primary teeth (in months) • stages of development are important when considering loss of the Lower central incisor: 7–8 permanent first molars; Upper incisors: 10–11 • stage of apical development in incisors is important in cases of Upper lateral: 11 trauma to monitor pulp healing. Lower lateral: 13 It is also important for paediatric dentists to understand the difference First primary molars: 16 in growth between males and females to help in the management of Canines: 19 the developing dentition and provision of interceptive orthodontic Second primary molars: 27–29 care: • growth in height between boys and girls is almost parallel up to age Eruption times permanent dentition (in years) 10 years; First molar and lower central incisor: 6 • in girls, age 11–13 years, female oestrogens causes rapid growth and Upper central and lower lateral incisors: 7 bony epiphyses uniting at age 14–16 years; Upper lateral incisor: 8 • in boys, testosterone causes later prolonged growth (age 13–17 Lower canines and first premolars: 10 years). Upper canine and second premolars: 11 Disturbances in prenatal and postnatal development are shown in Second molars: 12 Tables 2.2 and 2.3. Third molars: 16 onwards Methods of assessing growth The growth periods as described by Lowrey (1973) are shown in Table 2.1. Growth and development Chapter 2 9 http://dentalebooks.com
3 Child cognitive and psychological development Proximity Maintenance Safe Haven ATTACHMENT Secure Base Separation Distress Figure 3.1 Characteristics of attachment according to John Bowlby (1969). Table 3.1 Erikson’s psychosocial theory – stages of development and crisis/ conflicts at each stage. Stages Crisis or conflict Stage 1 Trust vs mistrust Stage 2 Autonomy vs shame or guilt Stage 3 Initiative vs guilt Stage 4 Industry vs inferiority Stage 5 Identity vs confusion Stage 6 Intimacy vs isolation Stage 7 Generativity vs stagnation Stage 8 Integrity vs despair Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 10 Chapter 3 Child cognitive and psychological development http://dentalebooks.com
Introduction automatically triggers a response. A conditioned stimulus is one that In order to understand behaviour management for helping children is previously a neutral stimulus but after becoming associated with the accept dental care, a basic knowledge of the child’s cognitive and unconditioned stimulus, eventually comes to trigger a conditioned psychological development is essential. response, which is learned. 2. Operant conditioning by Skinner. This is learning through con- Theories of cognitive and psychological sequences. The term operant refers to any “active behaviour that development operates upon the environment to generate consequences”. This is a The cognitive capability of children changes from birth through to method of learning that is possible through rewards and punishments adulthood. Various theories divide this process into a number of stages for behaviour. Through this form of conditioning, an association is for clarity and ease of description. made between behaviour and a consequence for that behaviour. This theory is of great significance in paediatric dentistry as it is the basis John Piaget’s theory of cognitive development of the behaviour management technique called behaviour shaping. It This important theory has three important concepts, schema, assimila- has three main principles: tion and accommodation. Schemas are categories of knowledge that • Reinforcement: a consequence that causes behaviour to occur help us to interpret and understand the world. The process of taking with greater frequency in future. Positive reinforcement is the addi- in new information into our previously existing schemas is known as tion of a favourable, pleasant stimulus following behaviour, such as assimilation. Accommodation involves altering existing schemas, or praise or giving a small gift, for example stickers. Negative rein- ideas, as a result of new information or new experiences. forcement is the removal of an aversive, unpleasant stimulus follow- Piaget believed that all children try to strike a balance between ing behaviour. assimilation and accommodation, which is achieved through a mecha- • Punishment: a consequence that causes behaviour to occur with nism called equilibration. As children progress through the stages of less frequency in the future. Positive punishment can be adminis- cognitive development, it is important to maintain a balance between tered through the addition of an unpleasant stimulus following applying previous knowledge (assimilation) and changing behaviour behaviour whereas negative punishment implies the removal of a to account for new knowledge (accommodation). Equilibration helps pleasant stimulus following behaviour. explain how children are able to move from one stage of thought into • Extinction is the lack of any consequences following behaviour. the next. Such an inconsequential behaviour will occur with less frequency According to Piaget there are four stages of cognitive in future. development: 3. Observational learning. Learning by observation. It does not 1. sensorimotor period; require direct personal experience with stimuli, reinforcers or punish- 2. preoperational period; ers. Children learn by simply watching the behaviour of another 3. concrete operational stage; person called a model and later imitating the model’s behaviour. This 4. formal operational period. technique is used often to manage behaviour of children in paediatric dentistry. Erikson’s psychosocial theory (Table 3.1) Erikson believed that personality develops in stages with each stage Social theories of child development characterised by a conflict or a crisis (Table 3.1). The stages are: The attachment theory by John Bowlby (Fig. 3.1) • Stage 1. Infancy: age 0–1 years. Child development is best understood within the framework of pat- • Stage 2. Toddler: age 1–2 years. terns of interaction between the child and the primary caregiver. If • Stage 3. Early childhood: age 2–6 years. there were problems in this relationship then the child is likely to form • Stage 4. Elementary and middle school years: age 6–12 years. insecure and anxious patterns. According to Bowlby there are four • Stage 5. Adolescence: age 12–18 years. characteristics of attachment: • Stage 6, 7 and 8 relate to young adulthood through late adulthood. • proximity maintenance – the desire to be near the people we are attached to; Freud’s psychosexual theory • safe haven – returning to the attachment figure for comfort and Freud’s theory stressed the importance of childhood events and experi- safety in the face of a fear or threat; ences, but are focused almost solely on mental disorders rather than • secure base – the attachment figure acts as a base of security from normal functioning. For this reason this is of limited importance for which the child can explore the surrounding environment; paediatric dentists, but is discussed here for the sake of completeness. • separation distress – anxiety that occurs in the absence of the • Oral stage. Age 0–1.5 years. attachment figure. • Anal stage. Age 1.5–3 years. • Phallic stage. Age 4–5 years. Vygotsky’s sociocultural theory • Latency. Age 5 years to puberty. Sociocultural theory stresses the important contributions that society • Genital stage. Puberty onwards. makes to individual development. Cognitive growth and complex thinking evolve out of social interactions. An important concept of this Behavioural theories of child theory is the “zone of proximal development”, which stresses development the ability of the child to learn under guidance and knowledge and 1. Classical conditioning by Pavlov. This is learning through asso- skills that a person cannot yet understand or perform on their own yet, ciation. The theory is based on conditioned and unconditioned stimu- but is capable of learning through collaboration with more capable lus and response. An unconditioned stimulus unconditionally and peers. Child cognitive and psychological development Chapter 3 11 http://dentalebooks.com
4 Behaviour management Building a trusting relationship with the child Strengthening of trust Giving a full and honest explanation of procedures Giving child control Agree a signal if wishes to stop and ensuring that this is adhered to Ensuring minimal pain during procedures Using a good technique through use of profound pain control (LA) for dental procedures Decreased perception of pain Lowered anxiety Figure 4.1 Building a relationship between child and dentist (adapted from Feigal, 2001). Table 4.1 Some “child-friendly” terms used to describe dental equipment and procedures. Slow speed hand piece Buzzy bee Air rotor Whizzy brush, tooth shower, Mr Whistle Air spray, Inhalation sedation Magic air/wind Local anaesthetic Jungle juice, sleepy juice, putting tooth to sleep Rubber dam Raincoat Suction Hoover Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 12 Chapter 4 Behaviour management http://dentalebooks.com
Introduction However, whether the parent stays in or out is a very much an indi- Helping the child to accept dental treatment without a negative experi- vidual decision based on the preference of the dentist, child and parent. ence that might influence the way the child views dental treatment and consequently dental health in the future is one of the most important Basic behaviour management techniques skills that a paediatric dentist must learn. Basic behaviour management or guidance strategies based on positive The successful management of children in dentistry is a team effort reinforcement include: with the parent, the dentist, the dental team and the ambience of the • tell–show–do; clinical environment all playing their part. • behaviour shaping; • modelling; Dentist’s manner and appearance • distraction. A paediatric dentist must like children for a start and be able to com- All these techniques are underpinned by effective communication, municate at the level of the child’s understanding. Ideas and concepts voice modulation and making the child feel in control of the treatment. have to be broken down in terms understood by the child. The use Voice modulation is learnt through experience, and the purpose is to of “childrenese” terms helps explain dental instruments and proce- affect the behaviour with subtle changes in the volume, tone or pace dures in a non-threatening manner that is acceptable to most children. of the verbal instruction, without any hint of anger or annoyance. Genuine interest in the child’s welfare can be transferred to the child Asking the child to raise their hand if they feel uncomfortable and and help them feel more secure and safe. Some personality types are wish for you to stop is effective in making the child feel in control. able to do this naturally without thinking, whilst others may have to However, if this instruction is given and the child does raise the hand, learn these skills. the dentist must stop, otherwise it can lead to a breach of trust between It seems that the dentist’s attire is not as important as general clean- the child and the dentist. liness and neatness. Personal hygiene is most important. However, some children do suffer from “white-coat” syndrome and a dentist Tell–show–do wearing child-friendly attire may help alleviate some anxiety. This forms the basis for most behaviour guidance strategies in the Protective equipment like facemasks and goggles are accepted well clinic. A short explanation of the next step before introducing it, rather by the patients if worn after a brief explanation of their roles and than the other way around, prepares the child and improves the accept- function. They have less influence on subsequent behaviour. ance of the procedure. Some child-friendly terms for description of Building trust with the child and empathy are two most impor the dental procedures and equipment are shown in Table 4.1. tant basic principles of the successful management of a child in a dental environment (Fig. 4.1). A trusting relationship with the dentist Behaviour shaping increases the child’s acceptance of dental procedures and the success This is based on Skinner’s theory of operant conditioning and positive of treatment will further strengthen trust and rapport. reinforcement is an important element of this technique. The dental procedure is introduced in small steps, the least anxiety provoking The dental environment first, and upon acceptance positive reinforcement is provided to the The clinical area for children should be designed to put children child. A simple “well done”, “your mum/dad are really proud of you” at ease. It should be carefully designed, welcoming, appear non- or “you are so brave/good” usually works well. Through a series of threatening and safe, yet able to function clinically. such approximations each followed by a positive reinforcement, the desired behaviour is achieved. A reward, such as a sticker or a small Parental and peer influences soft toy at the end of a visit, provided the child has done well, is also Parents’ and peers’ attitude to dental treatment has a profound influ- an effective reinforcement. No reward should be made if the visit has ence on the child. Although the parent must have an active and valued not gone well, especially if the child has behaved badly, as this just role in the child’s oral health, their presence in the surgery can pose a reinforces bad behaviour. challenge for the dentist, especially if the parent feels that they have to be involved in verbal communication with the child during treat- Modelling ment. There is no clear evidence on whether the parent is in or out of Other children in the surgery can serve as models, whilst they are the surgery has any influence on the child’s behaviour. The following having dental procedures being carried out. Alternatively video clips circumstances for inclusion of the parent are now generally accepted of other children having dental treatment playing on TV monitors can by paediatric dentists: also help. • all pre-school children; • children with physical, emotional or psychological impairments; Distraction • children having an examination carried out (for consent purposes, Various types of activities can be used to distract the child’s attention. especially for radiographs); Playing appropriate movies, playing on video games etc. can be useful. • when the parent and/or patient expressly wish for the parent to However, in the authors’ opinion, talking to the child throughout treat- remain present. ment is an effective method of achieving this aim. Behaviour management Chapter 4 13 http://dentalebooks.com
Aversive conditioning and management 5 of phobia Box 5.1 A suggested hierarchy for carrying Box 5.2 Development of fear out systematic desensitisation to achieve local analgesia in those who are needle 1. Classical conditioning (direct pathway) phobic • Children who had negative experiences associated with medical treatment may be more anxious about dental treatment 1. Instructions on relaxation breathing or administration of inha- (Wright et al., 1971) lation sedation • Fear sustained from previous unhappy dental visits has also 2. Explain the components of LA equipment been related to poor behaviour at subsequent visits 3. Allow patient to look at dental syringe from a distance 2. Modelling (indirect pathway) 4. Show and explain topical analgesia • Acquired fears from parents, peers, siblings 5. Explain factually how LA is administered • Relationship between maternal dental anxiety and difficulties 6. Encourage patient to hold syringe in hand in child patient management at all ages has been shown 7. Encourage patient to hold syringe against cheek (Freeman, 1999) and is particularly important for children less 8. Hold syringe with needle guard and against mucosa than 4 years old 9. Press syringe against mucosa 10. Apply topical anaesthetic 3. Information/instruction (indirect pathway) 11. Remove guard and hold syringe without needle guard against • From school, media, friends mucosa gently 12. Penetrate the mucosa gently without delivering any anaes- 4. Intellectual capacities thetic solution until patient is relaxed • Depend on age and psychological development 13. Deliver a minute amount of solution very gently and assess • Children with communication or learning difficulties patient’s relaxation 5. Dispositional factors 14. Continue slowly using positive reinforcement • Child’s coping style, values • Child’s age. Highest level of dental anxiety usually at 4 years of age and an overall decrease appears as children become older • Child’s familial situation (parents’ divorce) 6. Environmental factors and dental surgery • Dental setting; colours, smell, sounds • Time of the appointment • Dentist’s appearance (white coat phobia) and behaviour (verbal and non-verbal communication) • Dental staff’s appearance and behaviour • Appearance and sounds of dental devices and rotary instruments • Non-dental chat between dentist and nurse, dentist and parents Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 14 Chapter 5 Aversive conditioning and management of phobia http://dentalebooks.com
Introduction is recalled into the surgery, which being the negative reinforcement Many children who are either too anxious, used to having their own will strengthen the desired behaviour. way at home or harbour genuine phobia regarding various aspects of dental treatment, require more specialised approaches to management. Phobia For this reason an understanding of the theories of learning and devel- Phobia should be distinguished from anxiety. opment is important and will help the dentist not only to provide the Dental anxiety is a state of apprehension regarding the dental treat- immediate care that the child requires but also help shape the child’s ment. It is normal for people to be anxious regarding situations which positive attitude for future dental treatment. are perceived to be pain invoking. Dental phobia, on the other hand, is an irrational, intense, persistent fear of certain aspects of dental Aversive conditioning treatment, such as needle phobia. Aversive conditioning is a form of behaviour therapy in which an Dental anxiety is managed by the traditional behaviour guidance strat- aversive stimulus, which is an object or event that causes strong feel- egies, but the management of severe anxiety, and in particular needle ings of dislike or disgust, is paired with an undesirable behaviour in phobia requires special techniques, such as systematic desensitisation. order to reduce or eliminate that undesirable behaviour. The purpose of aversive conditioning is to decrease or eliminate Systematic desensitisation undesirable behaviours and it focuses on changing a specific behaviour This is a type of behavioural therapy introduced by Joseph Wolpe in order to bring out changes. In such situations, both the type of (1969) based on the understanding that relaxation and anxiety cannot behaviour and the type of aversive stimulus used will influence the exist at the same time in an individual. In practice, for the management treatment that is being undertaken. of dental phobia, a hierarchy of fear-producing stimuli is constructed In aversive conditioning negative reinforcement is deployed. and the patient is exposed to them in an ordered manner, starting with the stimulus posing the lowest threat. However, before this is done, Negative reinforcement the patient is taught to relax; only when a state of relaxation is Negative reinforcement procedure consists of presenting a stimulus achieved, the fear-provoking stimuli are introduced hierarchically with until a response is performed that removes or reduces the effects of the least fear-provoking introduced first and only progressing to the a stimulus. This is not to be confused with punishment, because next when the patient feels able. Often, inhalation sedation is used the removal of the negative reinforcement strengthens the desired to induce a state of relaxation where systematic desensitisation is behaviour. planned. A protocol that has been suggested in the literature is shown in Box 5.1. Behaviour modification strategies One of the key elements of systematic desensitisation is inducing a Aversive conditioning and negative reinforcement are usually state of relaxation, which may take several visits to achieve. Particu- employed in situations where all other avenues to establish communi- larly in adolescents where the anxiety about the needle is deep and cation with the child have been exhausted. These approaches are not intense, but not a phobia, a technique also known as rapid desensitisa- used again and again in the same child but on one occasion to establish tion can be used. After induction of a state of relaxation, the patient communication, following which conventional techniques based on is introduced to the anxiety-provoking stimuli quite quickly, one after positive reinforcement are introduced. another in the same visit, in order to achieve treatment in that visit. However, this may not be possible in those who have genuine needle Flooding phobia. Flooding is defined as a type of desensitisation for the treatment of Special devices for delivery of local analgesia, such as the Wand, phobias without being able to escape until the lack of reinforcement can also be used, as the patient may have had no previous exposure of the anxiety response causes its extinction. Essentially, flooding is to these and they would therefore not be anxiety provoking. This will “exposure treatment” where the patient is exposed to their greatest fear be discussed in Chapter 6. but are not in danger or harmed in any way. A simple example is to help the child confront their fears of sitting in the dental chair, the Preventing the development of dental child is lifted and placed in the dental chair which allows the child to phobia realise that this was not so threatening after all. Clinicians should make every effort to reduce fear in children during dental treatment. It is not always possible for all procedures to be Selective exclusion of the parent painless, or totally comfortable for the child. However, through good When the child exhibits tantrum behaviour and communication communication, empathy and a sound knowledge of behaviour- between dentist and child is lost, the parent is requested by the dentist guidance strategies, it is possible to prepare children to accept uncom- to leave the treatment room. Before this is done a full explanation fortable procedures without negatively affecting their view of dental should be provided to the parent, who must agree to comply. Also, the treatment, and through that the importance of good dental health. Box child must be told the conditions for the recall of the parent before 5.2 summarises the current understanding of how fear develops in they are sent out. Once the desired behaviour is exhibited, the parent children. Aversive conditioning and management of phobia Chapter 5 15 http://dentalebooks.com
6 Local analgesia Figure 6.1 Indirect palatal analgesia is achieved by injecting through the already anaesthetised (a) (b) buccal papilla. Figure 6.2 Lip injury inflicted by the child chewing the lip after an IDB. Children and parents must be given clear postoperative instructions after administration of an IDB. (b) Figure 6.3 (a) Wand. The speed of delivery can be controlled to be either slow (b) in anxious patients or faster (c) by applying the correct (a) (c) pressure on the foot pedal. Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 16 Chapter 6 Local analgesia http://dentalebooks.com
Philosophy Inferior dental block Many dentists are reluctant to administer an “injection” to children for • Required for most mandibular primary molars requiring pulpal dental treatment and feel that they can undertake restorative treatment analgesia. in children without the use of local analgesia. This is a myth, and in • Supplemented by a long buccal infiltration when placing rubber dam the authors’ view it is not possible to achieve good quality restorative clamp or for extractions of mandibular teeth. dentistry in children without local analgesia. It is incumbent on all In children this gives a feeling of profound numbness of the lip on the those who treat children to do so with adequate pain control. same side. Children and parents should be warned regarding this and child warned not to bite, chew or suck the lip or cheek (Fig. 6.2). Explanation The full procedure should be explained to the child in simple terms, Intraligamental such as “putting the tooth to sleep” or putting “jungle juice” around • Seldom required for primary teeth due to a small risk of damage to the tooth. A signal should be agreed with the child whereby they can permanent tooth germ. indicate when they are feeling uncomfortable, such as putting their • Very effective to supplement other techniques especially where it is hand up to indicate discomfort. proving difficult to achieve analgesia. Examples are hypersensitive carious exposed pulps in young permanent molars, hypomineralised Topical/surface analgesia permanent molars, or for extraction of permanent molars where other A flavoured topical analgesic should always be used. The most com- forms of analgesia have failed. monly used is topical 20% benzocaine, which is available in various Although many commercial syringes are available for this, the use of flavours. the Wand for intraligamental analgesia is the best and least painful 1. Apply in small quantity on cotton roll or cotton bud. method. 2. Ensure that area of application is dry to avoid it leecing into saliva as the taste might then upset some children. The Wand (Fig. 6.3) 3. Apply for at least 1 minute for best effect. This is a computerised delivery system based on two principles: • slow delivery, the speed of which can be controlled with a foot Commonly used local anaesthetics pedal; • Lignocaine 2% with 1:80 000 epinephrine. • extra-fine needle designed to be inserted with rotatory movement. • Prilocaine 3% with felypressin 0.54 µg/ml. The Wand is particularly useful in children in the following situations: • Articaine 4% with 1:100 000 epinephrine. • children who had a previous bad experience with conventional injec- Lignocaine 2% with epinephrine remains the most commonly used tion and associate a syringe with pain; anaesthetic solution in dentistry. However, in the last few years the • for intraligamental analgesia as the extra fine needle and slow deliv- use of articaine has increased. There is some limited evidence that in ery help reduce discomfort. young children infiltration with 4% articaine with 1:100 000 epine- phrine gives as profound an analgesia as inferior dental block (IDB) Contraindications of local analgesia with lignocaine for the restoration of mandibular posterior teeth, • Bleeding disorders. Block contraindicated except with appropriate including for pulp therapy in primary molars. In the authors’ opinion factor replacement. it certainly seems to give profound analgesia with mandibular infiltra- • Injection at infection site. Block analgesia or intraligamental might tion and with careful case selection can be used instead of an IDB in be effective in this situation. many cases. • Malignant hyperpyrexia. Pre-treatment with dantrolene sodium may be required, seek medical advice. Infiltration analgesia • Known allergy to the LA drug. • Most frequently used for restorative procedures in maxillary teeth • Use with caution in liver and renal dysfunction. and for minor soft tissue surgical procedures such as removal of mucocoele, epulis etc. Maximum doses • Lignocaine used as infiltration does not reliably provide profound These are shown in Table 6.1. analgesia for mandibular teeth especially for procedures involving the pulp. Articaine works better. Table 6.1 Maximum doses of commonly used local analgesic preparations. Direct/indirect palatal Drug Without With vasoconstrictor Required for: vasoconstrictor • extractions of maxillary teeth; • securing palatal analgesia for placement of rubber dam clamp in 2% lignocaine 4.4 mg/kg 6.6 mg/kg maxillary teeth. 4%/3% prilocaine 8.0 mg/kg 6.0 mg/kg In most cases a full palatal injection is not required. An indirect palatal 3%/2% mepivicaine 6.6 mg/kg 6.6 mg/kg injection can be given through the buccal papilla after administering 4% articaine 7.0 mg/kg 7.0 mg/kg buccal infiltration. The needle is advanced through to just below the palatal mucosa where the solution is deposited to secure palatal anal- gesia (Fig. 6.1). Also can be referred to as transpapillary injection. Local analgesia Chapter 6 17 http://dentalebooks.com
7 Conscious sedation Figure 7.1 A view of surgery, sedated child and essential equipment used for inhalation sedation. Active scavenging is essential and pulse oximeter should preferably be used for monitoring. © M Duggal. Box 7.1 Essential emergency drugs that should be available Oxygen Epinephrine hydrochloride 1:1000 in 1 ml ampoule for IM injection Hydrocortisone sodium phosphate 100 mg/ampoule Suitable delivery systems such as needles and syringes Flumazenil, for reversing oversedation induced by midazolam Box 7.2 Emergency equipment that should be available for sedation Positive pressure ventilation with self-inflating bag Emergency supply of oxygen in addition to working supply Appropriate face masks for children and adolescents Various sizes of oral airway Good high-volume suction with a long extension capacity Box 7.3 Signs and symptoms of oversedation Persistent mouth closing Spontaneous mouth breathing Patient complains of unpleasant feelings Lack of cooperation Nausea and vomiting Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. © 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd. 18 Chapter 7 Conscious sedation http://dentalebooks.com