Children's oral health has a crucial role in the development of their teeth and jaw. This section deals with dental issues relating to children and also addresses relevant questions on related issues.
Paediatric Dentistry is the branch of dentistry that includes the following: Training the child to accept dentistry, restoring and maintaining the primary, mixed and permanent dentitions, applying preventive measures for dental caries and periodontal diseases and preventing, intercepting and correcting various problems of occlusion. It is a combination of several areas of applied sciences related to general and dental health of the child.
Parents play an important role in shaping their child’s oral health practices from infancy upto their teens hence a complete knowledge about the oral cavity is a must.
Gum pads are the alveolar arches, which at the time of birth are firm and pink. The upper gum pad is horse shoe shaped and lower gum pad is ‘U’ shaped or rectangular in form. At rest the gum pads are separated by the tongue, which protrudes over the lower gum pad to lie immediately behind the lower lip. At this age the upper lip appears very short. The upper gum pad is wider than lower and when the two are approximated, there is a complete over-jet.
The oral cavity comprises of various structures such as:
This is a complex process which begins with teeth formation from the stage of embryonic cells growth to the eruption in the mouth. Deciduous teeth start to develop in the embryo\uterus between the sixth and eighth week and permanent teeth in the twentieth week.
The tooth bud\ tooth germ is an aggregation of cells that eventually form a tooth. The tooth bud is organised into three parts: The enamel organ, the dental papilla and the dental follicle. The enamel organ forms the enamel. The dental papilla contains cells that develop into odontoblasts, which are dentin- forming cells. Cells within the dental papilla are responsible for formation of tooth pulp. The dental follicle gives rise to three important cell types. Cementoblasts, osteoblasts and fibroblasts. Cementoblasts form the cementum of a tooth. Osteoblasts give rise to the alveolar bone around the roots of teeth. Fibroblasts develop the periodontal ligaments which connect teeth to the alveolar bone through cementum.
Some infants are born with one or more teeth i.e natal teeth or have teeth which erupt into the mouth within the first 30 days of life i.e neonatal teeth. Most often, these are the primary (baby) teeth, not extra teeth. If possible, these teeth should be maintained. However, natal or neonatal teeth may have to be removed if they are loose, it's risky as the child could swallow them. These teeth also may be removed if they interfere with feeding or irritate the child's tongue.
These are the first molars that erupt in the oral cavity. The first permanent molars are the most important teeth for the proper development of adult dentition. From six to 12 years of age, the dentition consist of both the primary and permanent teeth, hence it is called mixed dentition. By 12 years of age, all the permanent teeth except the second and the third molars have erupted in the oral cavity. During the mixed dentition at about the age of 9-11 years the upper front teeth appear non- aligned. This is called the `ugly duckling stage' and is self correcting, with the eruption of the permanent canines.
When the child is about twelve years of age, all the primary teeth have exfoliated and the permanent teeth continue to erupt. The dentition now consists only of the permanent teeth hence called the permanent dentition. The second permanent molars erupt at about 12 -14 years of age and the third permanent molars at 17- 21 years of age, hence called wisdom teeth.
sufficient amount of protein, calcium, phosphorus and vitamins A, C and D intake by the mother during pregnancy will ensure healthy teeth for the baby. Regular dental cleanings and checkups is must during pregnancy, as research links gum disease (periodontal disease) to premature birth and low birth weight. It has also been recognised, that mothers are the most common source of transmission of bacteria to their infant.
The primary dentition is more prone to decay than the permanent dentition in children. This may be due to lesser thickness of enamel and greater consumption of sweets.
Diet : Prolonged bottle or breast feeding provides an oral environment favourable to bacterial proliferation and formation of acidogenic plaque. It is recommended that nocturnal feeding be discontinued after the eruption of the first tooth.
Diet : Infants and children need to eat frequently more than three times a day. Sugary snacks like cookies, candies, cakes should be offered at meal times, than between meals.
Early Childhood Caries (ECC) is a specific term used to describe dental decay in infants and toddlers. This is also known as nursing bottle caries, baby bottle tooth decay, nursing bottle syndrome or milk bottle syndrome. Today, the new name for ECC is ‘Maternally Derived Streptococcus Mutans Disease (MDSMD).
Children who are breast fed on demand-specially at time other than normal feedings and throughout the evening, often develop early multiple carious lesions.
This is one of the most severe form of tooth decay, which involves the surfaces of teeth, usually considered immune to tooth decay. A special characteristic is that it typically involves maxillary primary incisors, upper and lower molars. The mandibular incisors are usually spared, probably because they are protected by the mechanical cleansing action of the tongue.
Children with ECC may show retarded growth as compared to normal children because nursing caries is a severely disabling condition causing unaesthetic appearance. Due to loss of tooth structure, the child may suffer from malnutrition as he/she is not able to properly chew food. Early extraction of maxillary incisors can create speech problems. Loss of primary teeth can cause space problems, which may result in malalignment of permanent teeth.
The treatment of early childhood caries can be divided into:
Counseling:The first step is to identify the cause. Abrupt cessation of the feeding habit is not advised; rather a gradual withdrawal must be done. The habit must be reduced to 70% at the end of the first week, 50% by the end of the second week, 20% at the end of the third week and so on. Feeding with a cup or spoon should be encouraged. Serial dilution of the contents of the bottle with water has been recommended over a period of 1-2 weeks so that eventually the child drinks only plain water. Feeding at night is to be strictly avoided. Water after feeding must be given. Infants must be weaned at 12- 14 months of age and on demand nocturnal feeding must be denied. Consumption of juices from a bottle should be avoided, juices must be offered from a cup.
Dietary modifications: Elimination or at least gradual reduction of additional sugar must be done. Depending on the child’s age and chewing capacity, natural food like fruits should be given to the child. Measures for oral hygiene must be implemented by the time the first tooth has erupted.
Restorative procedures:Small cavitations are commonly restored with glass ionomer restoration materials. Pulpal treatment as indirect pulp capping, direct pulp capping, pulpotomy and pulpectomy may be performed. These can be done under local or general anaesthesia if necessary and it involves a thorough excavation followed by placement of sedative dressings. The patient is then given the necessary instructions regarding oral hygiene and diet. Then, stainless steel crowns and polycarbonate or celluloid crown forms are placed. Extraction of teeth is never encouraged. However, if the teeth are beyond repair, extraction followed by placement of a suitable space maintainer is advocated. Fluoride supplements to prevent caries can be given depending on the age and need of the child.
The branch of dentistry which deals with the preservation of healthy teeth, gums and the prevention of dental caries and oral disease This includes:
Children with healthy mouths are able to chew food efficiently and more easily. A healthy dentition gives children confidence in their appearance. Preventive dentistry ensures less extensive and expensive treatment in the future.
Preventive Dentistry begins with the eruption of first tooth. The earlier the dental visit, the better the chance of preventing dental disease and inculcating oral hygiene habits in children which are beneficial for life.
The Pedodontist should evaluate the child’s oral health and accordingly design the preventive treatment plan which includes oral prophylaxis, topical fluoride application, pit and fissure sealants, early diagnosis and management of orthodontic problems, prevention of sports injuries to the face and teeth.
Minerals are lost (demineralization) from a tooth's enamel layer when acids - formed from plaque, bacteria and sugars in the mouth - attack the enamel. Minerals such as fluoride, calcium and phosphate are redeposited (remineralization) to the enamel layer from the food and water consumed. Fluoride is a mineral that occurs naturally. Fluoride prevents tooth decay by :
Teeth, which have developed under influence of fluoride, have shallow fissures, less steep cuspal inclines and rounder cusps. Systemic fluorides are thought to be effective if present only during the time of tooth formation and development. After that topical fluorides are supposed to play a vital role in increasing the resistance of the tooth to decay.
Critical Age for Fluoride Intake It is certainly important for infants and children between the age of 6 months and 16 years to be exposed to fluoride. These are the time frames during which the primary and permanent teeth form and erupt.
Risks Associated with Fluoride Use
Avoid fluoride toxicity by :
Dental amalgam is a self hardening mixture of silver-tin- copper alloy powder and liquid mercury and is sometimes referred to as silver fillings because of its colour. Dental amalgam has been used for restoring teeth since the 1880s. Amalgam’s properties, such as ease of moulding, durability, relatively low cost as compared to other restorative materials, have contributed to its popularity. Aesthetics and improved tooth colour restorative materials, however have led to a decrease in its use.
Advantages :Stainless steel crowns (SSC) are prefabricated crown forms that are adapted to individual teeth and cemented with a biocompatible dental luting agent. The SSC is extremely durable, relatively inexpensive, subject to minimal technique sensitivity during placement and offers the advantage of full coronal coverage. Stainless steel crowns can be used for the restoration of primary and permanent teeth with caries, cervical decalcification, and/or developmental defects (eg, hypoplasia, hypocalcification) and following endodontic treatment of teeth.
When aesthetics is a concern, the facing of the stainless steel crown can be removed and replaced with a resin-based composite (tooth coloured; open- faced technique). Several brands of primary stainless steel crowns are available with preformed tooth coloured veneers.
Means that the infection has reached the pulp of the teeth. If children have an infection of the pulp, they may not feel any pain at first. But if left untreated, the infection will cause pain and swelling. In some cases, an abscess will form. Eventually, the tooth may need to be extracted.
Root canal treatment can be done in one or more visits, depending on the damage. An infected tooth will need several appointments to eliminate the infection. Some teeth may be more difficult to treat because of the position of the tooth, as they have many curved root canals that are difficult to locate or for other reasons. An uncomplicated root canal treatment can be completed in one visit. Once the root canal treatment is finished, the tooth is restored with a crown or fillings.
Possible ComplicationsA fixed prosthetic restoration replaces one or more missing teeth in the primary, transitional or permanent dentition. This restoration attaches to natural teeth, roots or implants and is not removable by the patient. Growth must be considered when planning fixed restorations in the developing dentition.
Fixed prosthetic restorations to replace one or more missing teeth:
A removable prosthetic appliance is indicated for the replacement of one or more teeth in the dental arch to restore masticatory efficiency, prevent or correct harmful habits or speech abnormalities, maintain arch space in the developing dentition or obturate congenital or acquired defects of the orofacial structures.
Recommendations: Removable prosthetic appliances may be indicated in the primary, mixed or permanent dentition when teeth are missing.
Removable prosthetic appliances may be utilised to:
The premature loss of primary or permanent teeth results in loss of arch integrity, space and arch length, perimeter or circumference. Migration of primary and/or permanent teeth can reduce available space to cause crowding of the permanent dentition.
Diagnosis : The pre-mature loss of primary molars requires the placement of a space maintainer to prevent the migration of the adjacent teeth, depending upon the teeth present and the arch length. The premature loss of primary canines may therefore require the placement of a space maintaining appliance to prevent midline deviation and/or loss of arch length, perimeter and/or circumference which causes crowding of the permanent teeth which erupts in the place of the primary teeth.
Contra-indications : A space maintainer is not necessary, if there is a sufficient amount of space to allow for eruption of permanent tooth/teeth. A space maintainer may not be recommended if severe crowding exists, such that space maintenance is of minimal effect and subsequent orthodontic intervention is indicated. A space maintainer may not be necessary if the succedaneous (permanent) tooth will be erupting soon.
The treatment modalities may include, but are not necessarily limited to, the following types of appliances.
Fixed appliances :
Band and Loop
Band and Loop space maintainers are used when the first primary molar is lost. The fabrication of this maintainer for the clinician and maintenance for the patient is easy. But it can cause the opposing tooth to supra erupt.Crown and Loop
Used at the loss of first primary molar with significant loss of tooth substance of the abutment tooth. There is ease of fabrication for both the clinician and maintenance for the patient. It is more difficult to fabricate than band and loop.Distal Shoe (Intra-alveolar Space Maintainer)
Distal shoe is used at the loss of second primary molar when there is significant time for the first permanent molar to erupt. It is more difficult to fabricate than band and loop.Lower Lingual Holding Arch (LLHA)
LLHA is used at the loss of second primary molar in the mandible (counterpart to Nance). It maintains the tooth and the leeway space. First permanent molars may be susceptible to decalcification; may be prone to breakage unless the patient is well- informed on maintenance.Nance appliance
Used by the dentist at the loss of second primary molar in the maxilla- counterpart to LLHA. It maintains the tooth space and the leeway space but meticulous hygiene of the acrylic button is required.Removable appliances:
Hawley Appliance / Removable Acrylic plate
Hawley Appliance should be used when multiple primary teeth are lost and the space maintenance and mastication are of concern. It maintains space as well as aids in mastication but is susceptible to fracture or loss.Oral habits acquired during infancy (e.g. non- nutritive sucking) have adverse health consequences. The identification of such habits and assessment of immediate and long-term effects on the teeth and orofacial development should be made as early as possible. After infancy, persistent oral habits affect facial growth, oral function, the occlusal relationship and facial aesthetics.
Digit sucking, lip and nail biting, bruxism, mouth breathing, tongue thrusting etc. are some of the common habits observed in children. Persistent oral habits may result in long- term problems hence evaluation of the same has been recommended in children beyond the age of 3 years. Habit can be defined as a fixed or constant practice established by frequent repetition
Causative factors
It is observed that habits commonly occur in girls more than boys. A single child is more vulnerable to this problem.
Classification
Intentional
Unintentional
Guidance of the eruption and development of the primary and permanent dentitions is an integral part of the care of paediatric patients. Such guidance should contribute to the development of a permanent dentition that is in a harmonious, functional and aesthetically acceptable occlusion (the manner in which the upper and lower teeth come together when the mouth is closed).
Pedodontist have the responsibility to recognise, differentiate and either appropriately manage and treat or refer abnormalities in the developing dentition as dictated by the complexity of the problem and the individual clinician’s training, knowledge and experience. Early diagnosis and successful treatment of developing malocclusions (misalignment of teeth) can have both short-term and long-term benefits while achieving the goals of occlusal harmony, function and dental facial aesthetics.
The variables associated with the treatment of the developing dentition will affect the degree to which the treatment is successful. This is not limited to chronologic, mental and emotional age of the patient, but affects the ability of the patient to understand and cooperate in the treatment.
Following are the factors that are considered in the treatment of oral habits:
Many unpredictable factors can affect the management of the developing dental arches and minimise the success of any treatment. These factors cannot always be controlled by the pedodontist. Appropriate pretreatment records should include those deemed necessary by the individual clinician to adequately diagnose the patient’s condition.
Clinical Examination should include:
Commonly occurring habits
Thumb sucking : Thumb sucking and finger sucking habits can be grouped as ‘digit sucking’. Normally children suck their thumb up till 1- 2 years of age, then stop as they mature. When thumb sucking habit persists beyond the pre-school period then it is considered abnormal.Associated dental problems:
This employs applying bitter preparations like pepper, asafoetida, quinine, neem leaves etc. to the thumb or fingers. Thermoplastic thumb post can be placed on the offending digit.
This includes various orthodontic appliances such as removable appliances like palatal crib, rakes, palatal arch, lingual spurs, Hawleys retainer with or without spurs and fixed appliances like lingual tongue screens.
Mechano-therapy
Fixed intra-oral appliance
A fixed intra-oral appliance is attached to the upper teeth by means of bands fitted to the primary second molars or the first permanent molars. A lingual arch forms the base of the appliance to which are added interlacing wires in the area of the anterior part of hard palate.
Blue grass appliance
This appliance was introduced by Haskell. It consists of a modified six sided roller machined from Teflon to permit control by the tongue. This is slipped over a 0.045 stainless steel wire soldered to molar orthodontic bands. This appliance is placed for 3-6 months. Instructions are given to turn the roller instead of sucking the digit.
Quad helix
This appliance prevents the thumb from being inserted and also corrects the malocclusion by expanding the arch.Tongue thrusting is a common habit in children which is developed due to retained infantile swallow pattern. During swallowing the tongue pushes against the front teeth or through the upper and lower teeth. Abnormal tongue positioning or its deviation during swallowing results in the same.
Treatment
Myofunctional therapy
The child is asked to perform certain myofunctional exercises such as:
Mechanotherapy : Fixed and removable appliances can be fabricated to restrain anterior tongue movement during swallowing. A Nance palatal arch with an acrylic button is used as a guide to place the tongue in the correct position. Fixed habit breaking appliance can also be fabricated where in bands or crowns are given on the first molars adapted with a U- shaped wire which follows the contour of the teeth. Three to four projections of wire or cribs are soldered to this U shaped wire to prevent the movement of tongue.
A Oral or Vestibular screen can be given to effectively control the abnormal musculature and bring about the normal movements of tongue.
Surgical treatment : The treatment of the retained infantile swallow behaviour is difficult and often consists of orthognathic surgical procedures to correct skeletal malformation as well as myofunctional therapy.
Mouth breathingIt is commonly seen in children who have nasal airway impairment due to enlarged adenoids, deviated septum and enlarged tonsils.
Associated dento- facial abnormalities:Lip exercises
If maxillary incisors are protruded the lower lip can be used to augment the upper lip exercise.
Appliances
Oral Screen can be constructed to block the passage of air through mouth and effectively re- establish the nasal airway.
This can be done by minor removable orthodontic appliances like the oral shield, chin cap as interceptive method, monobloc activator.
Bruxism
It is the habitual grinding of teeth when an individual is not chewing or swallowing. It is more common during the subconscious state at night and is referred to as nocturnal bruxism.
Associated dental problems
Treatment:Mouth-guard is a plastic mouth appliance which absorbs the biting forces and prevents any damage to the teeth and its surrounding tissues. It is also called Night Guard or Dental Guard or Occlusal Splint. It is specially designed for each patient according to his upper and lower teeth and also their alignment. Mouth guards are helpful in various ways like
Occlusal adjustments
Any prematurities or occlusal interferences in restorations can be corrected by coronoplasty (re- shaping of the teeth).
Occlusal splints
Vulcanite spilts have been recommended to cover the occlusal surfaces of all the teeth as a treatment of bruxism. TMJ appliance can also be fabricated to treat TMJ disorders. Similarly LA injections or other vapo- coolants like ethyl chloride can be given in the TMJ pain area.
Psychotherapy
Counseling of the patient can lead to decrease in stress and create habit awareness.
Lip and nail biting
These are observed in children as a manifestation of stress but this is rarely seen before 3- 6 years of age.
Tooth brush for children
Toothbrushes for children must have soft bristles so as not to abrade the tooth enamel or harm the gum tissues. Replace the brush when the bristles begin to lose their shape. After each use, the toothbrush should be placed in an upright position to dry. A toothbrush should not be shared, replace it after a cold, flu or any mouth infection.
Electric Toothbrush
Electric toothbrush may be more effective at removing plaque and preventing gingival bleeding than the manual toothbrushes. They were developed in 1939 in Switzerland. Rechargeable cordless toothbrush were introduced in 1961 by General Electric, these moved up and down when activated. In 1987 the first rotary action toothbrush, the Interplak, appeared in shops for the general public.
Oral Hygiene involves the following:
Brushing-Parents should brush teeth with their children, showing correct brushing techniques. Brush gently in a circular motion at a 45 degree angle to the gum line (i.e. Bass technique). Consider the teeth as having four surfaces: cheek side, tongue side, the sides where teeth touch each other in each jaw and the chewing surfaces. Finding a brush that your child likes will help their desire to brush.
You should brush in the morning and before sleep. Brushing before sleeping is important because saliva flow decreases while you sleep. Thus, build up of bacteria does harm if not removed. The brushing technique is more important than the brand of toothpasteToothpaste
Toothpaste is a paste or gel used to clean teeth by the removal of dental plaque and food from the teeth. This eliminates or masks halitosis (bad breath) and releases fluoride to prevent tooth and gum disease. If children are prone to tooth decay, brushing with fluoride toothpaste after meals will help.
Toothpastes vs. Gels
The difference between paste and gel is their physical appearance and taste. While gels may seem less abrasive than pastes, this is not the case. Actually, gels can be more abrasive because of the silica used to make them. Children's toothpaste is different than adult toothpaste. Toothpastes for children are not as abrasive as adult toothpaste. It provides less fluoride and does not have the additives to fight tartar and gingivitis. Some children don't like the “fizz “and “tingly” taste of the toothpaste. There are brands of toothpaste without the fizzy taste but have fluoride that is important for fighting tooth decay.
Children should only use a “pea sized”amount of fluoride toothpaste until their permanent teeth appear. Brushing teeth is more important even without toothpaste. Toothpaste is not intended to be swallowed as some pastes may cause nausea or diarrheoa. Extended consumption while the teeth are forming can result in fluorosis. This is why children of a young age should not use toothpaste except under close supervision. Teenagers can use adult toothpaste. If your child’s teeth stain easily, a little adult toothpaste may be helpful in removing the stain.
The results show that products containing these agents have the ability to stop the growth of S. mutans. Products containing sodium bicarbonate and/or hydrogen peroxide may be useful to caries- prone children.
