Download Dentistry

Pediatric Dentistry Seminar
Dr. Christine Bell, DMD, Cert.Ped.Dent, FRCD(C)
Pediatric Medical Residents Seminar Series
January 2013
Objectives


Provide a basic overview of pediatric dentistry
Answer frequently asked questions raised by
Family Medicine and Peds Medicine Residents
Overview
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Normal Dental Development
Abnormal Dental Development
Early Childhood Caries
Common Pediatric Dentistry
Recommendations for Parents
When to Refer and For What
Special Needs Patients
Trauma
Education: General Dentist and
Specialist

Undergraduate Training


3-4 years
Dental School

4 years

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General Dentist
Specialty Training

2-4 years depending on the specialty and the
program
Dental Specialists

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Endodontist
Oral and Maxillofacial Surgeon
Orthodontist
Pedodontist/Pediatric Dentist
Periodontist
Prosthodontist
When should the first
dental check up be?
Age One
The American & Canadian Academy of Pediatric
Dentistry recommend a dental home be established as
early as 6 months of age or 6 months after the eruption
of the first tooth and definitely by 1 year of age
First Dental Visit

Comprehensive oral examination

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acute care, preventive services
assess for oral diseases and conditions
asses the need for fluoride
Anticipatory guidance

teething, digit/pacifier habits, trauma, prevention
Oral hygiene instructions
 Dietary counseling

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Prolonged breast/bottle feeding, sippy cup, juice
Caries- risk assessment

determine individualized dental health plan
Who can children see for dental
exams/treatment?

Family/General Dentist

Pediatric Dentist
Typically treats children from birth to age 18
 Some offices stop seeing patients at an earlier age


Hospital Pediatric Dentist
Alberta Children’s Hospital
Alberta Children’s Hospital Pediatric
Dental Clinic

Patients are seen by referral only

Referrals
Physicians/Medical Specialists
 Community physicians/pediatricians
 In-and Out-patient clinics/physicians
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Oncology, cardiology, nephrology, hematology, GI
Perinatology, endocrinology, genetics, infectious disease
Developmental Clinic, Neuromotor Clinic
Cleft Palate & Craniofacial Clinic, ENT, Plastics
Emergency Department
Community general and pediatric dentists
ACH Dental Clinic Patients

Medically compromised and special needs patients from birth up
to 18 years

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Children with craniofacial/structural anomalies

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Syndromes, autism
Immune compromised
Bleeding disorders
Oncology, transplant patients
Cardiac/vascular diseases
Uncontrolled seizure disorders, etc…
Genetic disorders, cleft lip and palate, craniofacial anomalies
velopharyngeal incompetency, sleep apnea
Healthy patients under the age of 4 years with significant dental
issues
Significant Dental Issues

Urgent, extensive or special oral needs
Early childhood caries
 Dental/periodontal abscesses, facial cellulitis
 Oral/dental trauma
 Oral surgery needs(surgical extraction, frenectomy,
gingivectomy, soft tissue biopsy)
 Unusual/rare dental conditions (amelogenesis
imperfecta, dentinogenisis imperfecta, ectodermal
dysplasia, cleidocranial dysostosis etc)

Cleft Lip and Palate Infants

Cleft lip and palate infants are referred to the
ACH Dental Clinic for consult by a Pediatric
Dentist certified in Nasoalveolar Molding
(NAM) Therapy
Nasoalveolar Molding Appliance


Consists of an intra-oral acrylic
plate with extra-oral nasal stent.
Adjustments are made weekly to
the appliance to guide tissues
into a more desired position
prior to initial lip closure
procedure
NAM: Objectives
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Reduce the severity of cleft
deformity
Approximate alveolar and lip
segments
Decrease nasal base width
Shape nasal dome and alar
cartilage
Promote columella elongation
Allow one-stage lip and nose
repair
No need for lip adhesion
surgery
a
c
b
d
Behavior Management Options
ACH Dental Clinic
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Non-pharmacologic techniques
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tell-show-do
positive reinforcement
voice control
distraction
medical stabilization
Nitrous oxide inhalation sedation
Oral conscious sedation
Combination of oral and inhalation sedation
General anesthesia
Dental
Development
2013 Pediatric Resident Seminar Series
- Dr. Christine Bell
Basic Structure of a Tooth

Two “parts”
Crown
 Root
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Crown
Tooth Structure
Enamel
 Dentin
 Pulp
 Cementum

Root
Dental Development

Two sets of teeth:

Primary Dentition
‘baby’ or ‘milk’ teeth
 20 teeth


Secondary Dentition
‘adult’ or ‘permanent’ teeth
 32 teeth

How are teeth numbered?

Different tooth numbering systems
Universal
 International (FDI)
 Palmer


Typically in Canada we use the International
Tooth Numbering System
International Tooth Numbering
System

Two digit numbering system
First number is the quadrant number
 Second number is the position/number of teeth
from the midline

Permanent Teeth
Quadrant I
Quadrant IV
Quadrant II
Quadrant III
Primary Teeth
Quadrant 5
Quadrant 6
Right
Left
Quadrant 8
Quadrant 7
Typical Eruption Sequence:
Primary Dentition

First tooth
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lower central incisor
6-10 months of age
General trends
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right and left erupt around
the same time
erupt in order from front
to back except the canines
complete by 25 -33
months of age
Timing of Tooth Eruption
Permanent Dentition
Primary Dentition
Mixed Dentition Stage


6 yrs – 14 yrs of age
typically initiated with eruption of the lower first
permanent molar
What to do for teething?
Teething

Massage the gums, have baby chew on cold wash cloth,
cold teething rings, give tylenol if necessary

We typically do not recommend oragel or baby oragel


Lidocaine or benzocaine content
Studies have not confirmed strong association between
tooth eruption and a range of teething symptoms.

Study by King et.al. 1992 found HSV associated with almost
50% of infants with teething difficulties
Herpes Simplex Virus

Everyone is exposed to it

1% present with primary herpetic gingivostomatitis


Typically occurs in children <4 years of age
7-18% end up with recurrent herpes labialis (cold
sores)
Primary Outbreak of Herpes Simplex
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Primary Herpetic Gingivostomatitis
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Fever
Malaise
Irritability
Not eating/drinking well
Red inflamed, possibly
bleeding gingiva
Herpetic ulcerations
intraorally, possibly extraorally
May not present with all signs/symptoms
Typically resolves within 14 days
Treatment of Primary Herpetic
Gingivostomatitis

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Encourage fluids
Treat fever (Tylenol)
Encourage good hand hygiene
Educate family: viral, can spread/inoculate other
sites (eyes, herpetic whitlow), contagious (others
can acquire)
Antiviral meds of limited value

typically prescribed if outbreak is severe or patient is
immune compromised (acyclovir)
Dental Development
Prior to Eruption
Dental Development

Initiation of all primary teeth occurs while IU
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Initiation of most permanent teeth occurs IU
(with exception of the premolars, 2nd and 3rd
molars)
Dental Development
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All primary teeth begin to calcify at 4 months IU

1st permanent tooth to undergo calcification is
the 1st permanent molar (birth)

All permanent teeth with the exception of the
wisdom teeth are calcified by 6-7 years of age
Dental Development

Complication or interruption of any of the
processes of development (initiation,
histodifferentiation, calcification or maturation)
could result in dental issues
Abnormal Dental
Development
2013 ACH Pediatric Resident Seminar
Series - Dr. Christine Bell
Dental Anomalies
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Natal/Neonatal teeth
Extra/supernumerary teeth
Missing teeth
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Malformed teeth
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Anodontia/oligodontia
Microdont/macrodont/conical/twinning/genination
Structural/mineralization anomalies
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Hypocalcification/hypoplasia/fluorisis/amelogenesis
imprefecta/dentinogenesis imperfecta
Natal/Neonatal Teeth
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Natal teeth
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Neonatal teeth
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teeth present at birth
Teeth/tooth erupt during
1st month following birth
Incidence 1:2500-3500
births
85% are mandibular
incisors
90% are true primary
teeth
Treatment

Monitor vs extraction

Indications for extraction
hyper-mobility
 difficulties with breast feeding
 traumatic ulcerations on tongue (Riga Fede Disease)
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Dental Anomalies
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Fused or geminated teeth
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Hypoplastic tooth
Some dental development issues may
be linked to genetics &/or medical
conditions
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Dentinogenesis imperfecta
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Oligodontia, conical teeth
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Osteogenesis imperfecta
Ectodermal dysplasia
Multiple supernumerary teeth
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Cleidocranial dysostosis
Dentinogenesis Imperfecta
Amelogenesis Imperfecta
Ectodermal Dysplasia
Conical teeth, severe oligodontia of
the upper arch
Anodontia of lower arch
4 year old male with Ectodermal Dysplasia and severe oligodontia
Dental Caries (Cavities)
2013 ACH Pediatric Resident Seminar
Series - Dr. Christine Bell
Dental Caries/Cavities

The Centre for Disease Control & Prevention
reports Dental Caries as being the ‘most
prevalent infectious disease in our Nation’s
children’
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5x more common than asthma
Estimated that >40 % of children have caries by
kindergarten
Preventable disease
Etiology of Dental Caries

Multifactorial
TIME
Bacteria
C
A
R
I
E
S
Tooth
Fermentable
Carbohydrate
The Caries Process
Streptococcus mutans

Main bacteria responsible for causing tooth
decay
Part of natural oral flora
 Can be acquired

Acquisition of Cariogenic Bacteria
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Vertical Transmission
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Passing of bacteria from caregiver to child
Studies have shown the strain of S.mutans in the mouths of
children are the same strain as that found in the mouths of
their caregivers
Horizontal transmission
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Passing of bacteria from someone other than a caregiver
Studies have found that in the environment of daycares, the
same strains of S.mutans are found among the children
Strategies to minimize transmission
from primary caregivers
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improve caregivers oral hygiene and dental
health
do not share utensils or tooth brushes
do not clean soother with your mouth
Pre-chewing food is not recommended

this is a practice in some cultures
Demineralization
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First stage of tooth decay

white spot lesion
Chalky white area usually following curvature of the gum
line
 demineralized enamel
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As the demineralization progresses, the surface
layer becomes weaker and eventually collapses
resulting in a cavity
White Spot Lesions
The Caries Process
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Dental decay is associated with frequency
and duration of exposure to cariogenic
substances

more frequent and longer duration of sugar in the mouth produces a
lower pH and longer exposure to the change in pH (favoring
demineralization)
Stephan Curve
7
pH
Re-mineralization
6
5.5
5
Critical pH
Demineralization
0
10
20
30
40
Minutes
- The average baseline oral pH is ~7
- pH of 5.5 is considered the critical pH
- The Stephan Curve shows changes in oral pH following exposure to a sucrose solution
- pH drops significantly below the critical pH on initial exposure
- takes ~20 minutes to recover to the critical pH and ~40 minutes to return to
baseline
Early Childhood Caries (ECC)

May be referred to as:
Baby bottle decay/Baby bottle mouth
 Nursing bottle syndrome/Nursing caries
 Rampant caries

What is the impact of ECC on a
Child’s quality of life?

Pre-school children do not necessarily complain of tooth
pain
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they manifest the effects of pain by changing eating and sleeping
patterns
Reported effects of untreated caries include:
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Low percentile weights or failure to thrive
Risk of delayed physical growth and development
Loss of school days
Diminished ability to learn: irritability, inability to concentrate
Pain
Risk of dental abscess, facial cellulitis and potentially life
threatening infections (Ludwig’s angina, cavernous sinus
thrombosis)
Hospitalizations and emergency room visits
Resolving Periorbital Cellulitis
Secondary to Odontogenic Infection
We need to work together to help
decrease the prevalence of this
preventable disease
Physician’s Role in Caries Prevention

Early identification and referral of high risk
children
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Discuss caries prevention information with
families
Caries Risk Assessment

A systematic evaluation
looks at the presence and intensity of etiologic
disease factors
 It is designed to provide an estimation of disease
susceptibility
 aids in formulating preventative and treatment
strategies
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Caries Risk Screening Tool
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Caries-risk Assessment tool (CAT):
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Check list
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Gather information from a primary caregiver
Conduct clinical evaluation of child’s mouth
Can be used by dental and non-dental health care
providers

American Academy of Pediatric Dentistry website:
www.aapd.org

Provides a current caries risk assessment form
Risk Factors for Caries Development

Primary caregiver or sibling with active caries
Low socioeconomic status
Child has >3 between meal sugar containing snacks/beverages
per day
Child is put to bed with bottle/cup containing something other
than water
Not receiving optimally fluoridated drinking water or fluoride
supplements
White spot lesions on teeth
Visible cavities or fillings
Visible plaque on teeth (poor oral hygiene)

special health care needs
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Recent immigrant
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Other Risk Factors for Caries
Development
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Breast or bottle feeding beyond
12 months of age
feeding throughout the night or
allowing baby to fall asleep for
the night while feeding
Oral medications (suspensions,
inhalers)
Nutritional supplements such as
Pediasure or Nutren Junior etc.
Physician’s Role with Dental Caries
Prevention

Ask families if they have a dentist for their child

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Review feeding habits
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are they seeing a dentist regularly
recommend first dental visit by age one
Prolonged breast/bottle/sippy cup use and feeding throughout the night
juice, grazing habits, hidden sugars
Discuss oral hygiene practices
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Brush 2x day by parent
Start using fluoride toothpaste at age 3 (1/2 pea sized amount)
<3 years of age; fluoride use is prescribed on an individual basis by the
dentist
Do not share tooth brushes
Lift the Lip
Look for…
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Dental caries at any stage of progression
Chipped or broken teeth
Crooked/crowded teeth
Discolored teeth
Abscesses
Poor oral hygiene
Red inflamed gums
Anomalies
You may find…
White spot lesion
decay
abscess
1
2
Discolored tooth - indicates pulp necrosis
3
Supernumerary tooth (“mesodens”)
4
Retained primary teeth
Stain/poor oral hygiene
Malocclusions
R
L
Crossbite
Open bite
Crowding
Eruption Cysts
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May appear as a bluish-black or translucent, smooth,
painless swelling over an area of an unerupted tooth
associated with an erupting primary or permanent
tooth
no treatment necessary
Generalized Gingival Hyperplasia

Fibrous overgrowth of
gingiva

Congenital
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
Gingival fibromatosis
Mucopolysaccharidoses
(Hunter, Hurler syndrome,
I-Cell disease)
Acquired

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Plaque induced/poor oral
hygiene
AML, aplastic anemia
Medication induced
Common Medications Linked to
Gingival Overgrowth

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Cyclosporin
Calcium channel
blockers
Anti-seizure
meds
Gingivectomy
When to refer

Recommend they see a dentist if they do not have one
and:
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No sign of decay
No significant findings
Low risk for caries
Refer to a dentist
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Obvious decay or dental trauma
Significant findings
High risk for caries
Oral Hygiene
2013 ACH Pediatric Resident Seminar
Series - Dr. Christine Bell
Oral Hygiene Recommendations
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Parents should brush their
children’s teeth until they are
about 8 yrs old
Always use a soft bristled
toothbrush
Floss teeth that are contacting
one another
Rule of 2’s

Brush 2x a day, for 2 minutes and visit the a
dentist 2x a year for regular check-ups
Oral Hygiene Recommendations

Prior to eruption of first tooth

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Eruption of first tooth


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wipe gums with wet washcloth at least 1x day
Wipe tooth and gums with a wet washcloth 2x day or after
every feed
Be aware that feeding during the night or at bedtime can
cause tooth decay
Eruption of molars

Use toothbrush with water or ‘safe to swallow’ toothpaste 2x
daily
Recommendations:
Fluoride Use

Under 3 years of age
non-fluoridated toothpaste is recommended
 fluoride recommendations based on caries risk
assessment
 dentist develops an individualized caries prevention
plan and recommendations for fluoride use

Recommendations:
Oral Hygiene and Fluoride Use

Age 3-6
Brushing 2x day using fluoride toothpaste (grain of
rice sized to half the size of a pea amount of
toothpaste)
 Flossing 1x day where teeth are contacting


> 6 years of age
Brushing 2x day using fluoride toothpaste (pea sized
amount of toothpaste)
 Flossing 1x day

Mechanism of Action of Fluoride

Topical and Post-eruptive

Increases the remineralization process

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Prevents demineralization


Catalyst for remineralization (Ca, PO4)
Decreases tooth solubility
Decreases bacterial acid production

Inhibits enolase, enzyme required in glycolysis
Water Fluoridation

Optimum water fluoride level
1 ppm (1.0mgF/L)
 recommended range = 0.7-1.2 ppm

Fluoride Supplement Schedule
Fluoride concentration in community drinking H2O
Age
< 0.3 ppm
0.3-0.6 ppm > 0.6
ppm
none
none
0-6 months
none
6mo-3yr
0.25mg/day none
3-6yr
0.50mg/day 0.25mg/day none
6-16yr
1.0mg/
day
0.50mg/day
none
none
Fluoride Supplements



Very rarely do we Rx systemic fluoride
supplements
Consider all sources of fluoride
Young children with incipient decay (white spot
lesions) may benefit from application of fluoride
varnish
Dental Fluorosis

Ingestion of too much
fluoride during the
mineralization stage in
tooth development may
cause fluorosis
Common Pediatric
Dentistry
2013 ACH Pediatric Residency Seminar
Series - Dr. Christine Bell
Common Pediatric Dentistry

Prevention
Routine dental exams, cleanings, fluoride application
 Sealants (recommended on molars with deep
grooves)

Common Pediatric Dentistry

Restorations
Composite restorations (white fillings)
 Amalgam restorations (silver fillings)
 Stainless steel crowns
 Nerve treatments (pulpotomies/pulpectomies/root
canal treatments)

Common Pediatric Dentistry
Treatment



Extractions
Spacemaintenance
Guidance/monitoring of occlusion
Why fix a baby tooth? They just fall
out, don’t they?

Primary teeth are important:






Chewing
Speaking
Esthetics
Hold space for the adult teeth
Gives face shape and form
If not restored, decay will continue to worsen and
eventually lead to pain, discomfort and infection
Special Needs and Medically
Compromised Children
Special Needs and Medically
Compromised Children



Unique medical and dental needs
May not be the most cooperative dental patients
Best seen by a Pediatric Dentist
Private practice Pediatric Dentist
 Hospital based Pediatric Dentist

Children with Special Health Care
Needs

Typically have one or more risk factors
predisposing them to dental disease

Delayed first dental visit
Complex medical needs
 Parents overwhelmed with medical issues


Limited cooperation for home oral hygiene
Mental and/or physical disability complicates oral hygiene
process
 Perioral sensitivity
 Behavior issues

Possible Risk Factors of Children
with Special Health Care Needs

Dietary
Need for frequent high calorie feedings, night feedings
 Tube feeding
 Behavior reinforcing therapy with sweet treats


Greater exposure to medications
Xerostomia is common side effect of many medications
 Suspensions contain sugar
 Oral steroids/inhalers linked to tooth decay

Possible Risk Factors of Children
with Special Health Care Needs

Oral motor dysfunction/parafunction

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
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

Chewing, swallowing problems
Grinding/clenching
Self biting (lip, cheek)
Chewing objects
Pouching of food
Gastro-esophageal reflux, frequent vomiting
Greater susceptibility



Periodontal disease (Down Syndrome)
Trauma (CP, seizure disorder)
Neglect and abuse
Tube Fed Children

Oral aversions


Aspiration risk


Parents afraid to brush teeth as worried about
secretions
No oral feeds


Uncooperative for tooth brushing
Parents incorrectly think they are not eating so no
need to brush teeth
May take tastes, usually sweet foods/drinks
Common Oral Findings with Tube
Fed Children

Significant calculus build-up
Gingivitis
 Periodontal disease


Possible GERD

Acid erosion of teeth
Calculus: 2 year old G-Tube fed
patient
Gastro-esophageal Reflux (GERD)


Enamel erosion due to
acid reflux
Role of physician



Awareness
Referral
Importance of early
detection, prevention
and rehabilitation
Cardiac Patients

Some are at risk of Bacterial Endocarditis


Prophylactic antibiotic coverage may be indicated
prior to dental treatment
Prior to open heart surgery patients require
dental clearance letter

Cardiac surgery may be cancelled if unable to
complete dental work before scheduled surgery
Transplant Patients



Will be immune suppressed
Should have all dental treatment completed
prior to transplant
bone marrow or organ transplant may be
postponed if oral health is not satisfactory
Immune Compromised Patients and
Oncology Patients



Issues with low counts (CBC)
Issues with low platelets
Unable to deal with infection
Septicemia/Bacteremia
 Delayed healing
 Other serious complications

Prior to Dental Work

Consult specialist team



Proper timing for safe dental treatment
Blood work, medications/antibiotics,
transfusion etc may be necessary pre and post
dental treatment
Dental work, dental cleanings etc may need to
be postponed until health of patient is more
ideal
Absolute Neutrophil Count (ANC)
and Dental Treatment

ANC >1000/mm3


ANC of 500-1000/mm3


No antibiotic prophylaxis necessary unless infection
present
Antibiotics indicated, may defer treatment
ANC <500/mm3

Defer elective dental treatment
Platelet Count and Dental Treatment

>75, 000


40, 000-75,000


no additional support except aggressive local
measures
consider platelet transfusion prior to and 24 hrs post
dental treatment
<40, 000

defer care
Considerations: Bleeding Disorders


May need factors, transfusions etc
Early detection and early treatment allows for
minor procedures and less bleeding
issues/complications
Antibiotics in Dentistry
2013 ACH Pediatric Resident Seminar
Series - Dr. Christine Bell
Antibiotic Prophylaxis
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May be indicated for some patients:
Cardiac conditions at risk for sub-acute bacterial
endocarditis
 Immune compromised patients
 Patients with VA (ventricular-arterial) shunts,
indwelling vascular catheters (central line, chemoport)
 Some orthopedic patients (VEPTR, joint
replacements)
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Antibiotic Coverage
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Cardiac and Immune Compromised Patients:
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Follow American Heart Association Guidelines –
reviewed/revised 2007
Amoxicillin: 50mg/kg (max 2g) 1 hr prior to dental
procedure
 Clindamycin: 20mg/kg (600mgs) 1 hr prior
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Orthopedic Patients:
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Follow the American Academy of Orthopedic
Surgeons Guidelines
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50mg/kg Keflex 1 hr prior; amoxicillin or clindamycin
could be given instead
Reason for coverage
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Dental procedures may cause a transient
bacteremia
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Prevent seeding of bacteria in susceptible area
Vulnerable areas of the heart
 Certain implanted hardware (VEPTR)
 Central lines, etc
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Those with compromised immune systems may be
unable to handle a transient bacteremia
Potential Oral Source of Bacteremia
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Routine tooth brushing or chewing
Poor oral/dental hygiene
Periodontal or dental infections
Oral/dental procedures associated with bleeding
Immune Compromised
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Includes but not limited to:
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Chemotherapy, radiation, bone marrow transplant
HIV, diabetes
Neutropenia
Chronic steroid use
Hemodialysis
Status post splenectomy
Organ transplant
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Consultation with medical specialist indicated
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Standard AHA prophylactic regimen recommended
Hemodialysis: Coverage is two fold

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Immune suppressed
At risk of infective endocarditis even in the
absence of a structural cardiac defect
Altered host defence
 Altered cardiac output and mechanical stresses
 Bacterial seeding and growth on shunts

Peritoneal Dialysis
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Lower risk for infection of catheter from
transient bacteremia
Have altered host defences
Antibiotic prophylaxis may be recommended;
consultation is indicated
Considerations when Prescribing
Prophylactic Antibiotics
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Patients already receiving antibiotics
select drug of different class, or
 delay procedure 10-14 days after completion of the
antibiotic
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Need for multiple visits
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wait 10-14 days between appointments
Unanticipated bleeding
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effective prophylaxis up to 2 hrs post-op
Antibiotics and Dental Infections
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Dental abscess
Antibiotics typically if systemically involved
 Pen VK, Amoxicillin, Clindamycin
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Facial cellulitis
Mild-Moderate: PO antibiotics (eg. Clindamycin)
 Moderate-severe: IV antibiotics (eg. Clindamycin or
Flagyl/ancef)
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Dental Infections
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Dental treatment necessary
primary tooth: extraction
 permanent tooth: extraction vs root canal treatment

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Dental infections will return if tooth is not
treated appropriately
Seek the most up-to-date information for
antibiotic recommendations
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It is possible that these current recommendations may
change as the result of more advanced research and of
the ongoing clinical guidelines development of
professional associations and academies
Therefore, clinicians are encouraged to consider the
recommendations in the context of their specific clinical
situation and consult, where appropriate, other sources
of clinical, scientific, or regulatory information prior to
making a treatment decision and seek most-up-to-date
information
Dental Trauma
2013 ACH Pediatric Resident Seminar
Series - Dr. Christine Bell
Dental Trauma
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Fractures
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Ellis Class I:
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Ellis Class II:
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enamel and dentin
usually sensitive to hot/cold and air
Ellis Class III:
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enamel only
patient usually not sensitive
enamel, dentin and pulp
you see red and they are in pain
Root fractures
Alveolar fractures
Pulp Exposures
Pinpoint pulp exposure
Frank pulp exposure
Displacement Injuries
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Concussion (A)
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Subluxation (B)
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displaced forward or backward
May be accompanied by alveolar
fracture
Intrusion (E)
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displaced away from the gums
ie. the tooth looks longer
Lateral Luxation (D)
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loose but not displaced
Extrusion (C)
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no mobility, no displacement
displaced into the gums
ie. the tooth looks shorter
Avulsion (F)
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tooth completely out of the socket
1
3
2
4
Dental trauma that shouldn’t wait till
tomorrow for treatment
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Patient cannot close teeth all the way together
Fractures involving pulp
Mobility greater than 3mm
Intruded teeth
Extruded teeth
Avulsions
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This is a true dental emergency
survival is dependant on time out of the mouth
immediately place tooth in milk
ideally, place tooth back in the socket (permanent teeth)
DO NOT replant primary teeth
Intrusion
Intrusion
Lateral luxation
What do you think?
Complete Intrusion
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Looks like an avulsion
Palpate buccal gingiva
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may feel a bump
Radiograph to confirm diagnosis
Where could the missing tooth or
tooth fragment be?
1)
2)
3)
4)
lost extra-orally
ingested
aspirated
tissue inclusion
Alberta Children’s Hospital
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Dental trauma
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Pediatric Dentist is on call 24/7 at ACH
Facial cellulitis/odontogenic infections
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Emergency department physicians may Rx
antibiotics (IV/ PO). Patients are instructed to
follow up with their dentist, or referred to a dentist
(possibly the one on call)
Questions?
Thank you !
2013 ACH Pediatric Resident Seminar
Series - Dr. Christine Bell