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The School Age Child and Dental Considerations
- 1. The School Age Child and Dental Considerations
- 3. Dental Considerations 1. Preventive considerations related to tooth sealants, nutrition, and fluoride intake. 2. Prevention and management of trauma. 3. Development of skills in personal oral hygiene. 4. Participation in health care decisions.
- 5. Components of the dental exam • Medical history • Behavioral assessment and general appraisal • Extra-oral exam: head, neck, face, hands • Intra-oral exam • Caries risk assessment (CRA) • Radiographic examination
- 6. Extra-oral exam: facial profile • The ideal soft tissue profile for the bridge of the nose, the base of the upper lip, and the chin is slightly convex to straight in the anteroposterior dimension in the 6- to 12-year-old child.
- 7. Intra-Oral examination • Assess number of teeth, shape, and type (permanent or primary) • Tooth eruption patterns: ▫ Ectopic eruption-root resorption of the primary tooth, more common in maxilla, incisor resorbs primary canine, lingual eruption of lower incisors ▫ Transposition ▫ Impaction ▫ Failure of eruption
- 8. The maxillary right canine has erupted into the lateral incisor space and resorbed a portion of the root. This type of resorption is more common than believed, but often not to this extent. Ectopic eruption of the permanent lateral incisors is most common in the mandibular arch. In this example, the mandibular lateral incisors erupted lingual to their ideal position and the primary laterals are still present. In some cases, the lateral incisors erupt into a more normal position but cause premature exfoliation of the primary canine.
- 9. Tooth eruption • Transposition- occurs when there is “a positional interchange of two adjacent teeth, especially their roots or the development or eruption of a tooth in a position occupied normally by a nonadjacent tooth. • Impaction-maxillary canine most likely to be impacted • What are the most common missing teeth in the permanent dentition?
- 10. Gingival Evaluation • Selective probing of anterior teeth and perm. 1st molars • Evlauation of tissue attachments, facial clefts, attached gingiva, frena • Problem areas, calculus formation, inflammation, eruptive gingivitis
- 11. Gingival Evaluation • The GI uses the following scoring system: ▫ 0 = normal gingiva; ▫ 1 = mild inflammation: slight change in color, slight edema, no bleeding on probing; ▫ 2 = moderate inflammation: redness, edema, and glazing, or bleeding on probing; ▫ 3 = severe inflammation: marked redness and edema, tendency toward spontaneous bleeding, ulceration.
- 12. Periodontal problems in children and adolescents • Gingivitis-puberty associated (10 in girls, 13 in boys) chronic- mouth breathing • Drug induced • Frenum restricted • Aggressive periodontitis
- 13. Oral hygiene evaluation • Assess dexterity • Problem areas • History of pattern of care
- 14. Pediatric restorative dentistry • Rubber dam placement-calms children • Pulpal floor depth is 1.5 mm from the enamel surface • Can use resin based composite in posterior teeth but need a dry field • Stainless steel crowns-metal shell with some preformed anatomy and trimmed to fit individual teeth
- 15. Pulp therapy • Conservative treatment: placement of a protective base or liner on walls of a cavity prep • Indirect pulp cap-floor of pulp covered • Direct capping-calcium hydroxide place over the exposure site • Pulpotomy: radicular pulp tissue is healthy or capable of healing after amputation of the infected coronal pulp
- 16. Injuries • Falls, sports • More crown fractures seen than in primary dentition • Radiographs taken at 1 month and 2 months following injury • Enamel fractures/dentin fractures ▫ Direct pulp cap: small exposures that can be treated within a few hours of the injury
- 17. Orthodontics in mixed dentition • Consider: ▫ Difference in size between the primary and permanent dentitions ▫ Amount of space available for permanent teeth ▫ Dental and skeletal status of the patient Tools for assessment: diagnostic casts, panoramic xrays, cephalometric xrays
- 23. Sealants • Acid etch removes 75% of microorganisms from pit and fissures • “Over a 10-year period, it was found that the cost of restoring unsealed surfaces was 1.64 times the cost of a single application of sealant” • Used in permanent first molars and in some primary teeth
- 25. Caries Risk Assessment • Caries pattern in children ▫ Pattern of caries development is localized: incisal edge most often stays healthy due to self cleansing, the middle third had a thin layer of undisturbed bacteria, and gingival margin has a thick layer of plaque where the carious lesion is ▫ Studies show that in children, teeth without full mastication abilities (such as first permanent molars) are at a higher risk for developing caries because they do not have the self cleansing mechanism of chewing. Children are a special risk group for caries because of continued changing eruption patterns
Editor's Notes
- Table from Darby and Walsh
- 1. Preventive considerations related to tooth sealants, nutrition, and fluoride intake. The eruption of permanent teeth may require that a decision be made about sealant application. Entry into the more heterogeneous, less controlled environment of school places the child at risk for increased carbohydrate exposure. Finally, the child’s access to fluoride in school, diet, and other sources makes regular reevaluation of fluoride exposure a necessity. Preventive issues must be reviewed as risk factors change during this dynamic period. 2. Prevention and management of trauma. The school-aged child may be active in sports. For a period in the school years, the permanent maxillary incisors are at greater risk for traumatic injury, especially if they protrude. 3. Development of skills in personal oral hygiene. The child emerging from the middle school years should acquire the skills and knowledge to conduct effective personal oral hygiene. 4. Participation in health care decisions. Classically, dentists are taught to see the school-aged child as a passive recipient of care. Unfortunately, the result may be poor compliance and a tendency for the child to consider the dentist rather than himself or herself as responsible for his or her own health.
- Differences from younger age groups: 1. Medical intervention has usually occurred. Most children have a physician and may have experienced an emergency visit or some invasive procedure. School enrollment has required a physical examination and other treatment for the majority of children. 2. A health history has evolved. The coagulation and immunologic systems have been tested, and a developmental profile is available. Most childhood-onset disorders manifest themselves at some time during this period, but some have not been noted. Therefore, symptoms remain an important aspect of history taking. 3. A dental history should be evolving, and caries experiences and prevention, care delivery, and dental development should be established. Children usually have undergone a dental visit as part of school enrollment. 4. The history should capture those children early on the curve of health experiences. We would be naïve to presume that children are not exposed to different environmental, social, and other issues than a generation ago. The history form, unfortunately, should address substance use and pregnancy.
- Pedo I through A
- In examination of the profile one notes the anteroposterior and vertical dimensions of the face and the position of the lips and incisors relative to the face. The ideal soft tissue profile is slightly convex to straight (Fig. 30-1), practically speaking a bit straighter with more mandibular contribution than that of the preschool-aged group. The ideal soft tissue profile for the bridge of the nose, the base of the upper lip, and the chin is slightly convex to straight in the anteroposterior dimension in the 6- to 12-year-old child. This child demonstrates that type profile and well-balanced vertical proportions with the lower face slightly larger than the middle facial third.
- Minor asymmetry in dental eruption is normal, and there is little cause for concern if less than 6 months difference in eruption exists between contralateral sides of the mouth. Four tooth positioning problems are associated with the mixed dentition: ectopic eruption, transposition, impaction, and primary failure of eruption and the midline diastema. Interestingly, there appears to be a genetic component to some of these tooth position problems. Several studies have shown a genetic link between missing teeth, tooth anomalies, and altered eruption paths.1,21,22,23 There seems to be clustering of these problems. For example, a missing maxillary lateral incisor is often associated with an altered canine eruption pattern. If one of these conditions is identified, the clinician should examine the patient for these other related problems. Ectopic eruption describes a path of eruption that causes root resorption of a portion or all of the adjacent primary tooth. Ectopic eruption is most often associated with the permanent maxillary first molar, mandibular lateral incisor, and maxillary canine.9,16,24 In ectopic eruption of the permanent first molar, a portion of the erupting first molar resorbs the distal root of the primary second molar and is inhibited from erupting by the distal portion of the primary molar (Fig. 30-11). In many cases, the permanent molar spontaneously “jumps” or moves distally and erupts into the correct position. In other cases, the permanent molar lodges under the primary molar crown and no longer erupts. Usually, no pain or discomfort is associated with ectopic eruption unless a communication develops between the oral cavity and the pulpal tissue of the primary molar, causing an abscess. Permanent molar ectopic eruption is often detected during clinical examination and confirmed with routine bitewing radiographs.
- The maxillary right canine has erupted into the lateral incisor space and resorbed a portion of the root. This type of resorption is more common than believed, but often not to this extent. Ectopic eruption of the permanent lateral incisors is most common in the mandibular arch. In this example, the mandibular lateral incisors erupted lingual to their ideal position and the primary laterals are still present. In some cases, the lateral incisors erupt into a more normal position but cause premature exfoliation of the primary canine.
- Transposition occurs when there is “a positional interchange of two adjacent teeth, especially their roots or the development or eruption of a tooth in a position occupied normally by a nonadjacent tooth.”23 Usually transpositions are observed later in the transitional dentition years. The early-stage transposition is uncommon but is the type of transposition observed in the early mixed-dentition years (Fig. 30-15). This usually is a transposition of the mandibular lateral incisor and canine.22 The lateral incisor will show distal tipping, resorption of the primary canine (and sometimes the primary first molar), and rotation as it migrates. Other transpositions that are observed later in the transitional years are likely to be the mature mandibular lateral and canine, and the more prevalent transpositions of the maxillary canine and first premolar and maxillary canine and lateral incisor.23 Answer: maxillary lateral incisor and mand second premolar, also third molars Odontomas may interfere with tooth eruption-compound versus
- 1. Selective probing of anterior teeth and permanent first molars. A periodontal probe is necessary to evaluate the health of the tissues properly (Fig. 30-3). The probe measures the depth of the sulcus and the amount of free marginal and attached gingiva. Sulcular depths of greater than 3 mm and attached gingiva of less than 1 mm indicate possible periodontal disease, and further evaluation is warranted. The likelihood of bone loss and apical migration of the attachment is low, but some children in this age group experience aggressive periodontitis. Erupting teeth usually have a deep sulcus until the crown is fully erupted. Gingival inflammation in early puberty may also confound pocket-depth measurements. 2. Evaluation of tissue attachments, especially those of the lower anterior teeth. Facial clefts as a result of malpositioning of teeth and inflammation, if identified early, can be successfully managed with grafting, tooth movement, or a combination of both (Fig. 30-4). The amount of attached gingiva also should be considered in the context of the type of tooth movement being planned. Facial movement of a lower incisor with minimal attached gingiva may cause further loss of attachment, and a gingival grafting procedure should be considered. Lingual movement of the same incisor does not involve the risk of loss of attachment and may even contribute to an increase in attached tissue. Last, the position of the frena and their height of attachment on the alveolar ridge should be determined via gentle manipulation of the lips and cheeks. Occasionally, frenal attachments near the crest of the ridge must be repositioned prior to or after orthodontic treatment because they pull on attached marginal tissue and compromise gingival health or prevent space closure. 3. Identification of problem areas, such as mandibular and maxillary anterior teeth. Calculus accumulation, inflammation secondary to anterior crowding, poor cleaning, and eruptive gingivitis are examples of localized problems that require specialized attention.
- Numerous gingival indices exist to assess inflammation.29 The gingival index (GI)17 can be adapted for pediatric use.
- Gingivitis
- Indications for stainless steel crowns: extensive caries, 1st primary molars with mesial interproximal lesions, hypoplastic teeth, primary teeth following pulpotomy or pulpectomy, imperfectas, oral hygiene is very poor, abutment for space maintainers or prosthetics appliancs
- Puplotomy-remove coronal pulp Pulpectomy: in teeth with gross loss of root structure, advanced internal or external resorption Overshoot to cold stimuli or spontaneous pain will frequently lead to a diagnosis of irreversible or untreatable pulpitis, and these teeth will in many instances need root canal treatment. Infancy through adolescence Spontaneous pain occurs without any external stimulus and frequently indicates that the damage to the pulp is irreversible. Sensitivity to pressure may indicate that the pulpal damage has extended to the periodontal ligament causing extrusion of the tooth from the socket. Test with pulp tester, young permanent teeth may not be as developed as mature teeth so they may not feel the pain
- For fractures that reveal the pulp 1. Vitality of the exposed pulp2. Time elapsed since the exposure3. Degree of root maturation of the fractured tooth4. Restorability of the fractured crown
- orthodontic treatment in the mixed dentition is more complex than treatment in the primary dentition. The clinician must consider the difference in size between the primary and permanent dentitions, the amount of space available for the permanent teeth, and the dental and skeletal status of the patient. Tools for assessment: diagnostic casts, panoramic xrays, cephalometric xrays
- Class II maxillary protrusion is best managed by headgear therapy to restrict or redirect maxillary growth on the basis of retrospective studies and randomized clinical trials.4,50 Headgear places a distal force on the maxillary dentition and the maxilla (Fig. 35-1). Theoretically, the relative movement of dental and skeletal structures depends on the amount and time of force application. In actual practice, it is probably not possible to move selectively only teeth or bones.4
- The mandibular-deficient patient is usually treated with a removable or fixed functional appliance that positions the mandible forward in an attempt to stimulate or accelerate mandibular growth (see Fig. 35-2). Retrospective clinical studies have shown that these appliances can produce a small average increase in mandibular projection (2 to 4 mm/year).
- The class III maxillary deficient patient is treated by using a reverse pull headgear or facemask to exert anteriorly directed force on the maxilla. The force is provided by rubber bands extending from the facemask to intraoral hooks or wires.
- Class III mandibular protrusion has been historically managed with chin cup therapy (Fig. 35-5). The theory of chin cup therapy is to apply a distal and superior force through the chin that inhibits or redirects growth at the condyle. Again, studies in animals have shown some change in absolute mandibular size, but clinical application in humans routinely has been less successful.45,46 The typical short-term treatment response to chin cup therapy is a distal rotation of the mandible and lingual tipping of the lower incisors.
- By the time the first permanent tooth has erupted (posterior or anterior), an anterior occlusal radiograph should be made. This allows detection of conditions such as supernumerary teeth, missing teeth, and dens in dente. A radiographic examination that includes the tooth-bearing areas of the mandible and maxilla is recommended at approximately the time of the early mixed dentition to assess the dental age of the patient and to aid in the early diagnosis of congenital and developmental anomalies. Infancy through adolescence: For the primary dentition, no radiographs are indicated when all proximal surfaces can be visualized and examined clinically. When the proximal surfaces cannot be visualized and clinically examined, bitewing radiographs are indicated to determine the presence of interproximal caries (Fig. 18-16). Other projections are indicated in the following circumstances: history of pain, swelling, trauma, mobility of teeth, unexplained bleeding, disrupted eruption pattern, or deep carious lesions.8 These views include the maxillary (Fig. 18-17, A) and mandibular (Fig. 18-17, B) periapical views and the maxillary (Fig. 18-17, C) and mandibular (Fig. 18-17, D) occlusal views. a dentist may always start in the upper right quadrant, work around the maxillary arch, move down to the lower left quadrant, and end the examination in the lower right quadrant. Morphologic defects and incomplete coalescence of enamel at the base of pits and fissures in molar teeth can often be detected readily by visual and explorer examination after the teeth have been cleaned and dried. When indicated, radiographic examination for children must be completed before the comprehensive oral health care plan can be developed, and subsequent radiographs are required periodically to allow detection of incipient carious lesions or other developing anomalies
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