Table of Contents

Title Page

Copyright Page

Foreword

Acknowledgements

Preface

Chapter 1 The First Visit

Aim

Objectives

Introduction

First Visit – First Impressions

Parent in or out of the Surgery: the Treatment Triangle

The Child is Part of the Family

Information Gathering

The History

The Clinical Picture

The Dentition

Radiographic Assessment?

Caries Risk Assessment

Treatment Planning

Recommended Reading

Chapter 2 Interceptive Orthodontic Treatment

Aim

Objectives

Introduction

The Developing ‘Normal’ Dentition

Screening for Problems

The Dilemma of the First Permanent Molars

The Occlusion

The Prognosis of the Teeth

The Patient’s Compliance with Treatment

The Wishes of the Parent and Patient

Timing of Extractions

Recommended Reading

Chapter 3 Planning for Prevention

Aim

Outcomes

Introduction

Why Prevention?

The Problems with Prevention

Whose Responsibility is it?

What are we Trying to Prevent?

Where does Prevention come in a Treatment Plan?

‘Tailor-Made’ Prevention

Dietary Advice

Dietary Advice for Dental Caries

Dietary Advice for Erosion

Antimicrobial Therapy

Oral Hygiene Matters

The Scale of the Problem

Why Should Children Brush their Teeth?

Practical Instruction

Which Toothbrush?

Oral Hygiene Aids

Monitoring Oral Hygiene

Specific Gingival and Periodontal Problems

Fluoride: Friend or Foe?

Fluoride Dietary Supplements

Fluoridated Milk

Fluoridated Water

Fluoridated Varnishes

Fluoride Gels

Fluoridated Toothpastes

Fluoride Rinses

Fissure Sealants

Who Should Have Sealants?

When and What to Seal

Which Type of Sealant?

Mouthguards

Practical Prevention: Putting it all Together

Recommended Reading

Chapter 4 The Restorative Phase of Treatment

Aim

Outcome

Introduction

Why Bother Filling Primary Teeth?

Where Does Restorative Treatment Fit into an Overall Treatment Plan?

Sequence of Restorative Treatment

The Rampant Caries Case

Use of Local Anaesthetic for Restorative Treatment

Use of Rubber Dam for Restorative Treatment

Restorative Materials

Temporary Dressings

Glass-Ionomers

Compomers

Composites

Amalgam

Preformed Metal Croums

Fixed Prostheses

Porcelain Veneers

Indirect Composite Restoration

Porcelain Crowns

Post Crowns

Metal Onlays

Adhesive Bridges

Implants

Removable Prostheses

Partial Acrylic Dentures

Complete Acrylic Dentures/Overdentures

Cobalt Chromium Dentures

Bleaching

Management of Pulpally Involved Teeth

Primary Dentition

Permanent Teeth

Special Restorative Problems

Recommended Reading

Chapter 5 Management of the Dental Emergency

Aim

Outcome

Introduction

Principles of Management

The History

Examination and Special Investigations

‘Toothache’

Referral for Extractions under General Anaesthesia

Orofacial Infections

Bacterial Infections

Viral Infections

Fungal Infections

Trauma

Stage of Dental Development

Delay in Treatment

Patient Cooperation

Maintaining Roots and Alveolar Bone

Orthodontic Considerations

Medical Status

Risk of Repeat Trauma

Tooth Colour Changes

Ankylosis

Fractures of Facial Bones and Soft-Tissue Injury

Non-Accidental Injury

Acute Temporomandibular Joint Dysfunction

Oral Lesions

Clinical Features Justifying Specialist Referral

Radiographic Features of Concern

Recommended Reading

Chapter 6 Recall Strategy

Aim

Outcome

Introduction

Caries Risk

Compliance

Medical Status

Dental Development

Specific Dental Conditions

Trauma

Periodontal Disease

Dental Anomalies

The Recall Appointment

Summary

Recommended Reading

Foreword

Good treatment planning for the developing dentition gives the child patient life-long benefits. Indeed, getting things right in the management of developing dentitions may make a major contribution to many more patients enjoying the benefits of having teeth and oral health for life. Treatment planning for the developing dentition is therefore an onerous responsibility, with tremendous implications for patients, let alone oral healthcare systems. Furthermore, there is enormous professional fulfilment in seeing young patients mature dentally fit, subsequent to effective management in the developing dentition phase of their formative years.

Treatment Planning for the Developing Dentition, Volume 26 in the very successful Quintessentials series, gives excellent, new insight into the many, interlinked complexities of the management of the developing dentition. The need to adopt a forward-looking, holistic approach to developing dentition management is the thrust of this most helpful book. Needless to say, being a volume of the Quintessentials series, this addition to the dental literature is well produced, easy to read and attractively illustrated. In congratulating the authors on a job well done, I am pleased to recommend this Quintessentials volume to all those who care, and anticipate caring for patients with a developing dentition. I consider it a disappointing day if I do not learn something new about clinical dentistry. The day I read Treatment Planning for the Developing Dentition was a very good day, given all that I learnt about the complexity of the development of the dentition. Hopefully, you, like me, will find this book both informative and most worthwhile – a pleasure to read and a reliable text for future reference.

Nairn Wilson
Editor-in-Chief

Acknowledgements

We would like to express our thanks to a number of people who have helped us with this book. First, we are very grateful to Nairn Wilson (Editor-in-Chief) and Marie Thérèse Hosey (Editor) for their meticulous review of the text and constructive comments. Thanks are also due to our colleagues Iain Buchanan, Sarah North and Zoe Marshman for their valuable advice.

We would like to acknowledge the Medical Illustration Departments of Sheffield Teaching Hospitals NHS Trust and Glasgow Dental Hospital (Gail Drake, in particular) for the excellent clinical photography. A number of colleagues also provided some figures for inclusion in this book – Ian Ball (Figs 2-11, 2-12(b), 2-15(b), 2-16(a, b), 3-11(c), Iain Buchanan (Figs 1-6, 2-5(a, b), 2-13), Sally Craig (2-14(b), 4-7, 5-3(a, b), 5-16), Peter Robinson (5-19) and Melanie Stern (Figs 2-6, 6-3).

Dr Rodd would like to take the opportunity to thank her Sheffield orthodontic colleagues Melanie Stern, Fiona Dyer, Philip Benson and Derrick Willmot for their constant readiness to give advice and support for any patient at any time. Thanks are also extended to the Derbyshire Craft Centre Cafe for the free coffees during proof-reading sessions and to James Marson for his support in every endeavour.

Dr Wray would like to thank particularly Iain Buchanan for his willingness to review Chapter 2 and for providing constructive advice. Thanks also to Fiona Gilchrist and to Cameron and Blythe Wray for help with clinical photographs. Finally, thanks to David Wray for making the time available to allow completion of this manuscript.

Preface

Treatment planning is the foundation of good clinical practice. But how much time and thought is actually put into a treatment plan? For some practitioners, the process may be intuitive, while others may spend considerable time weighing up the pros and cons of alternative plans according to each patient’s particular needs and circumstances. Whatever the approach, we hope this book will help to outline some principles of good treatment planning for the young patient. Treatment planning for children involves greater responsibility than for most patients. As early dental experiences may shape future behaviour and attitudes, the aim is to ensure that the child has a pleasant and positive introduction to dentistry. Good dental care in childhood helps attain a healthy, functional and aesthetic adult dentition. Conversely, ill-made decisions at an early age may lead to a compromised dentition in later life.

A good treatment plan should be:

• Realistic – don’t expect too much from young patients.

• Personalised – every child has different social, medical and dental needs; one treatment plan definitely doesn’t fit all.

• Holistic – a treatment plan is not just a sequence of procedures, but something that, in children, includes behaviour-shaping, prevention and interceptive orthodontics.

• Flexible – circumstances and dental status change, therefore a treatment plan should not be too rigid.

• Progressive – it is essential to introduce children gradually to the more demanding aspects of their treatment plan, rather than diving in, for example, with a dental block on the first visit.

• Forward-thinking – it is important to consider the longer-term picture, keeping options open or carrying out interventions that may avoid, or at least reduce, the complexity of future treatment.

Spending time to develop a treatment plan is not only beneficial for the young patient and their parents, but it also helps the operator by:

• reducing stress levels

• optimising time management

• increasing job satisfaction.

Skilled treatment planners are much less likely to run into difficulties with patients refusing to cooperate or agitated parents who claim not to know what is going on. Certainly, litigation problems are substantially reduced if one can demonstrate a comprehensive treatment plan for each patient that has been discussed and agreed with all concerned. As we are now increasingly working with professionals complementary to dentistry, it is mandatory that we provide these colleagues with a clearly itemised programme of treatment for young patients. This book does not set out to dictate rigid treatment plans for every clinical scenario, but rather aims to explain the basic principles behind good decision-making. On reading this book we would hope that the reader would have an understanding of the following:

• the importance of the child’s first visit to gain all information necessary to form a comprehensive treatment plan

• the importance of interceptive orthodontic treatment planning

• the preventive phase of a treatment plan

• the restorative phase of a treatment plan

• how to manage the emergency presentation

• recall strategies for the young patient.

Helen Rodd & Alyson Wray

Chapter 1

The First Visit

Aim

In this chapter the importance of introducing a young child to dentistry is emphasised and a strategy for structuring dental treatment is outlined.

Objectives

After reading this chapter the dentist should be able to:

• understand the importance of the child’s early impressions

• plan first visits according to the age of the child

• appreciate the need for a thorough history and clinical examination

• undertake caries risk assessment

• understand the need to initiate a hierarchical treatment plan.

Introduction

Children are the adult dental patients of the future, and good groundwork in the early years of dental monitoring and treatment planning will pay dividends in both the short and long term (Fig 1-1). Furthermore, children are infinitely variable in their behaviour, their development and in their dental needs, and therefore one of the key aims of this book is to establish the importance of individualising treatment planning and dental care.

There are many reasons why appropriate treatment planning is important – for example, the avoidance of unnecessary treatment such as repeat general anaesthetics or endodontic treatment on a tooth with an unrestorable crown, the facilitation of future interventions, such as retaining roots to maintain alveolar bone, and reduction in stress for operators and patients. It is particularly important with young patients to set easily achievable targets for each visit and for the overall treatment plan. The overall aims of a course of treatment may be very different from those for an adult patient.

First Visit – First Impressions

We are all aware that first impressions can be lasting ones. It is very important that any child’s introduction to dentistry leaves as favourable an impression as possible. This is one of the many reasons why it is so helpful if children begin attending when they have no immediate treatment need. A child who first attends in pain and who may require operative treatment at that visit will have a very different first impression from one who attends symptom-free and only requires a dental examination. For an overview of the approach for a child presenting in pain see Chapter 5.

It is usually beneficial to give children a morning appointment. Although parents may be resistant to this, preferring appointments after school, many young children are tired and hungry at this time of day, and their behaviour is affected accordingly. Seeing young children in the morning, when you are both relatively fresh, is usually more productive.

Wherever possible the practice environment should be child-friendly. Bright decorations, good lighting, simple toys or games in the waiting area go a long way to making a positive first impression. All appointments run late from time to time, but ideally children, in particular anxious ones, should not be kept waiting. If waiting is unavoidable, toys, storybooks and appropriate videos will help to make the wait more pleasant (Fig 1-2).

Dental practices are very busy places, and it is commonplace for the dentist to stay in the surgery for most of the session and have the dental nurse go to the waiting room to escort the patients to the surgery. This is usually acceptable for adult patients, and those who are very familiar with, and relaxed in, the dental environment. For new, young patients it is much less intimidating if the dentist greets the child in the waiting room, with an accompanying adult close at hand, and then escorts the child into the surgery. Remember that eye contact is very important, in particular at a first meeting. It may be necessary to bend down, or even kneel, to make good eye contact with a small child. Communication involves words (verbal), tone and actions (non-verbal). With children, the verbal component is the least important.

Parent in or out of the Surgery: the Treatment Triangle

Whether or not to have parents in the dental surgery during treatment of their child is an issue most dentists feel quite strongly about. Some advocate always having parents present, others would say never. In reality, it is probably inappropriate to have a hard and fast rule. It is well documented that separation anxiety begins to develop in children around the age of eight or nine months, usually peaks around two to three years of age and for most has dwindled again by the age of five. It would seem reasonable, therefore, to have children accompanied by their parent or carer until the age of three or four, and to make individual decisions about accompaniment from then on (Fig 1-3). A self-confident four-year-old who knows the dentist well will happily sit for a check-up on his or her own. An anxious five-year-old, new to the practice, who needs a first local anaesthetic should, however, have a parent present, provided that the parent has a positive effect on the child’s behaviour.

It is helpful to establish with the parent that his or her role is to provide support for the child, not to become a communication barrier between the dentist and the patient. An outline of the pros and cons of having parents in the surgery is given in Table 1-1. More detail is given in another volume in this series, Child Taming (see recommended reading).

The Child is Part of the Family

Before any treatment plan can be drafted, the process of information-gathering must be completed. This can begin even before the first visit, as many children will be part of families already attending the practice. Thus knowledge of the family’s attitude towards dentistry and dental treatment, together with the family history of dental needs, provides a useful base for treatment planning.

Ideally young children should be regular dental attenders as part of family visits from the time of tooth eruption. In reality many children do not attend for dental care until the age of three or four, or until they are experiencing symptoms. Later in this chapter some examples of treatment plans for different age groups are given by way of suggestions for the possible structuring of a series of appointments.

Information Gathering

There are varying opinions regarding the degree of formality appropriate between the dentist and the patient: where children are concerned, it is usually helpful to be informal and to proceed on first-name terms. There are no hard and fast rules, however, and there is scope for individual preferences. Once introductions are complete and the child has been escorted into the surgery, the information-gathering process can begin. It is all too easy to assume that an accompanying adult is the child’s parent but, in fact, members of the extended family, child-minders, even neighbours often bring children to the dentist. It is therefore important to always ask the specific question ‘Are you the mother/father?’ to preclude misunderstandings. Some children will immediately climb up into the dental chair, but others are hesitant and need more time to become confident. It is helpful to establish a rapport around a subject of relevance and interest to each individual child. A few moments discussing non-dental topics, such as siblings, school or nursery, favourite toys, TV programmes, special holidays or birthdays can provide a wealth of information for both immediate and future use. Making a brief note of special interests on the record card comes in handy at the six-month recall.