Illustrated Pediatric Dentistry - Part 2

Orofacial swelling is clinically a common problem found in pediatric dental patients. The causes of these swellings are mostly diverse, and the knowledge about specific clinical as well as imaging manifestations along with the most affected sites of these swelling is needed for the formulation of a differential diagnosis. Mid-facial nonprogressive swelling is usually suggestive of a congenital defect (like a cephalocele, nasal glioma, epidermoid cyst or nasal dermoid). Swelling that is slowly progressive, may be indicative of a neurofibroma, hemangioma, vascular malformation, lymph angioma, pseudocyst or fibrous dysplasia. In cases of facial swellings that are rapidly progressive and associated with cranial nerve deficits, rhabdomyosarcoma, Ewing sarcoma, Langerhans cell histiocytosis, metastatic neuroblastoma and osteogenic sarcoma should also be included in the differential diagnosis. 

The oral examination of the pediatric patients involves detailed evaluation and assessment along with comprehensive history taking. The pediatric history involves prenatal history, birth history, past medical history, past dental history, and family history. The examination part includes a general examination, extra oral examination and intra oral examination. The pediatric examination specifically includes dental caries, eruption pattern, shedding pattern, type of dentition, occlusion, supernumerary teeth, missing teeth etc. Various new diagnostic modalities have been introduced in the pediatric oral examination for both the hard tissues and soft tissues. Early diagnosis is mandated for precise treatment and proper prognosis for any disease which can be achieved by thorough examination through conventional and modern diagnostic techniques.

Dental radiology occupies a pivotal role in pediatric dentistry and acts as an aid in the diagnosis of oral health and disease states. It is used in conjunction with clinical examination for the final diagnosis. It includes the intraoral radiograph, extra-oral radiograph, and specialized radiographs like Cone Beam Computed Tomography (CBCT), computed tomography (CT) etc. The Intra Oral Periapical Radiograph (IOPA) and orthopantomogram (OPG) are commonly used in the dental setting owing to the low exposure and broad coverage of the areas. Radiation protection includes many entities, which must be provided for both the patient and the accompanying person. The radiographic requirements differ for neonates, children, and adolescents. This chapter emphasizes the importance of dental radiology in pediatric dentistry and the various aspects of radiology from the perspective of the pediatric population

Cephalometrics, introduced by BROADBENT in the year 1931, plays a crucial role in Pedodontics and Dentofacial Orthopaedics. It has made it easier and economical to predict the post-orthodontic results of the patient using this as a tool. This chapter outlines the basics of cephalometrics, including the indications, limitations, etc., with special emphasis on its role in Pediatric Dentistry. It lays down the recent guidelines given by the American Academy of Pediatric Dentistry for using cephalometrics in children. It provides details regarding various tools, equipment required, and methodology of tracing as well as analysing the cephalometric radiographs. It also enlists the skeletal and dental landmarks and planes needed for the analysis. Details regarding Down’s, Steiner’s, Tweed’s, and Wit’s analyses have been explained in this chapter. With the new era of digitalization, this chapter also highlights the recent advances made in Cephalometrics, providing information about the different computer-based programs and smartphone applications available for efficient landmark identification and analysis. The fundamental essence of the chapter is to help both undergraduate and even post-graduate pediatric students to have the basic knowledge and information about Cephalometrics, including its advancements made.

Centres for disease control and prevention (CDC) has developed a framework for healthcare personnel and healthcare systems for the delivery of nonemergent care. Infection control is important in dentistry because patient saliva may be contaminated with oral commensal and opportunistic pathogens. In addition, it can harbour specific pathogens during infection as well as during the carrier state, including SARS-CoV-2. Due to the nature of the dental procedures, exposure to the blood and saliva aerosols is unavoidable. Direct contact with fluid-contaminated environmental surfaces, instruments and equipment is also a potential source of pathogen transmission. In a dental practice, the dentist, dental assistant, instrument processing and administration staff, as well as the patients, are at risk of transmission of infections. Dental laboratory staff members are also at risk due to the cross-contamination between the clinic and the laboratory. In addition, it can be extended to their families if the infection control measures are not taken correctly. Therefore, historically step by step infection control measures have been recommended by the CDC and countries across the globe have drawn up individual country-specific guidelines.

Isolation of the operating field is a fundamental aspect of pediatric dentistry. The complexity of the oral environment presents many obstacles to performing dental treatment procedures. To minimize them, proper isolation is required to control the operating field as well as provide safe and quality treatment [1]. A rubber dam is considered the optimum isolation technique due to several advantages, such as providing an aseptic environment, minimizing the potential risk of transferring infective microbes between the operator and the patient, and preventing any ingestion or aspiration of dental instruments during a dental procedure [2]. Children may feel that the treatment takes place outside of their mouth. Nevertheless, children indeed tolerate longer treatments once the rubber dam has been applied. Other techniques such as cotton rolls and saliva ejectors are routinely used in paediatric dentistry besides rubber dams due to their ease of usage.

Deciduous teeth play a significant role in the normal development of occlusion, as a guide for the eruption of permanent successors. Early loss of deciduous teeth in the primary and mixed dentition stage alters the integrity of dental arches and is one of the main causes of malocclusion in permanent dentition. Management of space created by early loss of the deciduous tooth is important to prevent or intercept malocclusion, either by eliminating the need for orthodontic correction in future or to reduce the complexity of correction in permanent dentition. Hence, the role of paediatric dentistry is immense in space management as a part of managing developing dentition and occlusion in comprehensive oral health care of children. 

A habit is a repetitive action that is being done automatically and is resistant to change. In the infantile period, certain repetitive behaviours are common, the majority of them begin and stop spontaneously. If oral habits persist beyond a particular developmental age, it results in unfavourable outcomes for the developing teeth, occlusion and surrounding orofacial tissues. Oral habits are considered one of the main causes of malocclusion, leading to unfavourable growth and development of dentoalveolar, which starts in the early childhood and mixed dentition stage. The severity of malocclusion depends on the frequency, duration, and intensity of the habit. Early detection and interception of the habit should be done by parent/child habit awareness and counselling, elimination, etiology, behaviour modifications and correction of malocclusion.

Guidance of eruption and development of primary, mixed, and permanent dentition has a pivotal role in comprehensive oral healthcare in paediatric dentistry, which helps to achieve more stable, functionally, and aesthetically acceptable permanent dentition. Interceptive orthodontics includes procedures carried out in mixed dentition, and it takes advantage of the growth pattern and development during this phase. Early diagnosis and treatment of certain malocclusions will eliminate or reduce the severity of developing malocclusion, which would lessen the complexity of orthodontic treatment in the future, overall time, and cost. It also improves the child’s self-esteem, confidence, and parental satisfaction. Overall clinical examination, radiographic evaluation, and study model analysis with thorough knowledge of growth and development help in diagnosing and carrying out appropriate interceptive treatments necessary.

Pediatric population experiences a wide array of gingival and periodontal diseases. Studies have shown that gingivitis is almost universally prevalent among pediatric patients. However, lesser attention is given to periodontitis in children owing to the shorter life span of primary dentition. Periodontal assessment must be incorporated into the routine oral examination of the child since prompt diagnosis plays a crucial role in successfully managing periodontal conditions. Severe periodontal disease may also occur among children with concomitant systemic conditions. Therefore, the presence of a destructive periodontal condition may serve as an early indicator of an underlying systemic condition, and the dentist may be the first to notice such a condition. Hence, a thorough medical evaluation should be performed for children exhibiting severe periodontitis, especially for cases that appear resistant to therapy, to determine the systemic causes of the condition. Although at present, there is increased awareness regarding periodontal health and treatment modalities, it is restricted to adults with a negligible focus on children. Intraoral assessment of children is cecentredroundan examination of hard tissues with minimal focus on the health of soft tissue. Hence, this chapter enlightens various gingival and periodontal conditions and the importance of overall health during childhood. 

Infant oral care is the foundation on which motivation and education for oral hygiene and various preventive dental care must be relied upon to augment the possibility of a life free of preventable dental ailments. Dental assessments and evaluations for children during their first year of life have been recommended by various organizations such as the American Academy of Paediatric Dentistry and the American Association of Paediatrics. A comprehensive infant oral health care program may include risk assessments at regular dental visits. Preventive approaches include topical fluoride application, sealants, parental education on the correct methods to clean the infant’s mouth and establishing a dental home. Infant oral health is an integral part of the general well-being of an infant as they grow. It encompasses the care of the oral cavity and monitoring of the teeth’ development. Unfortunately, many expecting mothers, parents and caregivers of infants often do not receive timely and accurate education about preventive oral and dental health care. This chapter discusses the importance of infant oral health care and its clinical implications. The transition required to maintain oral health as an infant progress to early childhood is highlighted. Appropriate use of topical and systemic fluoride providing timely and appropriate oral hygiene instructions is encouraged and discussed.

The chapter describes various dental materials commonly used in Pediatric dental practice. Making an informed choice of the restorative material to be used in different clinical conditions is essential to ensure a successful and satisfactory restorative outcome. Knowledge of dental materials with their unique set of advantages and applications is an important determinant in the formulation of a treatment plan. Dental materials used for pulp therapies and full coverage restorations in primary teeth are exhaustive in their scope and as such, have been dealt with in depth in separate chapters.

Minimally invasive treatment of dental caries is an approach that uses conservative management strategies focusing on maximum preservation of tooth structure. Unlike the principles enumerated by GV Black, which advocated maximal excavation of carious tooth structure, Minimal Invasive Dentistry (MID) conserves as much tooth structure as possible and provides a conducive environment for the affected tooth tissue to self-heal. This chapter enumerates the various modalities of Minimal Intervention Dentistry or Minimally Invasive Dentistry (MID) and discusses Atraumatic Restorative treatment (ART) in detail. 

Developmental defects of enamel a commonly encountered condition in both primary and permanent teeth enamel. Ameloblasts being highly specialized cells are highly sensitive to a host of environmental factors. As a result, a large number of factors can cause hypomineralization. Of the various hypoplastic and hypomineralization defects affecting the enamel, this chapter focuses on a distinct condition of hypomineralization involving mainly the molar and incisor teeth. 

Restorative procedures involving primary teeth constitute a major segment of clinical pediatric dentistry. Anatomic and histological differences between primary and permanent dentitions necessitate modifications of cavity preparation in primary teeth. Cavities must also be prepared keeping in mind the needs for newer restorative materials currently in use. Meticulously adhering to the principles of cavity preparation is essential for the longevity of restoration.