Many dentists do not see or treat preschoolers and infants for various reasons, from being uncomfortable to lacking the essential experience. All these factors result in pediatric patients being a neglected population. If you do not feel comfortable treating this population, do not neglect these patients, but refer them to a practitioner who will be able to treat them. If you have an interest in treating young patients, signup to good continuing education courses on how to deal with this population of patients. It is not professional to send patients away without appropriate treatment, and just monitor the decay and tell them to come back when they are older or when they are more co-operative.
First and most importantly, we are treating children, not teeth. When treating preschoolers, we must take into consideration not only dental disease but the age and disposition of the child. Not just from a compliance point of view, but also from a dental development point of view as well. Something to contemplate in a compliance point of view, will you be able to successfully carry out the restorative or surgical procedure in a safe and effective manner? From a developmental point of view, what will be the long-term consequences of your treatment, or lack of treatment, on the developing jaws and dentition?
Although newborns and infants can have dental concerns, that is rare occurrence. A good age to do your first initial exam is about 18 months of age. At this age, most teeth have erupted or will erupt soon. Pathologies may start to manifest themselves. Two types of parents will present themselves for early dental evaluation at this age. The first type of parent notices an anomaly, such as discoloration of teeth, that the teeth are not erupting, the child is not eating well, or the child is experiencing pain. It is important to note that a child may be in pain but is not able to verbalize it. When we think of pain, we think of acute pain that can keep parents up at night. There might also be chronic pain that manifests itself by change in eating habits, and/or crankiness. Thus, there are concerns that need to be addressed. The second type of parent is being proactive and wants the best dental care for their child but has no concerns. They want an intraoral examination to confirm that everything is normal, with an absence of pathology. In addition, they are interested in dental education on how to best avoid dental caries and maintain good oral health. Unless a child has ECC (early childhood caries) or hypoplastic teeth, dental caries are quite rare in most kids 18-60 months of age.
In the case of ECC and hypoplastic teeth, dental intervention might be necessary. ECC can be rampant, and spreads very quickly, so it needs to be addressed as soon as possible. First an explanation of the cause, which may include night feeding by bottle or on demand breastfeeding. In these cases, it is important for these feeding habits to stop immediately, giving the child only water at night. The child can be fed before falling asleep. Treatment of EEC will need to be carried out, most likely utilizing a general anaesthetic (GA).
The age, development, and weight of child should be considered before treatment is carried out. Very young patients are best treated in a hospital setting. General anaesthetics carried out in a dental operatory should be reserved for older children.
Another dental problem that requires prompt attention is hypoplastic and hypocalcified teeth. Teeth that are hypoplastic/hypocalcified can range in colour from mild, cloudy white spots to yellow or to orange colour in more severe cases. Severe cases can exhibit a loss of enamel. These teeth are highly cavity prone, and the decay will appear early and spread quickly. If the tooth is not yet decayed, an extensive hygiene program can prevent this decay from starting and progressing even long-term. Once decay has started, restorations need to be done ASAP. Many of these teeth will require a full coverage crown. If restorations are not required, the child will need to enrol in an extensive oral hygiene program. The program should be set up to meet the needs of the child. An early introduction of dental fluoride and more frequent dental exams will benefit the child. As this decay spreads quickly, a 3-month check-up and fluoride program is initiated until the family shows good oral hygiene practices.
If dental decay is present, a decision needs to be made whether to restore or monitor the decay. If treatment is required, adjunctive sedative or anaesthetic services is most commonly required. Be aware that oral sedation is not always effective and may take from 30-60 minutes to reach effective levels. The child will still be conscious and may need to be restrained. A deep oral sedation is problematic because the medication is not easily titrated to exact levels and can lead to overdose levels that would require emergency intervention. An IV sedation or GA should be administered by a separate doctor, not the treating surgeon. For very young children, sedations and GA should be carried out in a hospital or hospital-like setting. Even when in full compliance to all safety protocols, things can go wrong quickly. A good team is required to carry procedures out safely.
The biggest problem I have seen over my 40 years of practicing pediatric dentistry is that some dentists do not treat extensive decay and choose to monitor the caries because the child is not complaining.
However, the child most likely has chronic dental discomfort and periodic pain but cannot verbalize it until it becomes acute. Many times, I have had to calm parents down and defend the dentist, who did not provide care and did not refer the patient in a timely fashion. A second major concern is not giving the parents a full list of options and alternative treatments, including the consequences of each. In many cases, dentists recommend extractions in circumstances where the teeth can be restored, keeping full function and aesthetics intact. The early extractions of incisors or molars can have long-term detrimental effects on the developing jaws and dentition.
Treating infants and preschoolers requires a good team, which you as the dentist are the head of. A good team consists of trained people to assist you to take care of your patients.
- A good dental assistant is invaluable to help calm the child, and monitor physical and dental behaviour
- Dental hygienist to instruct and implement your preventive program
- Anaesthesiologists who are experts in sedation to help us in making our patients comfortable
- Pediatricians or family doctors
- Pediatric dentist
There are only a limited number of pediatric dentists available, and many rural areas have no access to pediatric dentists. In fact, 95% of pediatric dental work is carried out by general dentists. If you have concerns regarding your pediatric patients, reach out to a pediatric dentist for assistance. The internet is full of information that may be inappropriate, so ask your friendly pediatric confrere for advice. In the end, we treat children, not teeth.
About the Author
Dr. Jack Maltz is a Pediatric Dentist providing dental care to children in Brampton for over 40 years. Dr. Maltz is the former head of the OSPD and Head of the Brampton Civic Hospital Department of Dentistry.
