Pediatric Dentistry for the General Practitioners

Abstract

The American Dental Association and the American Academy of Pediatric Dentistry recommend establishment of a dental home by a child’s first birthday. However, many children’s first encounter with a dentist is when they are 3–4 years and older at a general practitioner’s office, where their parents visit. During the child’s first visit, it is important for the general dentist to build a positive first impression of the dental profession. In this chapter, we will discuss tooth development and eruption, behavioral guidance techniques including pharmacological consideration in pediatric patients, preventive and restorative, common pediatric dental emergencies, orthodontic considerations, clinical pearls, and when to refer to a pediatric specialist.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Tooth Development and Eruption

A very important task a general dentist faces when meeting a pediatric patient for the first time and during subsequent periodic visits is to evaluate the child’s eruption pattern as well as identify any delayed, ectopic eruption or disrupted eruption sequence. The eruption charts are provided by American Dental Association to use as a general guideline. However, individual variances exist, and it is important for a general dentist to look for symmetry (Tables 16.1 and 16.2).

Table 16.1 Primary teeth eruption table

Table 16.2 Permanent teeth eruption table (AAPD 2014a, b, c, d, e, f)

Some general trends of eruption include: (AAPD 2014a)

• “Rule of 4’s” for primary teeth eruption: four teeth erupt every 4 months beginning with four teeth at age 7 months.

• The eruption of teeth usually occurs symmetrically in each arch.

• There may be ethnic and gender variations with respect to eruption times, e.g., African American children and girls may generally experience earlier eruption times.

• Variation of 6 months of either side of the usual eruption age may be considered normal for a given child.

• Mandibular teeth occur before the maxilla, except permanent premolars.

• Formation of all permanent teeth begins between birth and 2.5 years.

• Look for missing teeth, supernumerary teeth, submerged teeth (ankyloses), and malformed teeth. Inform parents and treatment plan for the future.

• Be aware that children with certain medical conditions such as Down’s syndrome or cleft lip and palate may experience generalized delayed eruption of teeth.

2 Behavioral Management Consideration

2.1 First Meeting with the Dentist

For most general dentists, especially the recent graduate, the idea of treating children can create a certain level of stress and anxiety. Although most practitioners may have received some didactic training during their dental school experience with regards to principles of tooth eruption, space maintenance, and management of children, their clinical experience is limited. This often creates a feeling of intimidation when asked to provide dental care to the pediatric population. The best way for young practitioners to gain experience in working with children is to be open minded and being familiar with AAPD policies and guidelines. In addition, reaching out to local pediatric dental faculty could be an additional resource when faced with particularly challenging cases.

A general dentist has one chance to create a good first impression of dentistry to a child (Fig. 16.1). The success of this interaction usually determines the outcomes of subsequent dental visits. For example, children can sense if their dentist is uncomfortable and this may inadvertently create mistrust between the child and the dentist. Depending on the age and cognitive development of the child, this distrust can manifest in the form of a refusal to cooperate, crying, and an adverse behavioral pattern, even with the simplest procedures. The authors recommend that the new practitioner review the AAPD policy guidelines on behavioral modification techniques. This can be accessed on ISSN: http://www.aapd.org/media/policies_guidelines/g_behavguide.pdf (Accessed on March 30, 2016).

Fig. 16.1

For younger children, the use of puppets is a helpful tool for many reasons (Photo courtesy of Dr. Khiem Truong)

Be confident when you speak to kids and remember that you are the adult and authority figure at that appointment. It is important to understand that not all children are the same nor will they behave the same. Greet them in a friendly manner and asses what type of child is sitting in your dental chair. Also try to engage the parents early to enquire about their child’s past dental experience. Some practitioners categorize children by the level of fear and their response to fear.

2.2 Types of Children (Casamassimo et al. 2013)

• 1. The fearless child. This is a happy and confident child. They are open to strangers and are willing to try anything once. These children typically have some dental exposure or good coaching/examples from parental figures. These children usually trust the dentist, and it is important to recognize and respect this trust so as not to break it.

• 2. The cautious child. This child may or may not have had any dental exposure. They are not quick to warm up to strangers. The cautious child will participate in treatment but may need some coaching from the parent. Tell-show-do works extremely well with these children. These children can be reasoned with and can easily be behaviorally managed.

• 3. The fearful child. These children may not seem afraid at first when talking to them and even act “macho” but may scream in terror at the sight of an exam mirror. They may have had a bad past dental experience or fearful parents who have reinforced bad behaviors in the chair. It is very important to educate the parent that their dental experience is not indicative of their child’s experience. When performing treatments, several behavioral techniques may need to be adopted. Chemical anxiolytics such as nitrous oxide gas or benzodiazepines may also need to be considered.

• 4. The scared-out-of-their-mind child. A completely terrified child. These children are very difficult or impossible to be reasoned with. They do not want to try anything new and do not trust anyone. These children may have had one or a few bad encounters with the dentist. Their parental figures may be also terrified of the dentist and impose this fear on the child. It is recommended to refer these children to pediatric dentist for sedation or more advanced behavioral modification modalities.

2.3 Kids’ Language

When speaking with children about impending dental treatment, a general dentist should be careful to use language that creates a positive mind-set. The dentist must gauge the child’s cognition and use “kids-friendly” words to convey their “dental” message in order to build and maintain trust. Depending on the age of the child, using words like needle, shot, drill, pull, or yank teeth or any other word that suggest unpleasantness and invoke fear must be avoided. Here are some suggestions (Table 16.3).

Table 16.3 Substituting dental terms for “kids’ language”

2.4 Tell-Show-Do

This behavior-shaping tool is well accepted and very popular with children and adult patients (Fig. 16.2).

Fig. 16.2

The dentist demonstrating the prophylaxis cup on the child’s finger before using it to clean his teeth

• Tell – The dentist informs the child in age-appropriate terms what is going to happen.

• Show –This is then followed by demonstrating to the child, in a nonthreatening way either on themselves, the parent, or the child.

• Do – Then without deviating from the demonstration, continue with the procedure that is to be performed.

2.5 Desensitization

This is considered an expansion of the Tell-Show-Do technique. Here stimuli with the least anxiety are presented first. Higher anxiety evokers are presented as the child is able to tolerate them, e.g., using a prophylaxis cup before using a high speed handpiece (Fig. 16.3).

Fig. 16.3

The dentist begins by using the mirror while the young child sits on her mother’s lap before proceeding to do a toothbrush cleaning using a lap exam

2.6 Positive Reinforcement

This is a technique used to reward desirable positive behavior by praising the child or providing a reward and this further strengthens the recurrence of such behavior in future. Many dental offices have small prizes to give to pediatric patients at the end of the visit such as stickers and simple toys. Other social reenforcers include positive voice modulation, e.g., being “goofy,” facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team.

2.7 Distraction

This is a technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure or sensation by focusing their thoughts on something other than what is being done. Examples include asking patient to wiggle his or her toes during impression taking; giggle the cheeks during local anesthetic injection; and giving patient storytelling, animated voices, or even a short break during a stressful procedure.

2.8 Modeling

This technique is very effective in families that have two or more children. A younger, inexperienced, or apprehensive child learns to stay calm and how to act properly by watching an older sibling or someone they look up to (Fig. 16.4),

Fig. 16.4

While the older sibling receives treatment, her younger brother holds her hand and watches on. This process usually reassures the younger sibling that there is nothing to fear

2.9 Voice Control

Here, the dentist uses a controlled alteration of voice volume, tone, or pace to influence and direct the child’s behavior. It may be uncomfortable for new dentists since it is not learned in dental school. It takes time and experience to develop; the facial expression is as important as voice, and it is important to explain this technique to parents beforehand to prevent misunderstanding the dentist or assistants for being “mean” to their child.

2.10 Parental Presence or Absence

There must be a discussion and agreement between the dentist and parent before the child sits in the chair. Parents of children >3 years that come into the operatory must be prepared to leave if/when child shows undesirable behavior. Generally children under 36–40 months do better with parents present. The behavior and attitude of a parent can be directly related to a good or a bad dental visit for their child. Children can sense their parents’ fear and parents can unintentionally transfer fear to their child by their body language or nonverbal cues. It cannot be perceived by either the parent or child as punitive. Sometimes, a dentist can use parents as leverage to obtain appropriate behavior response. First, explain the procedure to the parents separately. During the procedure, if the child shows negative or undesirable behavior, the parents are asked to leave the operatory immediately. Once the child’s behavior improves, the parents can return to the room.

3 Pharmacologic Considerations

Please always refer to a dental drug reference guide for the proper dosage to give your pediatric patients. There are numerous sources online that offer up-to-date dosages and precautions. One example is http://www.epocrates.com/marketing/products/rx/index.html.

3.1 Fluoride

Using fluoride for the prevention and control of dental caries is proven to be both safe and effective when dosed appropriately (AAPD 2014b). The frequency of fluoride exposure from various sources should be identified when formulating a dental plan for the patient. Fluoride sources could include water, dietary supplements, mouth rinses, and toothpaste. Prior to prescribing supplemental fluoride to any child, initial testing of the drinking water should be performed. A caries risk assessment is also essential in order for proper parental counseling to reduce the child’s caries risk (See Chap. 3 Caries Prevention) (Table 16.4, Fig. 16.5).

Table 16.4 Dietary fluoride supplementation schedule (AAPD 2014a, b, c, d, e, f)

Fig. 16.5

Commercially available fluoride comes in various “child-friendly” packages

3.1.1 Topical Fluoride

Topical fluoride application is available via professionally applied topical fluoride treatment, over-the-counter rinses for home use, prescription rinses and gels for home use, and fluoride-containing toothpastes. Over-the-counter fluoride mouth rinses are not recommended for preschool-aged children. Toothpaste usage should be always supervised by parents in young children. American Academy of Pediatric Dentistry recommends for children under 3 years old a smear or rice-size amount of fluoridated toothpaste twice a day. A small amount of toothpaste equal to the size of a pea should be wiped onto the toothbrush by the caretaker for children between ages 3–6 years old twice a day. Caution should be taken by the parents and prescribing dentists to not create fluoride overdose during critical periods of enamel formation and fluorosis (AAPD 2014a, b, c, d, e, f).

3.2 Local Analgesics

Dosage of local anesthetic in pediatric patients should be measure by the child’s body weight. Children do not have fully developed livers which slow down metabolism of certain anesthetics. Use caution in the amount of anesthetic you give and never exceed the maximum total dosage based on the child’s weight (Table 16.5).

Table 16.5 Local anesthetic efficacious dosage for pediatrics (AAPD 2015b)

To calculate the maximum amount of lidocaine 2 % with 1:100,000 epinephrine and the number of cartridges that can be safely administered to a 30-lb patient, perform the calculations below (AAPD 2015a, b):

• Maximum dosage (mg/lbs) × patients weight (lbs) = Maximum total dosage (mg) 2.0 × 30 = 60 mgs

• Maximum total dosage (mg) ÷ mg/cartidge = Maximum # cartridges 60 ÷ 36 = 1.67 cartridges

Clinical tips in administering local anesthesia (LA):

• Consider having an assistant place his/hers arms lightly across the child’s chest or hold their hands during the injection to protect the child from reaching up and grabbing the syringe.

• Use a bite block or a mouth prop during LA administration to prevent the child from suddenly closing their mouth; this is sometimes a reflex reaction to the LA “stab.”

• Use distraction techniques, like wiggling the cheek or lip when giving local anesthesia.

• For upper infiltration, insert a 30-gauge needle 1 mm or less into the tissue and very slowly infiltrate a quarter of a carpule. Wait a couple seconds and then proceed with normal injection protocol to give the rest of the carpule.

• After buccal anesthesia is achieved, you may give buccal intrapapillary injection numbing the palatal through the buccal. This is due to the porous nature of the maxilla. Then give normal palatal injection. This procedure may take longer but is a good way to reduce discomfort and introduce kids to dental procedures.

• Remember that pain is how you feel and a child in pain is an uncooperative child so it is important to try and achieve profound anesthesia as much as possible. Always test your LA subjectively by asking child if the area feels “heavy, weird, different, or swollen” compared to the contralateral side. Remember most children may not know what numb means especially if this is their first LA experience. You can also test LA objectively by using an explorer to gently touch the mucosa around the tooth and watch for signs of pain such as “wincing, raised, or hunched shoulders, withdrawal from injection site”. You can also ask the child to raise their hand, as a stop sign if they feel a sharp pain (Fig. 16.6).

  Fig. 16.6

  

  Local anesthesia should not be a problem in older well-behaved children

3.3 Postoperative Pain Control in Pediatric Patients

Pain management in children requires careful consideration. Anxiety also reduces the pain threshold so the dentist must take care to perform a behavioral evaluation ahead of time so as to plan for pain as well as anxiety management. If at all possible, it should be done by planning preoperative strategies to control and minimize physical and mental trauma to the child. A careful review of a patient’s medical history is necessary to identify allergies and contraindications to prescribed analgesics (Table 16.6).

Table 16.6 Dosage for pediatric pain management (Mosby 2014)

3.4 Common Antibiotics for Odontogenic Infection in Children

Following careful examination of the patient and determination that the infection is bacterial in nature, consideration of antibiotic prescription can be considered. A careful review of the medical history is also necessary to avoid contraindications. The most common side effects of antibiotics include mild diarrhea, abdominal pain, nausea, and vomiting. In teenage patients, precautions should be given to patients that antibiotics can affect effectiveness of oral contraceptives (Table 16.7).

Table 16.7 Antibiotic dosage (AAPD 2014a, b, c, d, e, f; Wynn et al. 2015)

3.5 Nitrous Oxide (Laughing Gas)

A general dentist needs to be certified by an institution after receiving proper education and clinical training hours prior to administering nitrous oxide in his or her own practice (Fig. 16.7).

Fig. 16.7

Nitrous oxide patients should be attended to by the provider and an assistant to monitor the patient through the whole procedure

Characteristics of nitrous oxide:

• 1. Reduces or eliminates anxiety, promotes analgesia, and potentiates the effects of sedatives

• 2. Reduces the gag reflex but not the cough reflex

• 3. Minimal or nonexistent toxicity when used on healthy patients properly

• 4. Highly insoluble in blood and water; therefore quick absorption and elimination

• 5. Mostly (99 %) eliminated from the body through the lungs without significant biotransformation, which makes it have minimal effect on other organ systems

• 6. Not metabolized through the liver

• 7. Reduces untoward movement and reaction to dental treatment

• 8. Enhances communication and patient cooperation. More effective when used in conjunction with hypnotic suggestions and other simple behavioral modification techniques

• 9. Raises the patient’s pain reaction threshold

• 10. Increases tolerance for longer appointments

Nitrous oxide is not indicated for every pediatric patient. The key to a successful dental appointment with the help of nitrous oxide lies in dentist’s patient selection. Here are the types of patients who could benefit from nitrous oxide:

• 1. The fearful and anxious, yet cooperative patients

• 2. Patients with a strong gag reflex

• 3. Patient who is fearful of specific procedures, such as the “shot” or the drill

• 4. A cooperative child undergoing a lengthy dental procedure

Nitrous oxide will not help in treatment with these types of children by a general dentist without other sedative measures:

• 1. Chronologically immature child

• 2. The cognitively impaired child

  The success and effectiveness of nitrous oxide is largely dependent on psychological reassurance. This can only be accomplished if the patient has the ability to understand verbal communication.

• 3. Defiant child

  This is the child that behaves poorly for dental treatment, not because of excessive fear or anxiety or a physical or mental disability, but because he or she just doesn’t want to. A general dentist should attempt behavior modification techniques or refer the child to a pediatric specialist.

3.5.1 Contraindications

• Absolute: Pregnancy (may cause spontaneous abortion in chronic exposure especially in the first trimester of pregnancy), otitis media, congenital pulmonary blebs, sinus blockage, bowel obstruction, nasal obstruction, cystic fibrosis, and COPD.

• Relative: URI, extreme phobias, hysterical behavior to dentistry, and patients with a previous bad experience with nitrous oxide and children who have no respect for authority, do not follow instructions, or are naturally defiant must be assessed with caution.

• Note: Nitrous oxide is not contraindicated in patients with asthma. It is nonirritating to the mucous membranes, and since anxiety can trigger an asthmatic episode, nitrous oxide usage can reduce the possibility of an attack in the dental chair.

3.5.2 Nitrous Oxide Dosage (AAPD 2013)

• Low = 33 % N₂O (children) – 2 L/min N₂O to 4 L/min O₂.

• Medium = 50 % N₂O (most adults, max children) – 3 L/min N₂O to 3 L/min O₂.

• High = 62.5 % N₂O (some adults) – 5 L/min N₂O to 3 L/min O₂.

• Maximum = 70 % – 7 L/min N₂O to 3 L/min O₂.

• Oxygen must always keep flowing at the rate of at least 3 L/min.

3.5.3 Delivery Protocol (AAPD 2013)

• 1. Give verbal instruction to the patient. Describe to child floating sensation (will be flying like Superman or Batman) and they may feel warm and tingly (ants are climbing on them).

• 2. Place monitors: pulse oximeter and BP cuff if available.

• 3. Turn on 5 L/min oxygen (100 %) before placing the mask on the patient.

• 4. Place mask on patient – ensure snug fit (no breeze in eyes).

• 5. Adjust scavenging system valve to green zone.

• 6. Two delivery methods:

  • (a) The standard titration process begins by decreasing the oxygen flow and increasing the nitrous oxide flow to obtain a concentration of 20 % nitrous oxide and 80 % oxygen. Then slowly increasing N₂O and decreasing O₂ until desired level is reached.

  • (b) Rapid titration (useful for nervous patients) administration is initiated with a 50 % oxygen/50 % nitrous oxide concentration prior to seating of the nasal hood.

• 7. When finishing procedure, turn off the nitrous and leave the patient on 100 % oxygen for 5 min.

• 8. The dentist must remember to document the amount and rate of nitrous oxide administered during the procedure along with the 100 % at the end of treatment.

3.5.4 Clinical Tips (Rappaport et al. 2011)

• 1. Nitrous too low: no effect.

• 2. Nitrous too high: oppression, unpleasant, nausea, sleepiness, sweating.

• 3. Quick onset in 2–3 min.

• 4. Total flow = 5–6 L/min = respiratory minute ventilation = tidal volume x respiratory rate = 500 mL × 12.

• 5. Fluctuating amounts during treatment may result in nausea and vomiting.

4 Treatment Considerations

4.1 Medical History: The Exam and Caries Risk Assessment

Before performing a clinical exam, a dentist should discuss past and present medical history with the parents and the children. Review any medical conditions and medications the child may be taking. If the medical history is too complicated for your practice, consult with the patient’s pediatrician or refer to a pediatric dentist. The general must know their limitations with respect to treating or managing medically compromised children in their office.

The actual exam is a great way for the dentist to access a child’s behavior and level of anxiety as well as gauge whether a child can be treated successfully with simple behavioral management techniques or requires sedation. A child’s caries risk assessment should be completed in order to determine the customized plan for the patient’s needs. There are many forms online that can be utilized such as those on the American Dental Association site: http://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.ashx.

4.2 Sealants

Sealants play a very important role in preventive dentistry and have proven to reduce the occurrence of pit and fissure caries. Prior to treatment planning for sealants, a general dentist needs to perform a thorough caries risk assessment. Sealants should be placed based upon the patient’s caries risk, and not the age or time elapsed since tooth eruption (AAPD 2014a, b, c, d, e, f).

Once treatment is planned, the key to clinical success is isolation. Rubber dam placement is highly recommended. The current sealant material of choice is resin based. Sealant placement method should include cleaning of the pits and fissures with pumice and without removal of any appreciable enamel. In some circumstances, preventive resin restoration (PRR) is indicated, where the dentist cleans out the pits and grooves with a small bur. The dentist needs to monitor existing sealants for incipient lesion progression and sealant retention.

Important Tip

When sealing mandibular permanent molar, it is important to seal the occlusal as well as buccal surfaces, whereas for the maxillary molars, the lingual surface must be sealed in addition to the occlusal surface.

4.3 Restorations Consideration in Primary Teeth (Casamassimo et al. 2013)

In primary teeth, considerations of the anatomical characteristics should be taken to ensure the success of restorations.

• 1. Mesiodistal dimension of a primary molar crown is greater than the cervico-occlusal dimension.

• 2. Buccal and lingual surfaces converge toward the occlusal.

• 3. Enamel and dentin are thinner.

• 4. The pulp chambers of primary teeth are proportionally larger and closer to the surface.

• 5. Primary teeth contacts are broader and flatter.

• 6. Shorter clinical crown height.

4.3.1 Composite Restorations

Composite is recommended for primary teeth in pit-and-fissure caries, class II lesions that the preparations do not extend beyond the proximal line angles, and class III, IV, and V lesions. Avoid using composite as the material of choice when:

• 1. Isolation is a problem.

• 2. Carious lesions involve multiple surfaces.

• 3. High-risk patients present with extensive rampant decay or with poor oral hygiene.

4.3.2 Amalgam Restorations

Amalgam is recommended for primary teeth in class I lesions, class II lesions where the preparation does not extend beyond the proximal line angles, and class V lesions.

In primary molars, 3-surfaced amalgam restorations can be placed, although full coverage with a stainless steel crown may be a better treatment option.

4.4 Pulp Therapies (Table 16.8)

Table 16.8 A summary of pulp therapy in primary teeth (AAPD 2014a, b, c, d, e, f)

Generally, stainless steel crowns (SSCs) are recommended for primary teeth having received pulp therapy. However, in a tooth with conservative pulpal access, intact walls, and less than 2 years to exfoliation, amalgam or resin restorations can also be considered.

4.5 Stainless Steel Crowns (SSCs)

Most of the general dentists’ offices do not routinely use stainless steel crowns. If your office is located in a relatively remote or rural area, or the nearest pediatric dentist is far away, you should consider stocking up stainless steel crowns in the office. It is the standard of care with many indications for use in pediatric patients. If a general dentist cannot provide stainless steel crowns, the patient should be referred to a pediatric specialist.

4.5.1 Indications for SSC (Casamassimo et al. 2013):

• 1. Following a pulpotomy or pulpectomy

• 2. Teeth with developmental defects such as molar incisor hypomineralization (MIH), dentinogenesis, or amelogenesis imperfecta

• 3. Extensive carious lesions, with multiple surfaces where an amalgam restoration is likely to fail.

• 4. Fractured teeth

• 5. Extensive tooth surface loss due to attrition, abrasion, or erosion

• 6. Children with high caries risk and rampant decay

• 7. Primary molars in children under 4 years old

5 Pediatric Emergencies

The most common pediatric dental emergencies involve:

• Odontogenic infections (OIs)

• Facial cellulitis from odontogenic infections

• Dental and facial trauma to the primary or permanent teeth

• Loose teeth

• Bleeding or pain following extractions

A general dentist should strive to provide emergency treatment as needed, stabilize the condition, and refer to related specialists as soon as possible.

5.1 Assess the Emergency

For emergency patients, a quick yet thorough soft and hard tissue exam followed by an extraoral and intraoral exam. Take periapical radiographs to evaluate dental damage, such as fracture of the crown or root. Take a panoramic radiograph to rule out possible alveolar, condylar, and jaw fractures. Look for subjects that may be dislodged inside the soft tissue of the lip or cheeks, such as pieces of a tooth, orthodontic brackets and wire, and foreign objects (Tables 16.9 and 16.10).

Table 16.9 Types of injuries to teeth (Diangelis et al 2012)

Table 16.10 Management of avulsed permanent teeth (Andreasen et al. 2012; Lambert 2015)

6 Pediatric Pearls

• Do not plan for more procedures in one visit than you or the child can handle. With deep sedation, a pediatric dentist may be able to do eight stainless steel crowns and pulpotomies in one visit. With only behavioral management or nitrous sedation, a general dentist may be able to do only one or two fillings in one setting. Keep in mind of children’s low pain tolerance and short attention span.

• Always warn children not to bite the “numb” check or lips post anesthetics.

• Teach parents to start flossing their children’s teeth around age 3–4, when contacts start to develop between the primary teeth.

• Bruxing is common and perfectly normal in the primary dentition.

7 Miscellaneous Pediatric/Orthodontic Considerations

The American Association of Orthodontists recommends that every child should first visit an orthodontist no later than age 7. Although comprehensive orthodontic treatment does not start at age 7, interceptive treatment may be appropriate in children with specific problems, such as anterior crossbite, posterior crossbite, open bite, ectopic eruption, complete skeletal Class III, and oral habits.

A general dentist is often the first dental professional to see a patient and first to recognize that the patient may have an orthodontic problem. It is important to refer to the orthodontist in a timely manner, so the most appropriate treatment can be produced at the most appropriate time. From age 6 and older, there are a few different types of treatment approaches an orthodontist can provide: space maintainers, orthodontic appliances, guiding general dentists for serial extractions, and phase I or full orthodontic treatment.

7.1 Common Space Maintainers

Space maintainers are known by many parents are “spacers.” They are generally indicated in early loss of primary teeth, prior to ½–2/3 of root formation of the succedaneous teeth. In some children, space maintainers need to stay for 2 years or more. Therefore, it is important for the general dentist to perform periodic checkups on the health of the banded teeth and oral hygiene (Tables 16.11 and 16.12).

Table 16.11 Space maintainers and their indications

Table 16.12 Correctional orthodontic appliances (Proffit et al. 2012; AAPD 2014a, b, c, d, e, f)

7.2 Common Orthodontic Appliances

Many orthodontic appliances can be used with or without braces to facilitate habit cessation, correct functional shift, and deliver minor orthodontic correction.

7.3 Extraction Under Orthodontic Guidance

After a child has seen an orthodontist for a consultation, sometimes the orthodontist will refer the patient back to the general dentist for extraction of primary or permanent teeth. Early extraction of primary teeth can lead to arch length deficiency, midline shifting, and impaction of permanent teeth. Extraction of carious permanent teeth can lead to shifting of the rest of the permanent teeth and not enough space available for future tooth replacement.

Serial extraction is a planned extraction of specific primary teeth and permanent teeth in a timely manner due to foreseen crowding. If done at the right time, serial extraction can facilitate eruption, prevent canine impaction, and reduce the complexity of future orthodontic treatment (Proffit et al. 2012).

7.4 Phase I Orthodontic Treatment

Phase I orthodontic treatment is also limited treatment, designed with specific goals to correct early skeletal discrepancies and functional occlusion shift and provide early esthetic corrections. Most children who received phase I orthodontic treatment eventually end up choosing to go through phase II treatment for esthetic concerns.

7.5 Full Orthodontic Treatment (Proffit et al. 2012)

The average time for a simple full orthodontic treatment is between 18 and 24 months. During this time, it is important for the general dentist and orthodontist to maintain frequent conversation about patient’s oral hygiene and restorative needs. The general dentist should be actively involved in the orthodontic treatment planning when there is restorative needs post orthodontic treatment such as build up for peg lateral incisors, veneers/crowns for transposed teeth, flippers, or Maryland bridges for missing teeth.

7.6 Orthodontic Myths Among General Dentists (Proffit et al. 2012)

• A child is too young to get braces until he or she has all permanent teeth. Endlessly waiting for all permanent teeth to erupt prior having an orthodontic consultation can lead to missing the golden timing for interceptive or phase I treatment. Growth modification in hope to guide skeletal development sometimes needs to start at the transitional dentition age, in order to catch the peak of growth.

• Wisdom teeth need to be extracted prior to start of braces. Teeth will shift and get crocked again when wisdom teeth come in. Many research studies have shown that late mandibular incisor crowding is multifactorial. Relapse after orthodontic treatment happens to anyone at anytime, regardless of whether wisdom teeth were extracted. Just like the rest of human body, teeth and occlusion are constantly evolving as we mature. The key to prevent relapse is excellent retainer wear.

• All cavities need to be filled prior to an orthodontic consultation. Orthodontic treatment should not be started without a patient first completing all restorations and has a good oral hygiene. However, a general dentist should recognize a child’s orthodontic needs and refer for consultation prior to starting extensive restorations, noting that sometimes posterior permanent teeth can be extracted instead of filled.

8 When to Refer to a Pediatric Dentist

Being the first professional for many children, the general dentists have an important responsibility to build the best first impression possible for the generations to come. The dentists should always keep the patients’ best interests in mind. The bottom line is “Do no harm.” If you cannot provide the best care or feel uncomfortable treating a child, refer. Build the best first impression of dental professionals. Here are a few examples when you should refer.

• 1. Unmanageable children and/or their parents, after several attempts of behavioral management.

• 2. The patient has extensive needs that may be better treated under sedation or general anesthetic, i.e., rampant decay.

• 3. The office is not equipped with the armamentarium needed for the procedures, i.e., SSCs and nitrous oxide.

• 4. Developmentally or physically disabled patients who the dentist cannot communicate well with.

• 5. The dentist and/or the staff do not have the kids’ friendly personality and patience. It is ok to admit that you are not good with children. That is why we have the specialists. Instead of putting the children and yourself through the suffering, please refer them to someone who will give them a much better experience and care that they deserve.