Pediatric Dentistry: Dentistry for Children

Feb 5, 2018

The special psychological challenges and often peculiar conditions presented by children require the need for their own dental specialty: pediatric dentistry. While general dentists perform most types of pediatric dentistry, a pediatric dentist is required for treating some conditions.

While children and adults share many of the same potential dental conditions, the development and eventual loss of primary (baby) teeth present their own unique challenges.

These challenges, in addition to increased fear of health practitioners, often require extra effort and specialist training to handle efficiently.

Early childhood experiences of dentistry can have a lifelong impact of their attitude to dental health and associated practitioners. Therefore, a proper introduction to oral health and hygiene is important for all children, so that they maintain appropriate hygiene habits throughout their lives. A child should be introduced to dentistry as early as possible – between 6 and 12 months is ideal – and should be closely observed every 6 months thereafter.

What You Feel or See: Symptoms, signs or conditions related to pediatric dentistry

  1. Holes in Primary Teeth

Holes in a child’s primary (baby) teeth typically indicate dental caries (tooth decay). These holes may be discolored (gray, black, yellow, brown, chalky). As primary teeth do not have as much enamel on them as adult teeth, the decaying process can be rapid. When holes caused by dental caries are found early, they can often be treated with standard fillings to extend their life, often for many years until they are replaced by adult teeth. Dental caries that have progressed into the dental pulp (nerve) of a primary tooth will require a pulpotomy (endodontic removal of the pulp).

If the hole is large and exposing the dental pulp, then a stainless steel crown (cap) may be required for back teeth, or a tooth-colored crown for front teeth for additional strength of the affected tooth or teeth. Alternative methods include:

  • Silver amalgam fillings
  • Tooth-colored fillings
  • Stainless steel crowns
  • Tooth-colored crowns
  • Extraction of the tooth and placement of a space maintainer
  • Pulpotomy and placement of a crown

 

  1. Permanent tooth will not erupt

Once the primary teeth have exfoliated (come out), the permanent adult teeth should begin to erupt within only days or weeks. Many conditions may cause permanent teeth to be slow to erupt, such as:

  • Trauma causing primary teeth to be lost prematurely
  • Abnormal positioning of either primary or unerupted permanent teeth
  • Lack of formation or presence of permanent teeth

 

Teeth that are slow to erupt are rarely a cause for concern, but occasionally may indicate a problem. You should seek professional advice if you feel there is an issue. Alternatives include:

  • Wait to see if the tooth or teeth finally erupt
  • Radiographic (x-ray) observation to see if there is a problem and wait for eruption
  • Assisted eruption – a dentist can encourage the tooth to erupt by making an incision in the gum tissue
  • Assisted eruption combined with orthodontic treatment to aid the tooth in erupting in the correct position

 

  1. Dark-colored Primary Teeth

It is not unusual for children to suffer a blow to their teeth, and it’s also common for a parent to not know about it. In some cases, a tooth may become dark, indicating damage to the dental pulp (nerve). The tooth darkens because of degenerative pigments in the blood supply to the dental pulp. The affected tooth may or may not be painful. The following options are usually available:

  • The discolored tooth may remain in the mouth if it is not causing pain.
  • Perform a pulpotomy (remove a part of the nerve) or pulpectomy (remove all of the nerve) and bleach the tooth to return to a near-normal color.
  • Extract the tooth and place a space maintainer.

 

  1. Primary (or Permanent) Tooth is Accidentally Forced Into the Gums and Bone

A tooth (primary or permanent) may be accidentally pushed into the gum tissue and underlying bone. In children only a few years old, this situation may damage the the developing permanent tooth beneath. If a child is older, the underlying developing permanent tooth may not be injured, depending on which tooth is involved. If a permanent tooth does become injured in this way, the extent of the damage cannot usually be fully assessed until the tooth erupts. A severely fractured primary tooth would require extraction. Alternatives include:

  • Allow the tooth to remain intruded and reposition itself over time. Teeth that have suffered only minimal displacement often adapt well to this option.
  • Have a dentist reposition and stabilize the tooth back to its original position.
  • Remove the tooth if it has suffered a severe fracture beneath the gum line, or if the root has fractured into two or more loose pieces. This option requires the use of a space maintainer.

 

  1. Infant/Child Has Several Decayed Teeth

This condition, which often affects the front teeth, is commonly known as baby bottle syndrome or bottle mouth syndrome. It is caused by allowing an infant to suck a bottle of any substance containing sugar for extended periods – often hours at a time. Affected primary teeth can be decayed moderately or severely, and usually require one of the following options to treat:

  • Silver amalgam fillings
  • Tooth-colored fillings
  • Stainless steel crowns
  • Tooth-colored crowns
  • Extraction of the tooth and placement of a space maintainer
  • Pulpotomy and placement of a crown

 

  1. Open Bite (Lower and Upper Front Teeth Do Not Meet)

Many early childhood habits such as thumb, finger, or other object sucking, or placing the tongue between the teeth when swallowing can lead to an open bite. Treatment options include:

  • Choose to do nothing and allow the condition to remain.
  • Eliminate the problem-causing habit, allowing the teeth to gradually reposition.
  • Have a dentist-build appliance placed that discourages or prevents the habit.
  • Orthodontic repositioning of the affected teeth, and elimination of the habit.

 

  1. Cleft Palate and/or Lip

Cleft lips or palate are birth defects that are caused by transfer of genetics from parent to child. Correction of this condition is usually highly successful, and often involves a team comprised of an oral surgeon; plastic surgeon; prosthodontist; ear, nose, and throat surgeon; psychologist; speech therapist, and sometimes others.

  1. Gums Puffy, Red, and Bleed Easily

This problem can be caused by many different conditions. Mouth breathing, where a child breathes primarily through their mouth rather than their nose can cause red gums. This condition is usually caused by a child’s inability to breath sufficiently through their nose, requiring the attention of an ear, nose, and throat specialist. Certain medications can also cause the gums to become red, puffy, and irritated. If these symptoms indicate periodontal (gum) disease, then the same options for adults are available to children.

  1. Child Sucks Finger or Thumb

Almost all children suck their thumb or fingers during infancy, and some continue after their permanent teeth have begun to erupt, usually at around 6 years old. While little or no damage to teeth from finger sucking is observed at an early age, continuation of this habit after the permanent teeth erupt can cause an open or incorrect bite. The resulting malocclusion (poor bite) should be corrected, and the habit eliminated. Alternatives include:

  • Allow the child to continue to suck their thumbs or fingers – this habit often eventually stops before damage occurs.
  • Reward and encourage the child to stop the habit.
  • Have your dentist create and place an appliance designed to prevent or reduce finger sucking.

 

  1. Crooked Teeth

Teeth can develop improperly for a variety of reasons, and can often be corrected at an early stage through interceptive orthodontic treatment, or full orthodontic therapy if the child has developed their permanent teeth.

  1. Child is Mentally or Physically Handicapped, or Requires Oral Therapy and is Unwilling to Permit Examination

Most pediatric dentists, along with many general dentists, are able to provide care for children who may be handicapped in some way, or present behavioral challenges. In-office sedation can usually be applied if necessary, however, healthy children often visit a hospital’s same-day general anesthetic facility to receive oral therapy while unconscious. In cases where a child is debilitated, unhealthy, or has some forms of birth defect, some procedures may require an overnight hospital stay. Most cases of oral therapy that take place away from a dental practice often incur significant additional costs to the child’s family.

  1. Bruxism

Teeth grinding and/or jaw clenching is a common condition many children experience. The noise can often be so great that it keeps other family members awake during the night. Enamel can quickly wear away from grinding teeth that have food between, and can cause the tooth chewing areas to grind flat. Irregular tooth spacing often occurs in children from around age 6, when the primary (baby) teeth begin to be replaced with permanent teeth. This stage, known as mixed dentition, is when many children stop grinding their teeth. Those that don’t stop often find they require bruxism therapy in later life. If a child doesn’t cease bruxing during the mixed dentition stage, they should receive bruxism therapy as soon as possible, as continued teeth grinding can cause often irreparable damage if left untreated for many years.

  1. Teeth are Unusually Shaped

Certain diseases and genetic abnormalities can cause primary teeth to develop unusually, such as teeth that are pointed, too small or large for the child’s head, or two teeth fusing together. In many cases, placing bonding or crowns can correct these conditions, although bonding is often the more preferable treatment for primary teeth.

  1. Some Teeth Did Not Erupt or Form

It is not unusual for some children’s teeth to not form or erupt, and this condition is often hereditary. A common treatment is to place a space maintainer to improve the appearance until the child matures, when it is hoped the permanent teeth all erupt. If full eruption does not occur, then options include placing implants, or fixed or removable prosthesis.

  1. Primary Teeth Are Discolored

There are many conditions that can cause teeth to discolor, and these can be hereditary, environmental, or both. Colors can range from yellow-orange-brown to blue-gray. While superficial stains can be removed quickly and easily, internal stains and discolorations typically cannot be removed through means such as bleaching. However, deep internal stains may be covered with a veneer or crown.

  1. Small, Dark Pits or Grooves on the Tooth’s Chewing Surface

The substance of the tooth doesn’t always completely form when the tops of the back teeth form. While these chewing surfaces always have a ‘rough’ appearance, improperly formed molars and premolars that have grooves or pits can collect and retain food debris. To prevent caries (decay) from developing, these pits should be sealed using a dental sealant as soon as they are detected.

What your pediatric or general dentist can do

While children share many of the same dental conditions and available treatments with adults, there are also several conditions that are experienced by children only. The following forms of treatment are typically only applied to children:

Pulpotomy – Removing a Portion of the Dental Pulp (Nerve)

Primary teeth respond relatively well to having a portion of the dental pulp removed when necessary, whereas permanent teeth do not. This procedure is performed by making a hole in the top of the tooth into the pulp, removing an amount of the dental pulp, then sealing the hole and placing a restoration (filling) in, or a crown on the tooth.

Advantages of pulpotomy

The affected tooth is able to remain fully functional in the mouth.

Disadvantages of pulpotomy

A crown is often required to be placed on the tooth after a pulpotomy to retain strength. The cost can be moderate if a steel crown is used, and high if it is made from gold alloy or ceramic.

Risks of pulpotomy

A pulpotomy can occasionally fail which requires extraction of the tooth, but this risk is low.

Alternatives to pulpotomy

Other options include removing the tooth and a space maintainer put in its place until the underlying permanent tooth erupts, a pulpectomy (removing all of the dental pulp) or endodontic  (root canal) therapy.

Cost of pulpotomy

Although a moderate fee for a pulpotomy and crown should be expected, the cost is usually lower than removing the tooth and placing a space maintainer.

Result of Nontreatment

The infection of the dental pulp will continue to cause pain in the tooth, and extraction will eventually be required.

Pulpectomy & Endodontic Therapy

Pulpectomy and endodontic treatment are not commonly performed therapies in pediatric dentistry as they are typically less successful than performing a pulpotomy.

Advantages of pulpectomy & endodontic therapy

The tooth remains functional.

Disadvantages of pulpectomy & endodontic therapy

This type of treatment, which usually requires placement of a crown for additional strength, usually incurs a moderate cost.

Risks of pulpectomy & endodontic therapy

The procedure may occasionally fail, which normally results in the need for removing the affected tooth.

Alternatives to pulpectomy & endodontic treatment

Other available options include pulpotomy, or extracting the affected tooth and placing a space maintainer.

Cost of pulpectomy & endodontic treatment

The cost of this form of treatment and placing a crown necessary for strength is usually similar to, or more than that cost of tooth extraction and placement of a space maintainer.

Result of Nontreatment

In most cases, the infection will continue to cause pain and extraction will eventually become necessary.

Stainless Steel Crowns

In cases where a primary (baby) tooth would benefit from a crown for strength and support, stainless steel is a popular option due to its relatively low cost compared to other materials. However, other materials may be favorable if appearance is likely to be an issue, such as for front teeth.

Advantages of stainless steel crowns

Stainless steel crowns are strong, reliable, relatively inexpensive, and can be placed easily by dentists.

Disadvantages of stainless steel crowns

Crowns made of stainless steel have a very obviously metallic appearance to them, much similar to polished silver. They do not usually last as long as other custom-made crowns, and are usually used for restoring primary back teeth which are eventually replaced by permanent teeth. As stainless steel crowns often contain chrome and nickel, they are not suitable for children with allergies or sensitivity to these materials.

Risks of stainless steel crowns

Although very infrequently, stainless steel crowns can sometimes come off the tooth and be swallowed. Dental caries (decay) may also form around the crown.

Alternatives to stainless steel crowns

Crowns made of other materials such as silver alloy, or even tooth-colored material are sometimes available at a lower cost, but are not usually as strong as stainless steel.

Cost of stainless steel crowns

Due to the necessary skill and time investment required for placing stainless steel crowns, the cost is usually moderate.

Results of Nontreatment

Untreated carious (decayed) teeth will eventually need to be removed, as the decay will destroy the affected tooth. If a stainless steel crown was recommended for strengthening or supporting a tooth, then the tooth will fracture or disintegrate further and will need to be removed.

Extracting a Diseased Primary Tooth

As the primary teeth are a specific shape and size, the space resulting from a removed tooth is filled by the remaining teeth which affects the development and eruption of the permanent teeth. This often leads to poor occlusion (dental bite) and an unsightly appearance.

Advantages of extracting a diseased primary tooth

The main advantage is that the infection is removed and the pain is soon gone.

Disadvantages of extracting a diseased primary tooth

The resulting space is filled by the remaining primary (baby) teeth, which causes problems for the underlying permanent tooth to erupt. This issue can be avoided by placing a space maintainer to prevent the remaining primary teeth from filling the gap.

Risks of extracting a diseased primary tooth

Only the typical risks associated with surgical procedures are involved.

Alternatives to extracting a diseased primary tooth

Other available options include removing a small part of the infected dental pulp (pulpotomy) or all of the pulp (pulpectomy) and endodontics, followed by the placement of a crown.

Cost of extracting a diseased primary tooth

The cost of extracting the tooth is relatively low, but the necessary space maintainer is moderately expensive.

Result of Nontreatment

The affected tooth will continue to cause pain, and the infection will eventually lead to loss of the tooth.

Surgically Stimulated Eruption

If a tooth is slow to erupt (come into the mouth), making a small incision in the overlying gum or bone can assist the eruption of the tooth.

Advantages of surgically stimulated eruption

The slow-to-erupt tooth comes into the mouth much faster.

Disadvantages of surgically stimulated eruption

Slight discomfort is experienced and minimal costs are involved.

Risks of surgically stimulated eruption

While minimal, typical anesthetic and surgical risks are present.

Alternatives to surgically stimulated eruption

Waiting to see if the tooth eventually erupts unassisted is the only alternative option. Radiographic (x-ray) observation can confirm whether or not this will happen.

Cost of surgically stimulated eruption

The cost of this type if treatment is usually minimal.

Result of Nontreatment

The unerupted tooth will enter the mouth much more slowly.

Surgically Stimulated Eruption and Orthodontics

If a radiograph (x-ray) shows that an unerupted tooth is positioned in such a way that will prevent it from erupting naturally, then surgically assisting the tooth to erupt followed by orthodontic repositioning will be required.

Advantages of surgically stimulated eruption and orthodontics

The poorly positioned tooth will be able to enter the mouth and function normally.

Disadvantages of surgically stimulated eruption and orthodontics

There is a great investment of time, money, and effort required, and some discomfort may be experienced.

Risks of surgically stimulated eruption and orthodontics

Along with normal surgical risks, there is the possibility that the dental pulp (nerve) becomes damaged, requiring endodontic (root canal) treatment.

Alternatives to surgically stimulated eruption and orthodontics

The unerupted tooth may left in place and might not ever erupt, or eventually erupt in an improper location, or the tooth may be extracted.

Cost of surgically stimulated eruption and orthodontics

Depending on how complex the case is, treatment costs can be moderate to high.

Result of Nontreatment

Choosing to forego treatment will result in an unsightly smile, and some other form of therapy will be required to fill the gap of the unerupted tooth.

Tooth Stabilization

It’s not unusual for children to suffer a blow to their teeth. If such trauma causes a tooth or teeth to become injured or loose, then a splint or other means of reinforcement will be required to stabilize the affected teeth.

Advantages of tooth stabilization

The affected teeth are unable to move while the underlying supporting bone is healing. Healing usually occurs at a faster and more predictable rate.

Disadvantages of tooth stabilization

Wires or other splinting material may be shown for several weeks. There is also a moderate cost involved.

Risks of tooth stabilization

A splint may break away from the treated tooth, requiring replacement of the splint.

Alternatives to tooth stabilization

The affected tooth may be allowed to stabilize itself by avoiding chewing or otherwise avoiding putting pressure on the tooth.

Cost of tooth stabilization

There is a moderate cost involved in type of treatment.

Results of Nontreatment

Although an untreated tooth may stabilize itself, it can occasionally heal in an undesirable location which would require orthodontic therapy. A splint ensures healing takes place more predictably.

Space Maintainers

A space maintainer is any dental appliance or device used to temporarily fill the gap created by a missing primary tooth, allowing adequate space for the underlying permanent tooth to erupt properly. There are similar devices available for reducing tongue thrust which can affect occlusion (dental bite), or for directing jaw growth for certain needs.

Advantages of space maintainers

Adequate space is maintained for the underlying permanent tooth to erupt, allowing normal appearance and function.

Disadvantages of space maintainers

A fixed or removable device must remain in the mouth until the underlying permanent tooth erupts, which could be several years. Appliances may need to be adjusted or remade as the child grows.

Risks of space maintainers

A space maintainer may be accidentally broken, lost, or swallowed by the patient.

Alternatives to space maintainers

The space from a missing tooth may be left to remain. However, this will lead to collapse of the bite and and continued unsightly appearance.

Cost of space maintainers

A moderate cost is involved in this type of treatment.

Results of Nontreatment

Teeth adjacent to the space will usually move to fill the gap, leading to reduced function and eventually requiring orthodontic therapy.

As one of the current seven dental specialist areas, pediatric dentistry not only includes all areas of dentistry that apply to adults, but also specializes in the unique and often peculiar challenges presented by primary (baby) teeth in developing children. Perhaps the most significant difference between pediatric dentistry and other dental specializations is that pediatric dentists must understand and apply certain psychological principles when treating children, and for preventing long-lasting, often lifelong traumatic dental experiences.

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About the Author:

Dr Aust is married to Mrs Dr Aust and has two children and a dog Max. You can read more here.

He is sharing his expertise with you. Download 5 Things I Learned After Treating Over 10,000 Patients from here.