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Child Friendly Dentistry - NZ Dental & Oral Health Therapists

1. Looe Plaque biofilm after Marsh with apologies to The Fantastic Voyage DE Sealing in caries techniques such as the Hall Technique manipulate the plaque s environment by sealing it into the tooth separating it from the substrates essentially nutrition it would normally receive from the oral environment There is a possibility that the plaque may continue to receive some nutrition from perfusion through the dentinal tubules However there is good evidence that if caries is effectively sealed from the oral environment the bacterial profile in the caries changes significantly to a less cariogenic community and the lesion does not progress What about the soft dentinal lesion It is easy to see how an enamel lesion can be reversed but it can be difficult to imagine how we can influence a change in the soft dentinal lesion However most clinicians will be familiar with this clinical picture Perhaps because the cavity has become self cleansing or the child s diet has changed the caries has arrested with the colour changing to dark brown or black This lesion was once soft and active and is now hard and arrested The evidence that caries can arrest is visible to us on a daily basis yet we continue to provide management therapies conventional restorative treatment based on its complete excision Arrested caries on primary molars the caries is dark and feels hard The key point for clinicians is that this all poin
2. If a dental abscess then antibiotics may have to be prescribed Ensure the parents provide adequate oral analgesia for their child an oral suspension of paracetamol is usually very effective for most paediatric dental pain Arrange a follow up appointment and pursue this if not kept Prevention Look after the living let the dead take care of themselves John It is important that Prevention comes before Caries management If it is anticipated the prevention will take some time then a part of that programme can be placing dressings in the more vulnerable carious teeth a process known as stabilisation However a really effective preventive programme will significantly slow down or even arrest carious lesions without dressings being placed The permanent teeth most vulnerable to dental caries are the first and second molars It must be an oral health care priority to prevent caries affecting either the pits amp fissures or the proximal surfaces of these teeth and if it does occur to identify it early and manage appropriately Further information on this and other aspects of managing permanent molar teeth is in the section on Prevention Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 52 Planned treatment Caries management The following are just general guidelines for no one approach will suit every clinician every parent carer every child or every carious tooth in that child e
3. onto the line Where the lines intersect insert the needle horizontally so as to pass between the teeth on either side Advance the needle 1 2 mm and gently inject a drop or two of LA solution Ensure the needle remains in the correct plane so as to neither obstruct on the interseptal bone nor emerge into the interdental col Advance another 1 2 mm and inject another drop of LA solution Continue to do this while observing the palatal aspect of the mucosa in your mirror After blanching is seen withdraw the needle and insert it into the blanched area on the palatal side The child will not feel this and the needle may then be advanced further apically if necessary until complete anaesthesia is achieved Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 87 Overview of dental caries It has been taught for many years that plaque sugar susceptible tooth surface caries If it was a simple as this then there would be far more dental caries to manage than there in reality is Plaque is ubiquitous in the mouth sugars are ubiquitous in the diet and there are not many tooth surfaces that are completely immune from dental caries as can be noted in extreme cases of dental caries So where is all the caries The explanation is that not all plaque is cariogenic All plaque is potentially cariogenic but it requires an extremely protected sheltered environment for it to mature to the complex biofilm
4. truly consent to those interventions and who have almost no capacity to accept responsibility for their own oral health Overview e Assessment of attitudes of parents principal carers who are they have they accepted responsibility e Assessment of attitudes of Oral Health Care Team can you prioritise prevention accept the child s outcome measures may differ from your own accept the need for assessment forms amp checklists in clinical care avoid being judgemental e Assessment of child s oral health needs see from age 1 year apply a risk based approach for pain sepsis when assessing need for caries management in primary teeth A gt B C gt D o O ie Apply the Fantastic Four to the highest possible standard e Toothbrushing use Motivational Interviewing techniques and Action Planning allow at least as much surgery time as for a large restoration e Fissure sealants place monitor and maintain with just the same care as for a restoration new fissure caries is not an option e Diet advice use the 24 hour recall diary e Fluoride varnish apply when indicated by a caries risk assessment e Nothing about me without me Involve the child in all decision making While the child is important the parents carers are key in implementing oral health advice and bringing their child for care try to meet their goals for treatment as well as your own be pr
5. A Affirmations identifying Use brushing Making them smile R Reflective listening specific times charts and or respond positively S Summarising and specific reinforce at to you Stage 2 people who recall visits You use to ensure you are amp are will be Open questions perceived as empathic then involved with Avoid judgement you brushing Follow their Stage 3 communication style develop discrepancy to assess the need rolling with resistance and to determine Stage4 adults responsible until the parent carer for care then verbalise the changes they need to make when you support them in their choice 2 Education amp Motivation The information e Adult paste lt 3 years smear of 1000ppmF e Twice daily 3 6 years pea size 1000ppmF e Spit not rinse years and over 1 450ppmF e supervised 2 Education amp Motivation Delivering the information to avoid losing empathy avoid giving advice directly preface with e Research shows e Some parents tell me 2 Education amp Motivation The materials e Disclosing solution e Mirror e Floss floss wand if child in mixed e Micro brush e Toothbrush dentition amp high caries risk 2 Education amp Motivation The technique with communication between you and parent carer following the guidance above 1 disclose 4 ask parent to brush other arch 2 ask parent about preference for 5 ask child to brush as well a brushing from in front or behind 6 demonstrat
6. e Spit don t rinse Children who spit out and don t rinse after brushing show an extra 10 reduction in caries experience compared with those who rinse their mouth out with water after brushing e Supervised Children under the age of 7 do not have the manual dexterity to clean their own teeth and must be helped by the parent amp principal carers Children older than 7 years will still need to be kept an eye on Notes to supplement lecture series given in Tasmania and New Z Making it happen As was covered in the section Changing behaviour simply telling the parent carer and child the above four points however enthusiastically is probably wasting your time and theirs There is good evidence that Information dumps simply giving patients a list of do s and dont s is ineffective Instead think of the process The four by four stages 1 Assessing 2 Educating amp motivating gt the need Having engaged by Stage 1 Use Eye contact O Open questions Make them smile A Affirmations R Reflective listening You use S Summarising Open questions Stage 2 Avoid judgement _ to be perceived as Follow their empathic then you communication Stage 3 style develop discrepancy to assess the need rolling with resistance and to determine Stage4 adults responsible until the parent carer verbalise the changes they need to make when you support them in their
7. managing the lesion with a prevention alone approach Caries risk assessment A caries risk assessment is an essential part of a comprehensive oral health assessment All children are at risk of developing caries in the future but for some the risk will be high while for others it will be moderate or low Assessing an individual child s caries risk will e Allow caries preventive interventions to be targeted at those who need them most e Aid selection of the optimum caries management technique for existing carious lesions Three easy to use evidence based factors which clearly predict future caries development and which all clinicians should use in their caries risk assessment are e Existing dental caries e Social deprivation Health workers intuition Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 39 Other factors related to increased caries risk which some clinicians might like to include in addition to those above are e Strep Mutans levels e Lactobacilli levels e Salivary buffering capacity e Parental amp sibling caries rates e Salivary flow rates A computer aided caries risk assessment tool Google Cariogram is available for free download It could be particularly useful as a patient and parent education tool Following this the clinician should assign a caries risk status to the child as either lower medium or higher risk of developing new caries and of existing disease
8. o Brushing advice amp Instruction For both of these use Motivational Interviewing o Dietary advice techniques and Action Planning O Fissure sealing Apply amp monitor with the same rigour as for restorations o Fluoride varnish e For permanent molars identify and manage early occlusal proximal lesions as a priority Caries management e Caries in the primary dentition should be actively managed to minimise the risk of pain abscess before exfoliation using a biological approach with the choice of treatment option based on a risk assessment for pain sepsis e If caries extending into dentine occurs in the permanent dentition then infected dentine should be removed minimising iatrogenic damage and a restoration placed If involving a fissure system then remaining unaffected fissures should be sealed Treatment provision and follow up e Make checklists an integral part of your practice e Audit your prevention and treatment strategies as a regular part of your practice Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 3 Child Friendly dentistry a family centred risk based approach to the prevention and management of adult dental disease in childhood A brief summary of the approach The premise underlying the approach The permanent dentition is for life while the primary dentition is transient and runs its course in patients who are limited in their ability to tolerate dental interventions and
9. worth taking a few minutes to look at just how important it is to involve them in this step which is often taken for granted Because we are so familiar with what we do it is easy to gloss over the treatment plan and not involve the child and parent carer in the discussion This section details what most clinicians do anyway but presents it in a very clear way The aim is for the child and their carer to be kept at the centre of the planned care by involving them in the formulation of the treatment plan It would be rare indeed that one single treatment plan would be derived and agreed upon by all clinicians who looked at a given child with a carious dentition This variation in treatment planning is the result of a complex process of decision making where many not always obvious factors are taken into account These include things such as health expectations payment systems previous experiences on all parts the ability of carers to bring the child for appointments perceived ability of the child to cope with invasive treatment whether the family believe they can influence their own health by changing their behaviours etc etc etc In order to reach a consensus treatment plan it is necessary that information is shared both ways e the parent carer and child share their expectations of treatment for example is the goal to remain pain free in as few appointments as possible or do aesthetics play an important part in the parent s pe
10. Clinicians are generally trained to diagnose whether caries is present or absent and the evidence is that even in this clinicians show poor reliability The biological approach requires clinicians to do something even more difficult diagnose whether caries is progressing over time and if so to identify it soon enough to apply a new management strategy before the patient is disadvantaged There is an increasing body of research supporting the use of a biological approach to managing caries in primary teeth in primary care with treatment provided by primary care clinicians Excluding irreversible pulpal involvement in primary teeth Before managing primary teeth with a restorative based biological caries management approach irreversible pulpal involvement of the tooth must be excluded A full history and clinical examination including bitewing radiography should be carried out Vitality testing of primary molars with Ethyl Chloride is unreliable Instead dentists should rely on their clinical acumen to assess the viability of a dental pulp based on a thorough assessment including Clinical signs or symptoms of irreversible pulpitis or dental abscess Radiographic signs or symptoms of dental abscess Non physiological mobility assessed by placing the points of a pair of tweezers in an occlusal fossa and gently rocking the tooth bucco lingually and comparing with a healthy antimere Obvious carious or clinical exposure of pulp
11. Invariably the you to rinse it away until the water stops coming parent carer the primary target out blue of this educational intervention will now be leaning forward to see the result indicating their engagment Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 67 Dialogue Teaching strategy Wow What do you think of that Peter Interaction Do you think that blue stuff has anything to do with you having the holes in your teeth we talked about earlier What do you think would get that blue stuff off Brushing Yes good boy that would certainly get it off if you brushed your teeth really well Now I d like to show you Peter how to brush your teeth clean would that be OK Yes Mrs McGregor do you prefer to brush Peter s teeth from in front of him Or from behind him Either is fine Baseline knowledge Oh from behind him usually And do you brush the outside top and inside of each corner of his mouth at a time before moving onto the next corner or do you do all the outsides Baseline all the way round then the tops then the insides knowledge Interaction A corner at a time usually OK ld like to show you a way of getting these teeth really clean can you see how I m keeping the brush in line with the teeth I m cleaning Can you see how I m using short little strokes to scrub the tops of the back b
12. Plan treatment to meet the following three goals Maximise the probability of the permanent dentition remaining caries free Minimise the risk of any carious primary teeth causing the child pain sepsis Minimise the risk of causing treatment induced anxiety e All interventions need to be provided within the child s ability to accept them and with their full consent e Following a risk assessment for pain sepsis consider which active lesions in primary teeth need to be managed soon and which might be left for a further course of treatment in a few months e Avoid the use of local anaesthesia dental handpieces and extractions until the child is able to manage them Taking a long view of oral health care and attitudes to it it may be better on occasion for a child to receive slightly compromised treatment in the early stages of attending for care for example managing fissure caries in a lower first permanent molar in a 7 year old with Fuji Triage postponing the IDB necessary to place a permanent restoration until the child is acclimatised to dental treatment Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 53 This section is draws extensively from an excellent short book Edited by Christoph Ramseier amp Jean Suvan Changing Health Behaviour in the Dental Practice Wiley 2010 and highly recommended for further reading Changing a parent carers behaviour regarding their child s ora
13. a Struggle at this age I know you are on your own at the moment and you ve a lot to do This will have been ascertained earlier in the first appointment see Communication What other mother s have said helps is to share the brushing allowing the child to brush the front teeth then letting you brush the back ones do you think that might work for you and Peter would that be OK with you Yes think we could try that eh Peter That would be great and it will really help you both to stop Peter getting so many holes Comments Open question Ambivalence she s indicating she s like to but can t This is completely normal and should not be misinterpreted as resistance to change Reflective listening Absolutely crucial to increase empathy at this stage and avoiding voicing judgement substituting it with affirmations where possible Using a Motivational Interviewing approach to guide the parent carer to voice the changes they need to make Emotive questioning Empathy Getting the parent carer to acknowledge a link between current practice and outcome developing discrepancy Listen to what the mother is telling you and respond to it above all resisting the righting reflex rolling with resistance and so increasing empathy Getting the information across without being authoritative and de personalising it other mothers rather than l suggest In
14. and assessing for change in caries risk They are also an extremely important adjunct to treatment planning for the child with dental caries Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 37 Agreed Lrealoent plan diagnosis amp findings with child amp parent carers OHA with history amp examination Y Agreed problem list Diagn r i LLL ll i osis amp The diagnosis of dental sepsis Dental sepsis chronic suppurating dental infection usually asympotmatic can be difficult to diagnose as the presentation can vary Sinuses are not always obvious but if present are usually located on the non attached mucosa adjacent to the attached mucosa A slight cleft or notch may also be noted in the adjacent gingival margin The following are indicators of established dental sepsis patient reported symptoms of dental infection swelling tenderness etc alveolar tenderness sinus or swelling inter radicular radiolucency tenderness to percussion in a non exfoliating tooth Pathological mobility compared with the healthy contralateral tooth when the tooth is gently rocked bucco lingually with the points of a pair of tweezers placed on the occlusal surface Alveolar inflammation that on gentle palpation Assessing for the increased non physiological releases infected material from a lower primary molar mobility often associated with sepsis It is n
15. and making new errors This is why the great majority of car accidents and air accidents are caused by human error see book The Naked Pilot for further information and if not intending flying again On a smaller scale consider how some clinicians are repeatedly amazed at the extent of a new carious lesion when they open into a suspicious fissure without stepping back for a minute and re evaluating their index of suspicion with regard to caries diagnosis There is evidence that significantly less clinical errors occur with Type 2 decision making Leitch but clinicians will only tend to adopt Type 2 thinking when presented with something significantly different from their experience To consciously change to the non default Type 2 decision making when carrying out an oral health assessment would require an almost superhuman effort of will by the clinician to maintain it for a treatment session Instead the mind must be tricked into Type 2 thinking and decision making and it s easy to do use a form or a checklist Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 49 The need for forms or checklists in oral health assessments Using a form or checklist forces a Type 2 approach to the information gathering part of the oral health assessment with two advantages e It reduces the risk of relevant information not being obtained due to the clinician forgetting to seek it and e by requiring t
16. as to whether there are other children in the family group and if so they should also be invited to attend Avoiding things the child doesn t like Working within the child s priorities and ability to cope has been covered in the section The Clinician Dental care often involves experiences that are totally outside a young child s familiar world cotton wool rolls in the mouth compressed air suction the sounds and sensations of handpieces local anaesthesia etc and it is a testament to a child s trust and fortitude that any of these can be used at all However with proper preparation see Managing behaviour the child can often be helped to cope with them Preparation is everything but if cooperation falters then the procedure must be stopped It is difficult to think of a scenario where continuing to work on a child who is crying can ever be acceptable Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 14 Children however young need to be managed with the same respect for their autonomy as would be given to an adult Using age appropriate language everything should be explained to them and their permission sought before beginning any procedure Children do not like being talked over they should be fully involved in any decisions about their care Things occasionally do not go well perhaps an injection was painful or some unpleasant taste was experienced In these situations a full explanation
17. at verbal and non verbal communication and we see fit healthy people who return on a regular basis The diagram shows how Motivational interviewing fits in when helping parent carers achieve a behaviour change in toothbrushing Nothing will be achieved unless you have already engaged with them before starting The stages in helping parent carers achieve a behaviour change in toothbrushing 1 Assessing the gt 2 Educating and Motivating gt 3 Action gt 4 Habituating need planning o supplement lecture series given in Tasmania and New Zealand 2010 2011 54 1 Assessing the need This is the process by which you determine whether there is an educational need and this will normally have been completed during the first appointment By using the communication techniques of open questions avoiding judgement and matching the parent carers communication style when obtaining this information you should have managed to maintain rapport and will not have alienated them It is fully described in the previous section Communication and in the Toothbrushing part of the following section Prevention 2 Educating and motivating Educating and motivating are considered together as they need to be delivered together for maximum effect Some degree of education will be required with most brushing and dietary interventions How this can be provided effectively following current accepted teaching strategies and without patronising or aliena
18. be checked for suitability the disadvantage is the hygiene issues with the brushes being caries in pockets etc e remember to demonstrate brushing from the side if there are erupting lower first and second permanent molars e Flossing advice Although the evidence linking flossing with a significant reduction in approximal caries in children is weak this may be a reflection of the study designs and further research is needed However with the Ecological Plaque Hypothesis now answering many previously unexplained questions about dental caries there would seem to be merit in asking parents to floss their children s teeth especially the DE6 contacts on alternate evenings immediately after brushing so that the paste is carried through the contact This is likely to be especially beneficial in higher caries risk children and those where radiographic examination reveals proximal enamel lesions Either floss or floss wands may be used as suits the parent carers preferences Notes to supplement lecture Series given in Tasmania and New EN 10 2011 70 e For higher caries risk children consider recommending the use of 1350 1500 ppm fluoride toothpaste for children over 3 years old e For higher caries risk children consider prescribing 2800 ppm fluoride toothpaste for children over 10 years old Step 3 amp 4 Action Planning and Habituation These have been covered in Changing behaviour but here is how they fit in
19. be considered to be used at a different time of day to toothbrushing Fluoride Varnish Application Technique Fluoride varnishes contain high concentrations of fluoride and it is important not to apply more than the manufacturer s recommendations For example for Duraphat varnish which contains 6 m MT 22 600 ppm fluoride the manufacturer s recommended dose for 9 children aged 2 5 years is 0 25 ml shown on the left of the picture and for 6 years and older is 0 4 ml shown on the right of the picture mT Approximal surfaces of primary teeth are particularly prone to caries Cmmi 2 3 40 Therefore it is particularly important to include these areas when applying varnish to tooth surfaces Isolate and thoroughly dry the teeth a quadrant at a time to optimise adhesion of the varnish to the tooth Apply a small amount of fluoride varnish to the buccal and then the lingual embrasure area using a small brush Advise that the child should eat soft food and should not brush their teeth for the rest of the day Notes to supplement lecture series given in Tasmania and New Zealand 2010 Successfully changing behaviour regarding a child s diet poses the same challenges to the oral health team as promoting good brushing practice The food parent carers provide for their children is at the core of parenting but there may be many factors impacting on their choices which are not always in the parent carers control The fact i
20. boosting self confidence Just reflect on the last time you said something nice to a parent carer not about their child or the child s outfit but about their oral health care for their child Affirmations e build rapport e increase the parent carer s confidence but not too many and look for signs that the parent carer is uncomfortable It s clear it s important to you You ve really tried to work with this That s a good idea Thanks for chatting this over with me can see you re a very determined person It s been good getting to know how you manage things Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 56 Reflective listening Reflective listening listening and hearing what they say and letting them know you ve heard what they say by your response The following is an example of how NOT to do it Do you manage to brush their teeth twice a day I try to but I find it difficult to find time in the morning It s important you know Yes know but there is so much else to do Have you tried getting up a little earlier But I ve so many children to sort out before go to work Will you try to find the time otherwise they ll continue to get cavities OK FII do my best Here the GDP is assuming the expert role but the patient is expert as to what fits in with their li
21. broadly the same processes as for brushing advice defining and agreeing with the parent carers achievable objectives then applying them for long enough for them to become habitual Additional points to note are e Sweets biscuits and fizzy drinks which aren t bought cannot be eaten and drunk no matter how persistently the child ask for them at home e Childcare arrangements during the day need to be explored sensitively with regard to snacking Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 76 4 of 4 Fissure sealing Fissure sealing key points e Children who are at medium and higher risk of caries should have all susceptible pits and fissures in permanent teeth sealed e Children who are at higher risk of caries should in addition have susceptible pits and fissure on partially erupted permanent teeth sealed with glass ionomer to protect them until they are sufficiently erupted to seal with a resin material e Sealants must be checked visually and physically for wear and leakage at review appointments e The most common reason for sealant failure is moisture contamination resin should only be applied when the dried etched tooth surface is completely frosty in appearance e Current advice is that sealants must not be applied in permanent teeth where caries extends into dentine the tooth should be restored see section Surgical management Fissure sealants have been shown to be very effective in preventi
22. caries The clinical diagnosis of dental caries The meticulous diagnosis of dental caries requires optimal conditions with regards to line of vision and access to potentially affected sites therefore e Teeth must be clean and dry and viewed under a bright light e The optimum tools for caries diagnosis are a mirror in one hand and a triple syringe in the other e tis no longer considered acceptable to probe suspicious fissures However a probe may be used to gently debride a fissure as an aid to diagnosis draw gently over the surface of enamel to determine if a white spot lesion is active or arrested see next section probe exposed carious dentine to determine caries activity see next section Additional aids to diagnosis include e Use of separators Orthodontic separating elastics can be placed for 3 5 days to allow visualisation of proximal tooth surfaces This could be a particular indication for managing suspicious proximal lesions on permanent teeth if found to be cavitated then the lesion should be restored e Transillumination With practice many clinicians find transillumination an effective method of caries diagnosis It can be particularly useful for diagnosing proximal lesions on anterior permanent teeth using the overhead dental lamp as the light source and placing the dental mirror in the shadow towards the back of the mouth and observing the light passing through the anterior teeth Notes to supp
23. chamber Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 90 Biological approaches to managing active dental caries in permanent teeth A significant advantage of using a biological approach to managing caries in primary teeth is that primary teeth shed therefore it may well be sufficient to simply slow down the carious process even if it is not fully arrested The same does not apply to permanent teeth The caries must be arrested and if the management strategy was unsuccessful then there must be diagnostic systems in place which are sensitive enough to reliably detect caries advancement at an early enough stage for the patient not to be disadvantaged Clinicians need to be trained and patients need to be aware of the responsibilities and pitfalls of this different approach to managing the carious permanent dentition and there needs to be further research based in primary care showing this approach is effective when provided by primary care clinicians before it can be generally recommended There are however two forms of biological management for caries in permanent teeth which have a strong evidence base supporting them e Indirect pulp cap e Stepwise caries removal Indirect pulp cap When preparing a cavity in a vital permanent tooth from which there have been no signs or symptoms of irreversible pulpal disease any remaining active caries for which removal would risk pulpal exposure should be left
24. child friendly approach highlighting areas differing from the provision of adult dental care QHAWwith 5 5 diagnosis amp history amp PEO findings with examination Agreed treatment plan Agreed findings child amp parent problem list Carers Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 Guiding principles Parent carers The child The clinician Review priorities The clinician key points e Give the parent carers at least as much attention as you give their child ensuring you engage with them rather than just talk at them e the origin of most adult dental disease can be traced back to childhood so make prevention a priority e Keep in mind that providing dental care for children is not the same as providing dental care for adults e he goal when managing the carious primary dentition is to prevent pain and infection until the tooth is shed and does not necessarily include the additional goals for adults restoration of function and aesthetics e Keep interventions within the child s ability to cope helping them to develop their ability to cope with treatment and their continued co operation is probably more important than the intervention in the long term e Be aware of the child s growth and development and constantly appraise their changing abilities to cope with experiences e As they become older start to hand responsibility over to them e Be open to using checklists at t
25. early occlusal dentinal caries is inadvertently sealed in provided the sealant is maintained the caries is unlikely to progress e If the tooth is only partially erupted or the child s cooperation is insufficient for placement of a resin fissure sealant or a restoration consider the use of a glass ionomer material as a temporary sealant or restoration e Monitor for any caries progression using radiographs Self audit of diagnostic decision making Reliable diagnosis of active dentinal caries is a fissure system is not easy Before cutting into a permanent tooth s fissure system with a handpiece and so starting the child off on the restorative cycle at least one of the three diagnostic criteria listed above should have been met However clinicians should constantly appraise what they expect to see when the dentine has been accessed with what they actually see If there is regularly no soft carious dentine visible then it is likely the clinician s index of suspicion is set too high and needs to be decreased If the carious dentine is always more extensive than anticipated then it is likely the clinician s index of suspicion is set too low and the clinician needs to be a little more pessimistic about the suspicious looking fissure The sealed restoration for managing a permanent tooth with active dentinal caries in a pit or fissure If one or more of the three diagnostic criteria listed above as indicating the presence of infected ca
26. extracted resulting in a poor relationship between the second premolar and the second permanent molar as for this patient When carrying out extractions of FPMs the optimal occlusal result will be obtained when e bifurcation of the lower second permanent molar J is seen to be forming on an orthopantomogram OPG full mouth panoramic radiograph usually around the age of 8 2 10 years e 5s and 8s are all present on an OPG e mild buccal segment crowding is present e Class incisor relationship is present When deciding on extractions each FPM should be considered on its own merit It is not necessary to balance extractions extraction of the contralateral tooth and evidence supporting the benefit of compensating extractions extraction of the same tooth in the opposing arch is weak The Royal College of Surgeons of England guidance provides more detailed advice on planned extraction of first permanent molars If FPMs are assessed as being of poor prognosis e Obtain a good quality OPG full mouth panoramic radiograph to ensure that all teeth are present in good condition and are well placed for eruption before extracting any first permanent molars e With the possible exception of the third permanent molars if any of the remaining permanent teeth are missing hypodontia or poorly placed have hypomineralisation and are not well placed for eruption or there is significant skeletal discrepancy refer for specialist paediatric
27. family members grandparents aunts amp uncles e Childminders nurseries family friends It is important that all of these are identified and their level of involvement recorded in the child s assessment sheet Appendix The OHC Team will then need to work with the adult or adults who are attending with the child to ensure transfer of knowledge and understanding regarding the preventive programme In addition and a significantly more difficult task the OHC Team must try to ensure that the individual adults in the child s care network also accept their personal responsibility for the child s oral health It is particularly important to identify and target any adults who provide regular over night care for a child due to the major contribution to caries prevention provided by effective toothbrushing with a fluoridated paste 2 3 History taking Dental history Using open questions explore the range of issues which will help you to build up a picture of how best to manage the child s oral health the issues which need to be addressed and the possible barriers to doing so These will include e History of pain if so time frequency severity etc to aid diagnosis e Brushing practice how often When By who F Concentration of paste Amount Spits out or rinses e Attitude and previous experience of dental care e Anxiety levels and causes of anxiety 3 3 History taking Medical history A comprehensive medical history should be
28. for example that while in some situations retained roots of primary teeth or primary teeth with pulp polyps might be managed very conservatively and simply monitored for signs of abscess if occurring in children at increased risk of infective endocarditis they should be extracted Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 21 Summary flowchart for taking a History at a first appointment The first appointment Parent carers and child enter surgery Give e Awarm welcome Smile gain eye contact make them both smile or at least acknowledge you as another person and thank the parent carers for bringing their child e Introduce everyone in the room Using open questions matching the parent carers communicating style and avoiding judgement ask permission to then take a social history Would it be alright to ask you for a bit of background information about who looks after Sophie e Who are the principal carers for the child during the daytime e Does the child stay overnight on a regular basis with another parent carer e Is this appointment time convenient Or would another suit better e Would it help if appointments were shared with another family member Following the same principles take a dental history e Ask about previous dental experience e Current pain swelling e Brushing habits see toothbrushing section in Prevention Now take your standard medical history Com
29. including e Visual colour translucency microcavitation e Tactile smoothness roughness surface continuity discontinuity hardness softness e Radiographic radiodensity e Electrical Impedance Applying the criteria will be aided by an understanding of the normal visual characteristics of healthy dental hard tissues Normal visual characteristics of healthy enamel and dentine For most people healthy enamel is e colourless and e translucent This can be readily observed at the incisal edge where the enamel wraps over the underlying dentine It can appear quite dark but it is the shadow at the back of the mouth which is being observed rather than the enamel itself Healthy dentine is e light yellow creamy e opaque Teeth gain their characteristic appearance due to the translucent enamel modifying the light reflected of its surface and the surface of the underlying dentine How this normal appearance is affected by dental caries Dental caries initially causes acid dissolution of the surface layer of enamel but differentially favouring the prism sheaths rather than dissolving the surface evenly This creates pores in the enamel surface If these pored are filled with a material of around the same refractive index as enamel water the optical characteristics will be largely unaffected However if the pores are filled with air then much of the light will be refracted many times before being reflected off the surfa
30. numerical codes are ascribed to each tooth surface the first represents any sealants or restorations present the second the extent of any carious lesion The codes are listed below along with some examples of charting Restoration and Sealant Codes Caries Codes 0 Not sealed or restored 0 Sound tooth surface 1 Sealant partial 1 Visual change in enamel only when dry 2 Sealant full 2 Visual change in enamel visible when wet 3 Tooth coloured restoration 3 Enamel breakdown no dentine visible 4 Amalgam restoration 4 Dentinal shadow not cavitated into dentine 5 Stainless steel crown 5 Distinct cavity with visible dentine 6 Porcelain gold PFM crown or veneer 6 Extensive distinct cavity with visible dentine 7 Lost or broken restoration 8 Temporary restoration Note how use of red indicates an active lesion this is the authors own approach A full chart for using with the ICDAS system is in the Appendix A training session for the ICDAS system is available for free download from the Web After a little practice a full chart can be completed in around 5 minutes and will contain much more information of clinical relevance than a standard dental chart 2 Another system is the NYVAD system named after Bente Nyvad who developed it Here a single number is ascribed as follows and with examples as above 0 Sound surface 1 active lesion intact surface 4 inactive lesion intact surface 7 fil
31. or always using only prevention to managing the carious primary dentition e The approach does not claim to provide all the answers and most areas of it will benefit from further research and development What the approach does offer is a method of providing high quality dental care for children managed in the context of their family and carers using techniques and interventions that both they and their OHC Team are likely to find acceptable whilst reducing the risk of the child developing treatment induced dental anxiety Reduced to a minimum the three defining characteristics of the approach are e A transfer of the principal responsibility for a younger child s oral health to the parent carers of the child This will be achieved using the latest behavioural management techniques to ensure the parent carers accept this role willingly with the knowledge and motivation to take it on and feeling they are working in partnership with the OHC Team without being judged by them e Intensive preventive dental care again employing evidence based educational and behaviour change techniques and provided by the OHC Team with the same attention to detail as for any complex dental restorative procedure Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 e A pragmatic approach to managing caries in the primary dentition where the disease is actively managed and not just left It follows biological rather than sur
32. preventive programme The four main caries preventive strategies to include in a programme Four main strategies are available to the oral health team e Toothbrushing with a fluoridated toothpaste e Additional fluoride therapy e Dietary advice e Fissure sealants The effect of caries risk assessment on a preventive programme Children assessed at higher risk of caries should receive e Hands on brushing instruction every year with appropriate F concentration paste 1 450ppmF if gt 3 years 2 800ppmF if gt 10 years and flossing advice e Fluoride varnish application at least three times a year and ToothMousse e Dietary assessment and advice every year e Sealing of all susceptible pits and fissures in permanent teeth with GI sealants being considered for partially erupted permanent teeth e 4month recall intervals until caries risk decreases Children assessed as at medium risk of caries should receive e Hands on brushing advice yearly with appropriate F concentration paste 1000ppmF and 1 450ppmF if gt 6 years and flossing advice if proximal enamel lesions visible on X ray Fluoride varnish application at least twice a year and ToothMousse Dietary assessment and advice every year Sealing of all susceptible pits and fissures in permanent teeth 6 month recall intervals and monitor for change in caries risk Children assessed as at lower risk of caries should receive e Brushing advice yearly with appropriate F concentration paste 10
33. risk of developing caries 6 12 months For all other children 12 18 months for primary teeth and 2 yearly for permanent teeth Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 29 2 3 Is the caries active Any carious lesion at any stage of advancement can be arrested and in some cases reversed Kidd For the primary dentition where loss of function and aesthetics are not major issues for the child caries which has arrested can often be managed with a prevention alone management strategy It is therefore essential for the clinician to be able to differentiate between active and arrested dental caries Enamel Enamel caries appears as a white opaque lesion due to the roughened surface reflecting the majority of the light that falls on it If caries is active the surface will feel slightly rough to the side of a probe drawn gently across the surface If the caries is arrested the surface will feel smooth to the side of the probe e Active enamel caries feels rough e Arrested enamel caries feels smooth Dentine The mineral content of dentine is around 75 much less than that of enamel As it has a well organised collagen matrix loss of some of the mineral does not always result in a complete collapse of the affected area Instead it can become softened while maintaining its shape Eventually a combination of proteolytic bacteria degrading the collagen and abrasion and attrition of
34. s notes so that reference can be made to it at a subsequent visit e At the next visit provide encouragement further advice and revise the action plan if necessary Even with Action planning and the best of intentions behavioural change can falter over time unless it is continued for long enough to become a Habit Habituation As you sit and read this page fed watered clean clothed over 95 of the stages you went through to arrive at this point will have been completed without any conscious thought but instead as a habit We are our habits they define us Living is too complex for us to waste time consciously thinking through every action Instead we save thinking time for new things the routine we complete on Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 58 automatic pilot The Holy Grail of behaviour change is habituation to continue with a behaviour change until it no longer requires conscious thought to initiate or complete it The key to habituation is repetition This begs the question how often is often enough Popular science has suggested the 21 day rule complete an action daily for 21 days and it will become a habit Recent research indicates that of course it is much more complicated than this and depends on a multitude of factors needing anything from 18 days to 80 days repetition to become habitual Pat Lally More research is needed on toothbrushing practice before there will be
35. to considerable personal inconvenience to bring their children for care and that must be recognised by a simple Thanks for coming to see us today and an introduction of yourself and any other members of the oral health team who are in the surgery There is a natural tendency to fuss over the child and it is important to acknowledge them as an individual and to welcome them However it s the level of engagement with the parent carers which is achieved that will ultimately determine the oral health of the child Engaging with the parent carers and the child The key first step to achieving positive health behaviour change is to engage with the patient and parent carers that state of connecting with another person such that you both have each others attention and in addition see each other as people rather than service provider and customer This is usually fairly easy to achieve by following the two key steps e Get eye contact and e Say something that makes them smile or at least respond to in a positive way The parent carer and or child may also initially say something to which you can respond positively and that is just as good Once you have engaged with them remember there will be a very few people will never engage with you you can then begin the process of building on your communication Good communication between the OHC Team parent carers and child will make any dental treatment much easier to Notes to
36. to take some personal responsibility i paren resource availability for materials training Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 51 There is however an accepted framework on which to base an effective treatment plan sometimes referred to as the 3 Ps Pain relief If necessary Prevention Planned treatment caries management It is essential that the treatment plan is fully discussed negotiated and agreed with the parent carers and the child before it is started Full involvement in decision making about their oral health is both their right and is likely to help with compliance with oral health care advice The following is a guide only Pain relief If a child is in pain then this needs to be managed However the following points should be noted Children can find invasive dental treatment injections extractions challenging at the best of times but especially if experienced in their first few appointments Try to avoid extractions on a child s first visit if at all possible even if under pressure from the parent to provide this treatment For reversible pulpitis restore the tooth if possible or if the child would find this too challenging at this stage place a temporary dressing in the cavity For an irreversible pulpitis in a primary molar try hand excavation then a Ledermix lining under a temporary dressing with a view to pulp therapy or extraction at a later date
37. to the child and an apology will prove more effective at settling things down than trying to brush over what happened Trust has been mentioned above and it is accepted that when an individual loses trust in a clinician the resultant mistrust phobia can be one of the most difficult forms of phobia to resolve While for an adult treatment is usually continued until the patient is dentally fit for children and their parent carers there may be value in trying to limit visits to around four per course of treatment with non urgent items for example an early dentinal proximal lesion in a primary molar being postponed till the next course of treatment This is more fully covered in Planning treatment Working with the things the child does like Fortunately there is much children do like They like being taken notice of and listened to They also like making adults laugh and they like receiving praise and rewards For some reason the sticker holds a special place in most children s hearts and should be used at the conclusion of a successful appointment and also an unsuccessful appointment if the child did their best The appreciation of stickers can also be used with toothbrushing charts see Prevention to help children motivate their parents Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 15 OHA with 5 history amp examination A i d Agreed Agreed problem list treatment
38. young as 4 years old Infiltrations are effective for most treatments on primary teeth including extractions However when carrying out pulpotomies on lower Es an inferior dental block IDB has been found to be more effective Most children will be apprehensive about receiving local anaesthesia However the use of sleight of hand techniques when giving LA may lead to mistrust phobias which may be difficult to resolve at a later time Ask the child if they want to see what you would like to use to make their tooth and not them go to sleep If they say yes then show them the syringe emphasising how fine ine eae is like a cat s whisker and that only a tiny part of it will go into their gum To reduce the discomfort of local anaesthesia use use topical anaesthesia use avery slow injection technique taking at least 60 seconds for an infiltration use intra papillary injections rather than palatal injections see below Intra papillary Injection Technique Intra papillary injections are useful for achieving palatal or lingual anaesthesia without any discomfort However it does take several minutes to complete Apply topical anaesthesia 2 Give a buccal infiltration injection adjacent to the tooth you want to anaesthetise 3 Draw an imaginary line across the base of one of the interdental papilla and drop a perpendicular down Notes to supplement lecture series given in Tasmania and New 2 86
39. 00ppmF and 1 450ppmF if gt 6 years e Dietary advice every year e 6 month recall intervals and monitor for change in caries risk The four caries prevention strategies will be described in turn The section on Changing behaviour should be read before beginning this section Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 60 1 of 4 Toothbrushing with a fluoridated toothpaste Toothbrushing key points e The four key components of effective brushing are Twice daily brushing Correct concentration minimum 1000ppmF and amount of paste Spit not rinsing Supervised e Hands on practical advice at the chairside using 1 Motivational interviewing techniques to increase empathy and so help parent carers discover their own motivation to change behaviour 2 Turning motivation into action through Action Planning 3 Turning action into habit through brushing charts e Including flossing for mixed dentition children at higher risk of caries e Ensure all adults with a responsibility for the child s oral health are identified and agreement gained from the attending parent carer as to how the information is to be shared with them An important word about fluoride aa Fluoride significantly reduces the risk of dental caries 99 of Pos vt D which begins at just two sites both of which are inaccessible to ii direct contact with fluoride containing vehicles such as toothpaste varnish mouthwash
40. 010 2011 63 This discrepancy between what the parent carer think they know and what they actually know poses some challenges for the oral health team There is a great risk in managing this discrepancy of coming across as one or all three of the human traits almost guaranteed to alienate and switch off the recipient of any educational intervention e Judgemental e Authoritative e Patronising However if any group of health professionals have the necessary skills it must include members of the oral health team who have been working with the public for a couple of years Finding out what happens now If the parent carers and the child are all fully on message and already following best brushing practice then there is no need to run through the entire process although positive reinforcement should still be used Step 1 try broaching the matter with the child first at the first appointment Child sitting up no protective glasses with eye contact with you and eyes at same level as yours Dialogue Comments Tell me about your toothbrushing Maintaining empathy Seeking factual information but in as indirect way as possible remember the parent carer will be listening intently I brush my teeth every day Every day That s really good well done Does mum help you Resist the righting reflex temptation to correct Affirmation and Praise I do it myself Oh you do it yourself What a bi
41. 10 2011 71 A technique for placing fissure sealants Cleaning the fissures Clean the tooth using one of the following methods to ensure it is free from obvious debris use of a 3 in 1 syringe alone is usually insufficient to clean fissures if debris is present alt it R e Wipe the tooth with Use a bristle Clean with a Clean Gently dredge cotton wool pledget brush without toothbrush with no the fissures with a prophy paste paste probe taking extreme care to avoid damaging the enamel Checking the airline for moisture Check the air line is free from water by blowing air onto the mirror surface to reveal any water contamination Achieving isolation Isolate the tooth using cotton wool rolls mouth mirror and saliva ejector and consider the use of dry guard Some clinicians use rubber dam and provided the clamp can be applied without upsetting the child this would be ideal Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 78 Etch the tooth Dry the tooth to avoid diluting Apply the etch 30 Wash the etch positioning the etch phosphoric acid not self the high volume aspirator so etch products for 30 that the water will flow off the seconds tooth into the aspirator Apply the sealant Avoid moisture contamination Apply resin to etched enamel Light cure the sealant of the tooth when changing ensuring the resin flows without cotton wool rolls Dry the tooth air inc
42. 11 61 Distance e Teeth at the back of the mouth must be brushed as thoroughly works against diffusion as the front teeth so that they are thoroughly covered by full concentration paste e Varnish also needs to be applied as close as possible to the sites it is designed to protect that is it needs to be applied to the approximal embrasure The toothbrushing advice session Toothbrushing with fluoride toothpaste along with fissure sealants are the closest things in oral health care to a magic bullet achieving astonishing reductions in disease if properly applied The four key components of an effective brushing programme that parent carers and children must put into practice are e Brush twice daily for at least two minutes being sure to reach all areas of the mouth in the morning and last thing at night before bed with nothing to eat or drink after brushing at night Night time brushing is particularly important due to the reduction in salivary flow at night allowing longer retention of i fluoride in the mouth which in turn allows more time for the fluoride ions to diffuse to where they re needed e Use the correct amount of a toothpaste with the correct fluoride concentration o Under 3 years old use a small smear of paste containing not less than 1000 ppm F o 3 6 years inclusive use a pea sized amount of paste containing not less than 1000 ppm F o 7 years old or over use paste containing 1350 1500 ppm F
43. 3 5 days later to remove them and to fit the crown but some clinicians find they ease the fitting of a Hall crown e If there is any possibility of the crown endangering the airway during fitting make a handle for it with a strip of sticking plaster or ensure the airway is protected with gauze e Select the correct size of PMC e Do not seat the crown through contacts prior to cementation as it might be difficult to remove e Ensure the PMC is well filled with a glass ionomer luting cement e Seat the PMC over tooth e Seating can be assisted by the child biting on the crown or on a cotton wool roll placed on the crown e Remove excess cement and clear the contacts using floss e Ensure excess cement does not flood over the tongue because it has a very bitter taste that children dislike Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 97 Indications and Contra indications for using the Hall Technique It is very important that selection of teeth for the Hall Technique is carried out carefully The following table lays out guidelines Indications include teeth with Contra indications include Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 Proximal Class II lesions cavitated or non cavitated Occlusal Class lesions non cavitated o If the patient unable to accept fissure sealant partial caries removal technique or conventional restoratio
44. A slightly less threatening method is to ask the parent carer and child m together to complete a 24 hour recall diary An example is shown in the Appendix Here the family group write down everything the child had to eat and drink from the time of the appointment on the day before up until they attended the clinic Action Plan 2 Educating and motivating The key dietary change messages are e Restrict sugar containing foods and drinks to mealtimes and certainly not more than four times a day e Drink only water or cows milk between meals Drinks such as sweetened milk soy formula milk and fruit juices increase the risk of caries Cows milk is non cariogenic Children aged 1 to 2 years should drink full fat cows milk in order to increase their intake of Vitamins A and D From 2 years of age semi skimmed milk may be slowly introduced into the diet if wished but skimmed milk should only be drunk by children over 5 years of age as it is so low in calories and Vitamin A e Snack between meals on fresh fruit or occasionally a small piece of cheese Oatcakes sugar free crackers or raw carrots can make an alternative snack e Nuthin after brushin The increased caries risk posed by the reduction in night time salivary flow to a tenth of daytime values has already been discussed e Children should not be put to bed with a bottle containing anything other than warm water 3 Action planning and habituation This involves
45. Avoids Class Il restorations which are approximal surfaces although there is destructive of tooth tissue and are growing evidence supporting infiltration challenging to place both for the clinician techniques and the child Identification and appropriate management of an early proximal lesion may prevent the child entering a the restorative cycle unnecessarily gt Approximal caries is particularly difficult to diagnose visually and radiographic examination is recommended when this is suspected Alternatively orthodontic separators may be used but this requires the child to re attend after five days Early diagnosis of lesions before they cavitate may allow them to be managed without operative intervention However cavitated approximal m lesions should be managed with a restoration as it will generally not be possible to alter the micro environment of aan the lesion sufficiently to prevent it progressing i a nE is e Make it a priority to identify and arrest earl eee ene Separate TEMoven S p y y y cavitated a separator days later allowing enamel only lesions on the mesial surface of Gan be applied visualigation orihe 6s proximal surface Techniques for managing non cavitated proximal lesions e Apply fluoride varnish and monitor with bitewing radiographs e Ensure the parent carers are fully aware of the potential impact on their child s oral health and encourage them to floss or use floss wa
46. Child Friendly Dentistry A family centred risk based approach to the prevention and management of adult dental disease in childhood Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 Not currently for circulation outside of the Dental Therapy Services of New Zealand and Tasmania Dafydd Evans amp Nicola Innes Unit of Oral Health University of Dundee With Jean Suvan and Christoph Ramseier on Motivational Interviewing Barbara Chadwick on Behavioural Management amp Thomas Lamont Illustrations by Amy McKay www amymckay com Acknowledgement The authors are grateful to the Scottish Dental Clinical Effectiveness Programme for permission to include some material previously published in the SDCEP Guidance Document The Prevention and Management of Dental Caries In Children www scottishdental org cep Also to Christoph Ramseier and Jean Suvan Editors of Changing Health Behaviour in the Dental Practice Wiley 2010 for permission to include material from their book University of Dundee 2011 Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 Child friendly dentistry a family centred risk based approach to the prevention of adult dental disease in childhood Introduction and acknowledgements Adult dental disease begins in childhood Richard Elderton Members of the Oral Health Care Team who work with children have the opportunity to help people avoid
47. I na Clinician s signature 119 ynpe ue q pedjay uisu you ds vwy EELEE NA NY SOE SS SY i Yo Aepse UP M yunowe 234109 2 419 yeyo buiysnig Aw Toothbrushing chart without the option of flossing three times a week Available to download as a pdf Ajiep JML sessssseesoosesesesoesssesesosese paubis SREY EA EUSA NESTS OF PAE RSEE NSS CAEN LES EA SES SPIRES SER EN SUR ER EE SSS pue Aas Aep e 301M Yy 03 AW Ysnig IIM I P1109 JP 120 Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 npe ue Aq padjay Buisuis you yds Ayiep 23ML e Oe eee eee ewe eee tenn eee ene ee eee eae eesseesseseees poaubis ya 114 ysnig 0 POeSEUCESICOCCCr errr rrrrerrrrr errr r rst Trier rT TITTTrririrrerrererirrrre ieee IM I udu sooeds y ije ul sS18 S ALyY IJI P PL AEE A NEA TO RE paubis ia aa ats SORA eee eee eee ee eee REE EEE HEHEHE EEE HEHEHE EEE HEHE EEE EEE EEE EEE EEE EE EEE EEE EEE HESS EE ES Ansty Aep p AMJ 432937 Aw usniq IM I qunowe 3291109 yey buiusnig W 10 help stop my tood and drink trom damaging my teeth will Toothbrushing chart with the option of flossing three times a week Available to download as a pdf 121 example have a bottle of water and a piece of fruit for my mid morning snack 24 hour recall Diet Diary Available to download as a pdf A Diet Diary for the previous 24 hours This Diet Dia
48. a lifetime of oral health problems This is both a privilege and a responsibility This guidance has been written to help in discharging that responsibility effectively Many colleagues too many to mention all of them have given generously of their time and ideas To David Marshall and David Butler we owe special thanks for their encouragement and advice in developing the approach and writing this manual to support a series of lectures we gave to their Oral Health Care Teams in New Zealand and Tasmania Thanks also to Professor Jan Clarkson Director of the Scottish Dental Clinical Effectiveness Programme for permission to include material previously published in the SDCEP Guidance Document The Prevention and Management of Dental Caries In Children and to Dr Doug Stirling Programme Manager and his team at SDCEP and all the members of the guidance development group which DE had the privilege to chair and NI served on However the opinions and guidance contained within this document are those of the authors and not of SDCEP Thanks also to Nigel Pitts for his foresight in getting SIGN 47 and SIGN 83 guidelines off the ground www sign ac uk which formed the basis for the SDCEP guidance and so this manual Tom Beckman for encouragement Ferranti Wong for discussions David Bearn for advice on the orthodontic component and Eleanor MacKay for developing the educational side of the brushing advice section All the photographs in this manual
49. advice it will be for parent and patient to be able to brush the entire dentition thoroughly Patient and parent to know core ideas of brushing twice daily with the correct amount of the correct strength fluoride paste spitting not rinsing on completion and if brushing is to be supervised Task analysis Breaking down the task into smaller stages Avoids trying to cover too much at once and allows you to check that each stage has been understood before moving on Baseline knowledge will have been covered already in Preparing the ground Have ready e Disclosing solution e Mirror e Micro brush e Floss floss wand if child in mixed dentition amp high caries risk e Toothbrush The child should have a bib on to protect clothing from the disclosing solution Toothpaste can be used but any advantage of using it is probably outweighed by subsequent mess and clean up impacting negatively on its implementability Dialogue Teaching Comments strategy Td like to put some special stuff on your teeth There is no evidence that Peter so that you can see where you need to disclosing or not disclosing brush would that be OK affects the uptake of advice but it does seem to help with engagement and children seem to like it Asking permission aids empathy as discussed above OK Good boy You watch in the mirror while paint Praise children really this stuff on that s excellent And now want appreciate it
50. alth team Parent carers thoughts sequence What do you think might happen know it s a problem if you dont manage to brush l his teeth twice a day It d be a if managed it What might happen if you I think could manage it did manage it I will manage it Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 57 Summarising By this stage you will have used your communication skills to e Identify the need for behavioural change in some area of oral health care e Addressed any knowledge issues using educational interventions e Helped develop the parent carers intrinsic motivation to change and all without losing rapport You will have achieved this by collaborating with the parent carer respecting their autonomy avoiding any sense of being judgemental and being perceived as empathic Once ready for change stop the Motivational interviewing Strengthen commitment by effectively summarising where you and the parent carer have reached It sounds like you want to change things What would you see as the next step So you find it difficult to brush his teeth twice daily but you appreciate that it will benefit him if you do this You think you may be able to find extra time by asking his older brother to take responsibility for the morning brushings during the week You now need to close the deal by turning the will for change into action an
51. and a lining placed over it before placing a permanent restoration ideally a sealed restoration The tooth should be monitored for vitality at follow up appointments It is worth reflecting that most clinicians are completely happy providing this well evidenced biological approach and use it regularly as part of their clinical practice yet it involves leaving active caries closest to the most vulnerable part of the tooth the dental pulp However the small amount of active caries left will be sealed in by a restoration which will generally be abutting sound dental hard tissue for the majority of its periphery reducing the risk of significant micro leakage Stepwise caries removal If a vital permanent tooth with no signs or symptoms of irreversible pulpal disease is found to have an extensive carious lesion present which threatens pulpal health then superficial caries only should be removed to an adequate depth to allow placement of a durable temporary restorative material for a period of 4 to 6 months This allows time for secondary dentine to be laid down and the pulp to recover from the caries insult After this period the cavity is re entered and the remaining caries removed unless felt likely to risk pulpal exposure in which case an indirect pulp cap is placed before sealing with a permanent restoration Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 91 Management Options for Carious Lesions in Prima
52. and is also self curing However while glass ionomer is satisfactory for use in Class cavities it has significant limitations in Class II cavities Therefore conventional glass ionomer should not be used when restoring Class II cavities Instead composite compomer amalgam or resin modified glass ionomer cement can be used Technique The technique relies on the use of very sharp hand instruments enamel chisels to cleave off unsupported enamel and then excavators to remove carious dentine Excavator and enamel Using a sharpening Excavator sharp enough margin trimmer stone to sharpen to cut paper e Ensure excavators and enamel chisels gingival margin trimmers are kept sharp e Use sharp enamel chisels to cleave off unsupported enamel enabling access to carious dentine e Advise the children that this part will sound scratchy or picky e Use a firm finger rest e Pare off carious dentine by cutting across the line of the dentinal tubules This will minimise pain during instrumentation of carious dentine which occurs when pressure is applied in a pulpal direction causing an increase in fluid pressure in patent tubules beneath the lesion which is then transmitted to the pulp e Restore the cavity with an adhesive material Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 111 e Do not use conventional glass ionomer materials for restoration of a Class II cavity due to the unacceptab
53. as you are able to and resisting at all costs being perceived as judgemental This means completely avoiding correcting at this early stage Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 19 The parent carers will then begin to see you and themselves as a team working together to improve their child s oral health and this will allow genuine empathy to grow This will be enhanced by subsequently asking if it s ok to talk about things they might regard as a not particularly relevant such as homecare arrangements b potentially embarrassing as usually considered part of good parenting and something they should know about This would include brushing instruction and dietary advice Empathy is the single most important component of successful behaviour change and it will be discussed fully in the section on Changing behaviour Having begun the process of establishing communication proceed to history taking History taking 1 3 History taking Social history A child s oral health status will largely be determined by the degree of compliance of the child s principal carers with evidence based guidance on best toothbrushing practice and diet Several adults may have regular significant involvement in a child s care particularly if the mother is working and for some children their care network can be extensive and include Parents and step parents A single parent s partner Siblings Extended
54. cation skills Before describing these four skills remembered using the acronym OARS O Open questions A Affirmations R Reflective listening S Summarising it will be helpful to review what their aim is to gain and enhance empathy Empathy is the fuel on which motivational interviewing and thus behaviour change runs no empathy no behaviour change Rapport is the process of simply engaging with someone empathy is the process of being at one with them of really seeing and feeling things from their perspective But take note a Universal truth is that when relating to another person it is not how you think you are coming across that matters it is how you are perceived And so with empathy feeling it is of little use the parent carer must be given enough cues to recognise it within you for themselves Open questions This form of asking questions was discussed in the section Communication It s worth repeating that whatever the answer it is essential to avoid coming across as judgemental To do so will lose rapport and without rapport gaining empathy will be impossible Affirmations Most parent carers will have feelings of insecurity regarding the quality of oral health care they provide for their children Self confidence the belief that they are fully able to take on the challenge of improving things lies at the heart of behaviour change and a positive affirmation from a member of the oral health team is a good way of
55. ce making the enamel appear a white and b opaque Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 26 How this affects the visual appearance of caries can be seen in the following demonstration Enamel is hard brittle Dentine is soft flexible and Together they give teeth their colourless and translucent Opaque characteristic appearance of colour and translucency If the surface is roughened by If the under surface of the However if the pores are filled caries or acid etch light is enamel is roughened by by a liquid of the same refractive reflected back off the surface dentinal caries the enamel index as enamel i e water the layer so it appears white and appears white and opalescent optical characteristics of healthy Opaque enamel are restored Clinical examples a Note how cleaning and drying the cervical margins of these teeth highlights the enamel caries b here the enamel has been undermined by caries spreading through the dentine Although the outer surface half of enamel is not affected the inner half is demineralised This can often be seen through the surface enamel as a characteristic bloom or opalescence as in the figure below Sound enamel Demineralised enamel Notes to supplement lecture series given in Tasmania and New Zeal c the transition from translucent to opaque caused by demineralisation of the inner surface of enamel due to undermining dentinal
56. ces Aural feedback aids correct technique You ve now transferred the information that it ll take about 2 minutes to clean his teeth Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 68 It took me about a minute to do that didn t it Now want you to spit out into the sink and that s what you need to do when you ve finished brushing with toothpaste spit not rinse Now do you want to brush your top teeth then let Mum help you get to the back ones Enactment Transfer Practice OK Peter that was really good now can Mum help you Good boy There Mrs McGregor can you now get to those back ones on that side Excellent That s good perhaps just a little firmer Excellent that s perfect This ll be really good for his teeth you could see he was struggling a Feedback little with the front ones Good you ve done both the insides and the outsides now on that side and you would go on to do the same on the other side are you quite happy with all of that That was fine but whether he ll let me do that at home is another thing Oh think you ll let Mum help you won t you Peter Because I m going to give you a lovely brushing chart and some stickers and if you finish it all then I think Mum might have a present for you That was good Mrs McGregor thought you both Repetition of did really well Just to pull everything togethe
57. choice for care then Although these four stages are shown in an itemised discreet sequence there will in reality be much crossover and merging between the stages In addition the dynamics between a health care worker and a patient can rarely be predicted or categorised and one of the satisfying parts of the job of health care is reacting to and adapting to changing dynamics when interfacing with patients The following is offered as general guidance for the oral health team as a source of ideas to be adapted rather than adopted verbatim as best suits their local situation With that proviso the key components of the four stages are 1 Assessing the need It is very likely that the parent carer knows that regular brushing helps prevent decay and that good brushing practice is part of good parenting However it is much less likely that the parent carers e Have knowledge of and awareness of the importance of the four key components of good brushing listed above e Are aware that children under 7 years of age require parental carer assistance with all brushing e Have the skills to thoroughly brush a child s dentition covering all surfaces so as to aid diffusion of the fluoride ion to reach where it s needed e Are currently fully discharging their responsibilities with encouraging and supervising good brushing practice for all children in their care Notes to supplement lecture series given in Tasmania and New Zealand 2
58. cing e g hyperventilation tension e Teach the child how to manage their anxiety principally with breathing but also using progressive muscle relaxation and other techniques such as guided imagery e Teach the child how to describe their level of anxiety using a scale from 1 to 10 where 1 is completely relaxed and 10 is the most anxious they have ever been e Break the procedure down into stages and describe all the stages to the child e Give control then try the first stage asking the child at the end of it to describe their anxiety level If rated above 5 ask them to spend a minute going through their relaxation regime and try again only proceeding to the next stage when 1 the child has reduced their anxiety to a manageable level and 2 the child has given their permission to proceed e Giving local anaesthesia could for example be broken down into holding the syringe by the side of the chair placing it in the child s mouth but with the cap on then holding the syringe in the child s mouth with the cap off and so on For children who continue to demonstrate significant anxiety consider the use of inhalation sedation if available or referral to a specialist Local Anaesthesia Local anaesthesia LA is recommended for any cavity preparation that involves cutting sound dentine in both primary and permanent teeth Dentine in primary teeth is as sensitive as that of permanent teeth LA can be used successfully in children as
59. clude the child for they will have been listening intently Change talk This is key Praise and explanation of importance Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 65 Would it be OK if I just spent a few minutes now going over brushing with you There s been some recent research which has shown how to make brushing even more effective at preventing holes developing Would that be OK to do that Peter Yes that ll be fine Asking permission of both parties is courtesy but also helps to further reduce the risk of seeming authoritarian avoiding the perception of I m going to show you something now that you should already know and should have been doing for years Autonomy of the parent carer is not being challenged With perhaps 1 2 minutes of dialogue you have e Sympathetically probed a personal area of home care Avoided judgement Increased empathy Highlighted the benefit of the intervention you are now providing Ascertained compliance with three of the four key parts of effective brushing frequency spit not rinsing supervised and identified a strategy for addressing one of them shared brushing e Prepared the ground to increase the chances of success for your intervention You can now progress onto the next stage Educating although the single word educating is used here in its broadest sense in that you will not just be transferri
60. cture series given in Tasmania and New Zealand 2010 2011 114 Appendix All the following documents are available for download please contact your Principal Dental Officer e Assessment form e Dental chart e Post treatment checklist The four A4 sheets that make up the assessment form dental chart and post treatment checklist are designed to be photocopied onto both sides of a sheet of A3 paper which is then folded to make a booklet They can be downloaded as Word documents to allow them to be amended to suit local requirements and also as pdfs allowing them to be printed off as a double sided A3 document e Toothbrushing chart without flossing e Toothbrushing chart with flossing e 24 hour recall Diet Diary Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 115 First page of Oral Health Assessment sheet Patient ID Oral Health Assessment Dort od e a ee ae History Reason for attendance History of complaint Attended with SRI EY cvcserovs N IS comer Dental History Date of most recent Medical History Child s observed anxiety level OCCCOAG S ON TT aaan A A E A S i hi t oca IS ory ilahidi adia ahaaa a eaaa AA EAA AAV NYZATI 00 8 Cea vib TE TEETE E OR eee ROS OOK bat oa esl ersav ess eee Principal carers By Oyon or EN EA E O AET RE AO PERRE E LN OENE Wey a E a EA a a a Current brushing and snacking practice without asking directly assess parent child aware
61. d A note should be made to fissure seal the mesial fossa in a couple of months with glass ionomer if necessary once the operculum has retracted and not to wait until the disto palatine fissure is also accessible Accepting the child s priorities when managing the carious primary dentition With a few exceptions children seem unconcerned about any aesthetic or functional problems with a failing primary dentition What they are undoubtedly concerned about is pain or infection Avoidance of this should be the management priority for carious primary teeth and not restoring function and aesthetics as would be the case for a permanent tooth Accepting this opens a whole range of alternative less invasive management options for the clinician other than the classical drill n fill approach As clinicians though we often feel more comfortable with the surgical approach Intuitively it may seem right and it was usually what we were trained to do We feel satisfied with a nice looking restoration and assume that it is always someone else who upsets children and not us Yet the evidence is clear that children really do not like operative interventions see Appendix for further details Stay within the child s ability to cope Children s different perceptions of and ability to cope with dental interventions was covered in the introduction Well intended attempts to impose dental interventions on the child when they are clearly s
62. d be monitored at each recall visit and fissure sealants maintained until the child is no longer at increased risk of caries Visually check fissure sealants With clear sealants opalescence visible at the sealant tooth interface usually indicates leakage and demineralisation This sealant should be removed Physically check fissure sealants with a probe An apparently sound fissure Probe inserted under palatal A stained fissure is revealed sealant at recall visit extension which lifts away Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 80 With a sound well retained but worn sealant the edge of the sealant should merge without a step with the enamel surface This example clearly needs topping up but close examination shows lumpy margins and a fractured mesial edge This suggests a lack of bond between some parts of the sealant and the tooth and in fact the whole sealant was easily flicked off with a probe e Top up any fissure sealants as required if the child is still at increased caries risk Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 81 Using glass ionomer cement as a sealant material Placing a resin sealant can be difficult on a partially erupted tooth or with a child whose cooperation is limited In these situations a glass ionomer material can be used as a temporary measure but the retention rates of this material are poor over the long t
63. d child Try to manage within 4 months Low Distal carious lesion May be managed with a hard to probing upper prevention alone approach but first primary molar 5 monitor for change year old child Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 32 Description Risk of abscess before Clinical scenario exfoliation High Distal carious lesion Imminent risk Or delayed soft to probing upper first primary molar 6 Imminent year old child Try to manage within this course of treatment High Pulp chambers cariously Imminent risk Or delayed exposed and open to the oral environment Imminent Try to manage within this course of treatment Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 33 Clinical scenario Description Distal carious lesion lower primary canine hard to probing and retained root first primary molar 7 year old child Several carious lesions in lower primary teeth hard to probing 7 year old child Mesial carious lesion upper second primary molar with pulp polyp and no signs or symptoms of abscess Risk of abscess before exfoliation Low May be managed with a prevention alone approach but monitor for change Low May be managed with a prevention alone approach but monitor for change Low May be managed with a prevention alone approach NB in primary molars pulp polyps by definition vital pulp might onl
64. d this is achieved through Action Planning Action planning Action planning is where the intended action is actually planned For example the typical New Year s resolution I will improve my fitness this year is changed to I will improve my fitness this year finish work an hour early on Tuesdays and Thursdays so I ll call in to the Gym on my way home tonight join up then go swimming on Tuesdays and work out on Thursdays and cycle to work every Monday and Friday There is evidence that forming an action plan increases the likelihood that a patient will perform a behaviour and a recent study in young adults showed action planning to have a significant effect on compliance with oral care Consider developing an individual action plan for the child as follows e identify a convenient time and place for the preventive behaviour to occur e g toothbrushing after breakfast in the morning and last thing at night and a date for when the task is to be started ideally from the day of the appointment and who is to carry it out e identify a trigger as a reminder for the child or parent carer to carry out the preventive behaviour e g when the child gets ready for bed e agree a date to review progress e g assess oral hygiene at the next visit e agree the action plan with the child and parent carer and write this down for them if necessary possibly on a copy of their toothbrushing chart e record the action plan in the child
65. dary care e As caries is left in the cavity the marginal and private practice that this approach seal must be effective to prevent caries can be effective progression e Reduced risk of pulpal exposure e No evidence as yet that this approach is e Reduced time for cavity preparation effective in Primary Care and less need for local anaesthesia e Particularly suited to ART approach As it is imperative to obtain a complete marginal seal in order to slow or arrest caries progression the use of plastic adhesive materials is likely to be most successful on Class lesions with preformed metal crowns being the preferred option for Class II lesions Technique for primary molars e f necessary gain access to caries using a high speed handpiece e As this approach rarely requires the cutting of sound dentine local anaesthetic is usually unnecessary e Remove superficial caries with a slow speed handpiece or excavators until there is no obvious caries visible at the enamel dentine junction and the cavity allows an adequate thickness of restorative material to be placed e Take extra care not to cause iatrogenic damage to adjacent teeth if cutting a Class II cavity see Section 9 3 Placing a matrix band around the adjacent tooth may help e Be aware of the pulp chamber anatomy to reduce the risk of pulpal exposure Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 93 e Place the restoration us
66. dge alone is not necessarily an indication When a narrow band of normal dentine can be seen on radiographs between a carious lesion and the dental pulp and when the tooth is otherwise free from clinical and radiographic signs of pulpal disease a pragmatic approach is to manage the tooth without a pulp therapy and to monitor vitality at subsequent visits As roots of primary teeth resorb conventional endodontics is contra indicated Instead removal of irreversibly diseased pulp tissue from the pulp chamber alone followed by placement of a preformed metal crown PMC to achieve a good coronal seal can resolve symptoms m Clinical view Radiographic view Pulp morphology of Perforated pulp Symptomatic upper left first primary molar in a upper first primary chamber floor 5 year old which requires pulp therapy Note from the radiograph and model e how much higher the pulp horns are relative to the central part of the pulp chamber roof in primary molars e how divergent the root canals are when leaving the pulp chamber Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 104 Care is needed to avoid perforating the floor of the pulp chamber which is very thin in primary molars photo on right The choice of pulp therapy technique will depend on whether the pulp is found to be vital or non vital once accessed Vital Pulp Therapy e Example shown pulp therapy of a symptomatic upper left first primar
67. e flossing of posterior contacts if appropriate b brushing the same surface in a complete 7 close with affirmations and encouragement arch or all 3 surfaces in each quadrant 3 demonstrate brushing in one arch 3 Action planning e Agree timings of home brushing sessions e Agree who will supervise each session 4 Habituation e Give and complete brushing chart e Reinforce at recall appointments e Agree rewards with parent carer e If available give paste brush and stickers Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 73 In addition to fluoride toothpaste other topical fluoride therapies are available including tablets mouthwashes and varnishes Daily fluoride tablets have been recommended but evidence indicates poor compliance rates so they are not part of current UK guidance Fluoride varnish has the advantage of not relying on parental compliance although the child does have to attend for it to be applied Note Fluoride varnishes often use the adhesive colophony also found in Elastoplast which is derived from Pine resins The oral health team should follow the manufacturers instructions but a child who has been hospitalised due to severe asthma or allergy or who is allergic to sticking plaster may be at risk of an allergic reaction to the varnish so it should not be used For such a child if they are older than 7 years of age and at higher risk of caries then an alcohol free mouthrinse might
68. e passed across the tooth surface when the teeth are in occlusion e Select the correct size of preformed metal crown PMC cement the PMC in place with glass ionomer cement remove excess cement and clear contacts using floss Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 103 Pulp Therapy for Primary Molars For the child with caries related dental pain or sepsis sinus or abscess the clinician has to decide whether a pulp therapy is required and if so whether this should be a vital or a non vital pulp therapy Aim to enable a primary molar with irreversible pulpal disease to be retained free from pain and sepsis until exfoliation Advantages Disadvantages e Evidence largely from secondary care e Techniques can be demanding both for and private practice that these the child and the clinician as they require approaches can be effective local anaesthesia and immediate e Can avoid dental extractions placement of a preformed metal crown PMC to maximise effectiveness Indications Contra Indications e Irreversible pulpitis vital pulp therapy e Tooth close to exfoliation e Dental abscess non vital pulp non vital e Tooth unrestorable pulp therapy e Pre cooperative child e Abscess e Multiple pulp therapies needed e Radiographic signs of pulpal involvement There is currently debate about the indications for pulp therapy when a primary molar is asymptomatic A fractured marginal ri
69. eatment checklist Post Treatment Checklist A as part of your Assessment of the child have you Identified all adults parents and other principal carers with a role to play in maintaining the child s oral health and encouraged them to take responsibility for the child s oral health particularly with regard to brushing diet and regular attendance O checked all existing sealants visually for wear e physically with a probe for integrity leakage and topped them up if necessary G checked radiographically the occlusal and approxima surfaces of the permanent molars for early caries or recorded a sound reason not to Q checked clinically and radiographically for sepsis associated with any carious primary teeth checked whether any previously selected prevention alone caries management strategy is effective caries arresting good plaque control on surface of lesion and if not chosen an alternative strategy carried out and recorded a caries risk assessment considered the possibility of dental neglect and taken appropriate action if suspected B as part of your Best practice Preventive care of the child have you O checked that the child and the parent carer understand the critical importance of e brushing twice a day e Nuthin after brushin e spit don t rinse e Supervised e use an appropriate amount of an appropriate F concentration toothpaste Minimum 1000pp
70. epared to stage treatment avoid at all costs being perceived as judgemental e Meticulous caries diagnosis is essential if early lesions are to be managed non operatively use radiographs where appropriate e In permanent teeth infected dentine should be managed operatively take exceptional care to avoid latrogenic damage to the pulp other teeth and the child s trust e In primary teeth consider a biological approach usually sealing in to reduce risk of pain sepsis before exfoliation sepsis from primary teeth must not be left unmanaged Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 An overview Child friendly dentistry is an approach which aims to provide high quality effective child dental care while minimising stress to children their parent carers and the Oral Health Care Team OHC Team with the aim of leading children towards adulthood with the skills and understanding to look after their own oral health The premise underlying the approach is that The permanent dentition is for life while the primary dentition is transient and runs its course in patients who are limited in their ability to tolerate dental interventions and truly consent to those interventions and who have almost no capacity to accept responsibility for their own oral health e t must be emphasised that the approach is not presented as a revolutionary new method of child dental care it si
71. erm Partially erupted lower 6 being inadequately cleaned in a child at higher risk of caries This tooth might be carious by the time it has erupted sufficiently to allow placement of a resin sealant For e when the child is pre cooperative or children assessed as at higher caries risk consider the use of glass ionomer sealant material as a temporary measure only e when resin sealant is indicated but there are concerns about moisture control or e on a partially erupted tooth For a child at increased risk of caries but not yet able to tolerate the resin sealant procedure consider placing glass ionomer sealants with the press finger technique If possible wipe the tooth surface with a cotton wool roll Firmly apply the finger tip with glass lonomer to the tooth Place a small amount of glass lonomer on one finger tip and Vaseline on the adjacent finger Lower 6 to be sealed surface to be sealed Keep finger in place for two minutes Place the second finger in the mouth and rapidly switch fingers to allow coverage of glass lonomer with Vaseline before moisture contamination In this example Fuji Triage was used Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 82 Changing behaviours Prevention Helping children cope Biological caries management Surgical caries management Helping children cope Simple effective techniques Help
72. etection or exclusion of oral health related disease It leads on to A problem list which is a collection of the oral health related issues arising from history examination and diagnosis which the clinician feels need to be addressed to improve the child s oral health From this is derived The treatment plan which is a sequence of interventions selected by the clinician to manage those issues most effectively for that particular child and family group Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 47 These should be kept separate For example the diagnosis for this lower second primary molar is active moderately advanced occlusal and proximal caries with no signs or symptoms of sepsis However the problem list and treatment plan for this tooth could vary with different scenarios as the following examples show Scenario 5 year old child lower first primary molar free from caries Lower second primary molar as above active moderately advanced occlusal and proximal caries 5 year old child lower first primary molar moderately advanced proximal caries Lower second primary molar as above active moderately advanced occlusal and proximal caries 10 year old child lower first primary molar already shed Lower second primary molar as above active moderately advanced occlusal and proximal caries Problem list Active proximal caries second primary molar High risk of seps
73. even outside the control of the parent carers Taking an autocratic paternalistic approach with parent carers even at a non verbal or a sub conscious level will not produce positive results Taking even a mildly critical approach with parent carers will alienate them They themselves might be struggling with very significant life problems about which we have no knowledge or experience and oral health theirs and their child s might be a long way down their list of priorities Generally it is necessary when working with people to change their behaviours to start where they are and not where you d like them to be More information on this is in the sections on Communication and Changing behaviours Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 12 Identifying the key carers Childcare arrangements can be complex Young children may spend significant amounts of time with grandparents or with a childminder It is important to identify the key adults involved in child care particularly those responsible for overnight care because of the importance of good toothbrushing practice and to find ways of involving them in your preventive programme This may involve sending out several copies of a preventive management plan with the carers agreed part clearly written out for each person The older child teenager may well be developing the ability to take responsibility for their own oral health care but most will s
74. fe In essence reflective listening involves making a statement which indicates you understand not just hear but understand what the parent carer has said It also e increases rapport which can go up as well as down and so empathy e gives you extra time and information to discern what s going on and what the barriers might be It does take time to become skilled at reflective listening When starting out try putting It sounds as though you In front of what they have said but be sure to make the intonation go down not up at the end of the statement confirming that you are understanding what they ve just said and are not simply asking another question Parent carers will normally respond with elaboration As you listen to the information the parent carer is telling you you are almost certain to identify Ambivelance i e know ought to brush his teeth but he just wont let mel A good response might be I appreciate that you know you want to brush his teeth for him because it ll help stop him developing cavities and you want to know how best to manage that It is crucial to recognise that ambivalence is normal and must not be confused with resistance to change Here you must resist the righting reflex and roll with any resistance Try using evocative questioning to develop discrepancy where the parent carer identifies for themselves what they know ought to happen and what actually happens Oral he
75. g a high speed handpiece leaving a wall of enamel to protect the adjacent tooth e Remove caries with a_slow speed handpiece and excavators e Be aware of pulp chamber anatomy to reduce the risk of pulpal exposure e Prepare approximal cavity margins with gingival margin trimmers to prevent iatrogenic damage to the adjacent tooth e Place the restoration e lf at risk of pulpal exposure place an indirect pulp cap e Do not use conventional glass ionomer materials for restoration of a Class Il cavity due to the unacceptably high failure rate Composite compomer resin modified glass ionomer amalgam and preformed metal crowns are may all be suitable the particular material choice depending on the cavity Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 102 Traditional technique for preformed metal crowns e Give local anaesthetic e Remove caries e lf at risk of pulpal exposure place an indirect pulp cap molar shown has had a pulp therapy e Cut a mesial slice and a distal slice The bur should pass through the crown cervically so as to avoid creation of a cervical ledge as this will impede the seating of the crown e Note how a wall of enamel is left while cutting the slice to ensure there is no iatrogenic damage to the adjacent tooth The wall will then fall away as the cut is completed cervically e Reduce the occlusal surface of the tooth enough to allow a straight probe to b
76. g boy you are for 5 Resist the righting reflex Praise When you ve finished brushing do you rinse the paste away Or do you spit it out I rinse with water from the tap That s fine I m very pleased that you can brush your teeth Resist the righting reflex Be positive about what you can You will have obtained much useful information with a veracity you might not have had from the parent carer Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 64 Step 2 now turn to parent carer and open a discussion with them Get eye contact with them smile remember that they might not be feeling entirely comfortable discussing something which is considered by most to be part of normal parenting Dialogue Can you tell me a little more about his brushing Well try to make sure he brushes his teeth every day but he won t let me help him and I do find it a bit of a struggle Oh know he s a lovely boy and they can be so independent at this age well done for trying though D you think though that he can brush his back teeth as well as he brushes his front ones Well there s paste everywhere when he does it but I m not sure how much gets to his back teeth I can imagine the mess Do you think that is maybe why he has some holes in his back teeth It might be yes but he just won t let me I know it can be such
77. ges the development of dental caries Changing behaviour The basic model for behaviour change stays the same as for toothbrushing 1 Assessing the gt 2 Educating and Motivating PAction P Habituating need planning 1 Assessing the need A high caries rate or erosion would indicate the need for a dietary intervention As part of this process a 3 day diet diary has been recommended The parent carer and child are given a booklet and asked to write down everything their child has to eat and drink over three days The days need Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 75 not be consecutive but one should be a weekend The diary then forms the basis for discussion between the parent carer child and the member of the oral health team There is as yet no evidence supporting the efficacy of diet diaries but they are useful as a basis for discussion Anecdotally however the diaries are often either left at home or can be seen to have been completed by the one hand and at a single A Diet Diary for the previous 24 hours sitting The food parent carers give to their children is potentially an saa emotive issue for the parent carers and it perhaps a lot to expect that they Sap will complete a 3 day diary reliably and without feeling that their autonomy was being challenged This would lead to loss of empathy and rapport and 20 without those behaviour change is unlikely to occur
78. gical principals to achieve the goal of reducing the risk of affected teeth causing the child pain or sepsis before they shed naturally while minimising stress to the child and the OHC provider all set against a background of using checklists to help ensure the optimum treatment is provided and audit to monitor effectiveness Whilst caries in the primary dentition is never left unmanaged it is the health of the permanent dentition that is prioritised Final thought The aim of the manual is to assist members of the OHC Team working with parent s carers in helping young people achieve and maintain oral health through childhood and adolescence into adulthood with a healthy dentition and the skills and motivation to maintain it Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 6 Introduction Providing dental care for children is not the same as providing dental care for adults There are some important differences Unlike adult dental care the most important person in determining the child s future oral health is not the person sitting in the chair It is the parent carers who hold the principal responsibility for their child s oral health and it will require great skill and expertise from the OHC Team to ensure that the parent carers appreciate this without inadvertently alienating them in the process However without the active willing participation of the parent carers the effectiveness of a
79. good evidence on how long is long enough but the research to date indicates that it is unlikely to be less than for around three weeks and it is likely that there will always be external factors which will influence this how entrenched are the involved parties in current bahaviours and how well does a habit change to the desired behaviour fit in with their existing day to day lifestyle This therefore suggests the need e for toothbrushing charts to aid compliance over time e to anticipate that lapses do not indicate complete apathy or resistance on behalf of the parent carer but will just be a normal part of behaviour change interventions which will best be managed by support and encouragement over successive recall appointments More on the use of toothbrushing charts will be found in the toothbrushing section of Prevention Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 59 Adult dental disease can be and needs to be prevented in childhood and there are a range of effective evidence based strategies for doing this As much effort and attention to detail should be put into applying them as with any other aspect of dental treatment such as advanced restorative procedures Not all children and parent carers will need a full caries preventive programme so a caries risk assessment should be carried out and the result recorded in the patient s notes The level of risk will determine the intensity of the
80. h For these reasons the management of caries in the primary dentition differs from that of the permanent dentition and a different diagnostic approach is required based on three parameters 1 Is caries present 2 If present is it active or inactive 3 If present and active what s the risk of it causing pain sepsis before the affected tooth exfoliates and is that risk imminent Or delayed How each of these three parameters can affect the treatment provided is shown in the summary table below The three stages of caries assessment in the primary dentition assumes all patients are receiving standard prevention 1 3 2 3 3 3 Is caries Yes gt s it active Yes gt Risk of pain sepsis gt Yes present before the affected tooth exfoliates No The OHC Team will need a thorough understanding of the pathology of dental caries in order to prevent it and manage it effectively if it occurs The pathology of the disease is covered later This section will cover caries diagnosis and assessment as follows and will finish with how this information might be recorded How this information is used will be covered in a later Section Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 25 1 3 Is caries present An overview of diagnosing dental caries There are several diagnostic criteria for dental caries based on detecting changes in the physical characteristics of affected tissues
81. h twice a day but it s so difficult Communicating styles may change during an appointment or a patient may indicate in a response that they want to change style if so change to accommodate them This is worth doing if you feel your hard won rapport starting to slip away As the patient responds to you avoid at all costs being perceived as judgemental This can take a real effort of will wnen the parent states something which is not correct or best practice but note what the parent carer says and deal with it later using Motivational Interviewing techniques see section Changing behaviour As will be explained in that section if you try to correct something at this stage by saying for example Actually he s too young to brush his own teeth you need to do it for him you will unwittingly be perceived as challenging the parent carers autonomy regarding their own child and they will immediately be on the defensive a state in which behaviour change will probably not occur Communication Pulling it all together In summary with your warm welcome and introductions of yourself and team unless you re single handed with eye contact and saying something they can engage with and respond to you will begin gaining rapport with the parent carer and child Then using open questions listening to the responses and the style in which they re given you respond in turn following the parent carers or older child s lead as far
82. he start and end of treatment they help prevent Type 1 errors the mistakes other clinicians make but never us Clinicians must appreciate that dental care for children is not the same as dental care for adults The aims for child dental care are broadly similar to those when providing adult dental care e to keep the primary and permanent dentition free from disease e to reduce the risk of the child experiencing pain or abscess or acquiring treatment induced dental anxiety if dental caries does occur e for the child to grow up and reach adulthood feeling positive about their oral health and with the skills and motivation to maintain it However choosing the best possible route to achieving those aims may involve a change in mindset from that when providing adult oral health care The imperative of engaging with the parent carers The oral health team needs to make a particular effort to engage with the parent carers when the natural tendency will be to focus on the child Of course the child is important but for the pre schooler and primary school child it will be the parent carers who will determine the success or failure of dental care and not the child The permanent dentition is the priority While the primary dentition is transient the permanent dentition is for life but like the primary dentition appears in the oral cavity well before the child is of an age to take responsibility for looking Notes to supplement lecture
83. he writing out of the problem list which A a is a verbal sequential Type 2 left brain activity it i G eS encourages the use of Type 2 thinking and decision N making for formulating the treatment plan W H Two methods can be used e A standardised pro forma to be completed and retained as part of the patient s clinical records e A simple checklist to be retained at the chairside and used to check that all the steps of an oral health assessment have been completed Traditionally and there is now evidence to support this many clinicians have baulked at using pro forma s or checklists seeing them as beurocratic and time consuming Interestingly after a large study in the USA showed significant benefits in terms of patient mortality and morbidity from using a simple pre and post op checklist around 60 of surgeons who were involved in the study said they would continue to use the checklists after the end of the study while 95 of the same sample stated they would wish their surgeon to use the checklist if ever they needed an operation Most of us clinicians believe it is other people who are occasionally slipshod or haphazard never us If we use pro forma s and checklists as part of our regular clinical practice we can prove to ourselves that this is true Assessment sheets and post treatment checklists for downloading The Appendix contains an Oral Health Assessment sheet two pages of A4 a dental chart with radiographic
84. hild s preventive programme e Ensure responsibility for the child s oral health is transferred from the OHC Team to the parent principal carers and that they acknowledge that this transfer has taken place e Engage with the parent carers be supportive empathic and encouraging avoiding at all costs being perceived as judgemental however persistent failure by parents principal carers to meet their child s oral health needs should be managed as a child protection issue The check up Oral Health Assessment appointment e Make both the child and the parent carer feel really welcome find out the most convenient appointment times for them and try to fit in with them e Work through the process of OHAwith history amp examination Agreed treatment plan Agreed Diagnosis amp problem list findings keeping in mind the three key goals 1 Maximise the probability of the permanent dentition remaining caries free 2 Minimise the risk of any carious primary teeth causing the child pain sepsis 3 Minimise the risk of treatment induced anxiety e Prioritise the treatment plan around the sequence of the 3 Ps Pain relief if needed Prevention Planned management e Nothing about me without me Prevention e Use a caries risk assessment tool to determine the caries preventive programme content e Apply the components of this programme to the highest standard e The big four normally included are
85. hildren for dental care is inconvenient for parent carers Be sure to show your appreciation for their visit and make efforts to find out which days and times suit them best it ll be the children who benefit from this e Children are entirely dependant on their parent carers for their oral health Parent carers may need to be guided to recognise their responsibility in this area If despite guidance they do not accept and discharge this responsibility then the oral health team in turn has a responsibility to follow this up as a possible child neglect issue following local protocols Parent carers hold the key to improving and maintaining oral health in children under their care A child s oral health is their responsibility and children are totally reliant on them discharging that responsibility The oral health team can assist with this process but cannot take on the primary responsibility for it that lies with the parent carers One of the key differences between providing dental care for the adult and the child is that with children especially young ones there is always a triangle of communication The clinician needs to take note of this when formulating a management plan Accepting and then working with the autonomy of the parent carers The quality of the oral health care provided for children by their parent carers is dependant on many factors most of which are outside the control of the OHC Team and some of which are
86. hildren which places a major emphasis on prevention will present challenges to the OHC Team in terms of maintaining their motivation There is a natural tendency for those whose training has majored on operative care to find a dental arch containing multiple well maintained polished restorations inherently more satisfying than a caries free arch There are no straightforward answers for this Undoubtedly though one route is through greater involvement with the children and their parent carers in the child s oral health care with freedom from caries becoming something to celebrate with stickers and rewards How often are children copiously rewarded for tolerating some difficult intervention compared with the amount of praise and excitement when a regular check up reveals a healthy mouth The origin of most oral health problems in adults can be traced back to their childhood What greater privilege is there than to be in a position to help prevent another person from having to cope with a lifetime of oral health problems Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 113 Further reading Child Taming How to Manage Children in Dental Practice Barbara L Chadwick amp Marie Therese Hosey Quintessence Pub CoLtd ISBN 1 85097 062 9 Health Behaviour Change in the Dental Dental Practice Christoph A Ramsier and Jean E Suvan Wiley Blackwell 2010 ISBN 978 0 8138 2106 1 Notes to supplement le
87. history exam radiographs etc discus findings e identify these and prioritise them in consultation identify and with the child and parent prioritise problems issues e for each problem issue identified e include the pros and cons _ discuss opticns e explain that the plan will be evaluated as treatment aweeateatment progresses to check any changing needs are met plan Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 46 SS Agreed F problem list Omai Diagnosis amp history amp amn ERE ti fin din gs examination Agreed Problem List What needs to be managed Problem list key points The problem list e Write out all the problems which need to be addressed to improve the child s oral health This might include Parent related issues Current attitude to oral health care Extended care arrangements for the child g Financial social or personal barriers to bringing their child for care Child related issues Fears and expectations regarding oral health care Relevant medical problems e Ability to cope with dental interventions Dental related issues Current presence of pain or infection Caries risk Vulnerable permanent dentition Primary teeth at risk of causing pain or infection before exfoliation Dental development problems The rationale for a problem list In the context of providing oral health care for children A diagnosis is the d
88. ial to ensure all relevant information is collected in a usable form and to prevent reversion to a habit based approach to diagnostic decision making see Section Problem List e The examination should include An extra oral examination An intra oral examination of the soft tissues An assessment for dental caries and sepsis Plaque levels A caries risk assessment e A review of the developing dentition with a particular emphasis on Identification and appropriate management of first permanent molars with a poor prognosis before the child reaches 10 years of age Identification and appropriate management of Maxillary permanent canines which are impacting palatally Missing unerupted permanent teeth Soft tissue examination An intra oral examination should always begin with the oral soft tissues This is to exclude pathology which for children will most commonly include signs of infection of dental origin such as dental abscess This will be fully covered in the section following caries diagnosis After this Recording plaque levels caries risk assessment assessing the occlusion and Managing first permanent molars of poor prognosis will complete the section on examination and diagnosis Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 23 JISCUusslONn of diagnosis amp findings with child amp parent carers N Diagnosis amp fin din gs OHA with hi
89. ing adhesive material and a bonding system Do not use glass ionomer materials for restoration of a Class Il cavity e Fissure seal the tooth surface and as many of the restoration margins as possible e Monitor for any caries progression using radiographs where appropriate e Inform the child and parent carer of the approach taken and record details in the patient s notes Partial caries removal with preformed metal crowns Preformed metal crowns are the best restoration for all but the smallest of Class II cavities One option for a proximal lesion in a primary molar is the Hall Technique see below however preformed metal crowns can also be used with a partial caries removal technique where the tooth is prepared as for a conventional preformed metal crown but with no additional caries removal This will however still involve the use of local anaesthesia and the high speed handpiece but reduces the risk of pulpal damage compared with conventional cavity preparation and avoids the bite propping associated with the Hall Technique Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 94 Technique for carious primary incisors e Thoroughly clean the teeth with prophylaxis paste e Caries removal will be minimal so local anaesthesia is not required e Acid etch the entire crown wash dry and apply a bonding system e Place the composite restoration either by handbuilding or using strip crowns e Info
90. ing children cope key points e Begin every session with Gaining rapport Giving control Teaching relaxation through diaphragmatic breathing if it hasn t already been done e Additional behavioural management techniques useful enough to be included at every intervention even if the child appears not to be anxious include Praise and reward Tell show do Structured time Systematic desensitisation e If local anaesthetic injections are necessary reduce discomfort by Using topical anaesthetic Injecting very slowly a minimum of 60 seconds for half a cartridge Use of intra papillary injections to achieve palatal or lingual anaesthesia Receiving any sort of dental intervention is likely to be challenging for the child until they have built up a good level of trust with their clinician There are a range of behavioural management techniques which can be used both for the anxious child and also for the child who is not anxious but is new to receiving dental care Use of these techniques can make a dental visit much less stressful both for the child and their clinician Getting off to a good start Before beginning e Engage with parent carer and chaild gaining rapport e Give control e Teach relaxation Engaging with the parent carer and child This has been covered in a previous Section Giving control For a child to have control over their treatment is an absolute basic right It is difficult to conceive of a cli
91. ir patients still feel comfortable with is arguably appropriate for a very few clinical situations However it is not conducive to behaviour change where the drivers and barriers to change exist in the context of patient s life outside not inside the dental surgery Instead a different model of care more conducive to behaviour change is Dentist Patient A person with some additional A person who might benefit skills and knowledge from those skills but who also has a whole lot of other things to think about By its very nature history taking with its reliance on question and answer will have a tendency to reinforce the old model Expert subject This will be unavoidable for the medical history but for the dental and social history the use of open rather than closed questions is a significant step to introducing the parent carer to the new relationship Open and closed questions A closed question such as How often do you brush his teeth Does he get fizzy juice anticipates a simple short response The problem with closed questions is that they inevitably carry an inference that there is a wrong answer as well as a right answer especially with the answers being scribbled in the notes as the patient speaks This in turn indicates the old model of clinical care is Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 18 being followed While the oral health team may obtain so
92. is but delayed Active proximal caries first primary molar High risk of sepsis imminent Active proximal caries second primary molar High risk of sepsis but delayed Active proximal caries second primary molar Low risk of sepsis Treatment plan Hall crown this course of treatment Hall crown first molar this course of treatment prioritise the more vulnerable tooth Hall crown second molar in 4 months time Prevention alone and monitor The treatment plan defines what the OHC Team will do to improve a child s oral health and it is clear that for it to be effective it must be based on the highest quality of history taking examination amp diagnosis and problem list formulation A good treatment plan can of course be spoilt by poor quality treatment delivery but that will be covered in the sections on treatment provision The following section will cover the difficulties in consistently achieving excellence in an oral health assessment and how these difficulties might be addressed Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 48 How clinical problems are usually diagnosed and solutions decided upon and problems with this approach Are you a Type 1 decision maker Or a Type 2 decision maker Type 1 decision making Type 2 decision making Intuitive Sequential Experiential Structured Non sequential Logical Habitual Analytical Non verbal thinking Verbal thinking in w
93. it Consider the use of radiography to monitor if the lesion is progressing at intervals informed by caries risk assessment When a fissure sealant that has been applied over a carious lesion has worn enough to expose some parts of the fissure system apply a fresh fissure sealant Inform the child and parent carer of the approach taken and record details in the patient s notes Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 96 Hall Technique using preformed metal crowns This technique involves sealing caries into gt primary molars with a preformed metal f T N crown PMC No local anaesthesia tooth A J preparation or caries removal is used E ex a CANA 7 F ee 7 R The Hall Technique caries in a lower E sealed in with a PMC Only an outline of the technique is outlined given below Before using it refer to the Hall Technique User s Manual available at www scottishdental org index aspx 0 1404 Early detection of proximal lesions with radiographs before there is marginal ridge breakdown will facilitate management with the Hall Technique as PMCs can be more difficult to satisfactorily fit if the mesio distal width of the carious tooth has been reduced by mesial migration of the tooth behind Outline of Technique e Ensure the child is sitting upright e Assess whether separators are required e Placing separators requires a second visit
94. ive you and Peter I d like you to sign it if you will then Mum can sign it so that you agree to Mum helping you And you ll see there is a space for a present if you fill in all the boxes with stickers Here Mrs McGregor I ve filled in the correct fluoride concentration toothpaste Peter should be using and here s a toothpaste packet to show you where you can find the concentration listed I ve also written in the amount you should put on Peter s brush You told me that Peter soends weekends with his Granny can you go through all of this with her and make sure she has the chart this weekend D you think Granny will be OK with all of this ce Additional points on brushing advice Repetition of core ideas see Changing behaviour The brushing chart properly used allows a number of bases to be covered It e gives written confirmation of the information covered e it may form a contract between the child the parent carer e it gives the child reward for completion e it may encourage the child to in turn encourage the parent carer to comply e it may help to keep good brushing practice going for long enough to become a habit which is the aim of all behaviour change interventions e it aids dissemination of information to other parent carers who did not attend the appointment e some clinicians ask parent carers to attend with the child s brush and paste The advantage is that both can
95. l health care is a key step arguably the single most important step in managing the oral health of children with active dental caries particularly in encouraging compliance with toothbrushing advice and diet advice It could also be used to encourage e completion of a course of treatment and reducing failed appointments e attendance for regular recall appointments Changing behaviour our own or another persons is hard in fact very hard but with an understanding of ourselves as people and our limitations it is possible What is Known is that simply giving patients information however intensely and earnestly is unlikely to change behaviour possibly because as adults we are generally happy with our behaviour or at least have rationalised it entirely to our own satisfaction and to respond to a request to change implies criticism of us and loss of our autonomy In a nutshell none of us like being told what to do Behaviour change is more likely to occur when the patient acknowledges to themselves that changing their current behaviour will be beneficial to them or their children rather than being told it will be beneficial for them by a health care worker as hear myself speak learn what I believe and it is persuasive to me because said it Bringing about that subtle twist is achieved using a communication method known as Motivational Interviewing and the oral health team are ideally placed to use it as we are skilled
96. l their tummy 3 Watch to see if their tummy rises if so praise them and ask them to release their breath slowly telling them that as they breathe slowly out so they will become more relaxed 4 Ask them to do this three times any time they feel tense and worried Other Behavioural Management Techniques Tell Show Do Explain to the child what you are going to do and then show them before continuing with the treatment The following example demonstrates how to encourage an apprehensive 5 year old child to accept treatment that involves use of a high speed handpiece for the first time 1 Gain rapport give control teach relaxation 2 Tell the child what you would like to do and show them the handpiece tell show do 3 Show them the high volume aspirator and ask them if it would be alright to try it If they agree ask the nurse to put the aspirator tip into the child s mouth switch it on then off and then remove it 4 Ask the child if that was OK 5 Tell the child you would like to put the handpiece in their mouth calling it whatever your favoured term is switch it on count to 4 structured time see below then remove it You will not touch their tooth Ask the child if this would be OK 6 Ifthe child agrees then proceed as above If the child is happy tell them you would now like to touch the tooth and ask if that is OK Continue using this technique for each new action Although this approach can appear
97. laboured after a child has accepted the procedure it is usually not necessary to work through all the stages at subsequent visits A child who has a profound needle phobia will need an enhanced version as described below Structured time Children can tolerate some potentially upsetting procedures such as use of a slow handpiece if they know it will only continue for a finite period of time Just a little bit more for a child could mean anything from a second or two to eternity Instead Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 84 e Break down time into units the child can understand For example lIl buzz your tooth while count to three then stop is that OK Good 1 2 3 Well done And again 1 2 3 etc e Note that young children up to 5 years old may not understand the concept of numbers above 4 despite being able to recite them Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 85 Systematic desensitisation Systematic desensitisation is a very powerful technique to for helping people cope with something they find fearful and is an enhanced version of the sequence above Only an outline is given here For further details refer to Child Taming How to Manage Children in Dental Practice by Barbara Chadwick see Further Reading section e Discuss with the child how to recognise the signs of stress and anxiety that they may be experien
98. lan treatment to meet the following three goals Maximise the probability of the permanent dentition remaining caries free Minimise the risk of any carious primary teeth causing the child pain sepsis Minimise the risk of causing treatment induced anxiety e All interventions need to be provided within the child s ability to accept them and with their full consent e Following a risk assessment for pain sepsis consider which active lesions in primary teeth need to be managed now and can be managed later Nothing about me without me The Treatment Plan is the selection and sequencing of interventions chosen by the clinician to manage the problems identified in the Problem List Effective treatment planning is a skill which takes many years to develop and is probably never completely mastered There are a great many variables which feed into a treatment plan some of which are shown below Diagnostic ability ability to attend Prognostic ability range of techniques he she is prepared to expectations use Parent carer involvement of extended carers pa l l l skill in selecting optimum technique technical skill in providing those techniques time available per visit willingness to accept responsibility extent to which will accept dental care extent to which will cooperate with parents regarding home care E beliefs regarding oral health care communication skills in motivating child amp ability
99. le to toothbrushing e The resulting cavity form will vary in shape depending on the lesion It might be opening out of an occlusal lesion or result in a slice preparation as shown in these photographs e Apply fluoride varnish e Inform the child and parent carer of the approach taken and record details in the patient s notes Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 100 Complete Caries Removal and Restoration Aim to remove all infected carious tooth tissue and restore the tooth to function Advantages e Evidence largely from secondary care and private practice that this approach can be effective e Currently accepted as best practice by British Society for Paediatric Dentistry Traditionally taught in most UK dental schools Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 Disadvantages some evidence that this approach is not effective in general dental practice in Primary Care in the UK Can be demanding of both the child and the dentist as this involves use of local anaesthesia and high speed handpieces and required requires good moisture control 101 Technique for plastic restorative material Example shown restoration of a mesial cavity upper left second primary molar e Give local anaesthetic before commencing cavity preparation as this will require sound dentine to be cut e Gain access to caries usin
100. lement lecture series given in Tasmania and New Zealand 2010 2011 28 Radiography Radiography is an essential aid to diagnosing caries for most children Due to the broad flat contacts of primary molars proximal caries may not be visible until at an advanced stage F ji pP r a 3 Note that while the mesial lesion on the lower second primary molar can be diagnosed from the opalescence of the marginal ridge the distal lesion affecting the first primary molar might have passed unnoticed The bitewing film demonstrates no intra radicular pathology affecting either of the lower primary molars however the intra radicular area of both upper primary molars is not visible on the film A useful film if the child can manage is the vertical bitewing film A disadvantage though is that great accuracy is required to include first and second primary molars and the first permanent molar on one film There is good evidence that the great majority of children are happy to tolerate bitewing radiography e Unless the dentition is spaced or the child is assessed as at very low risk of dental caries bitewing radiography should be part of the clinical examination for children aged 4 years and above e f radiographs have been taken previously take subsequent bitewing radiographs at the following intervals as recommended by the Faculty of General Dental Practitioners based on the child s risk of developing caries For children at increased
101. lieve they can do it The method will be described as a sequence of stages with the proviso that this is only for ease of description on the written page and in reality there may well be blurring of the boundaries between the stages In addition when written down it may appear long winded slow to use and overly complex In reality it is none of these things imagine how long it would take to describe on paper how to dance a Foxtrot or a Samba the concepts described will be very familiar to anyone who has been working with people for a year or two even if the descriptive terms applied to the concepts seem unfamiliar The experienced oral health worker should view the following as a guide rather than a script as flexibility is essential Members of the oral health team will not find success by applying the same approach all the time there will be a need to modify the approach for different patients and sometimes also for the same patient within an appointment Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 55 Overview of Motivational interviewing You use 4 specific to gain then you until the parent carer communication skills verbalise the changes they need to make when you O Open questions develop support them in making A Affirmations empathy gt discrepancy their choice self R Reflective listening rolling with efficacy S Summarising resistance The four specific communi
102. ling sound 2 active lesion surface discontinuity 5 inactive lesion surface discontinuity 8 filling active lesion 3 active lesion cavity 6 inactive lesion cavity 9 filling inactive lesion Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 36 Although simpler than the ICDAS system the Nyvad system records less information to assess change in lesion size over time and there is no capacity to record fissure sealants whether present or partially lost 3 Photography With practice a good digital camera with a ring flash and an assistant to hold the mirror full arch views can be taken within around 2 minutes The information they provide can be invaluable in determining whether carious lesions really have arrested and they can be very useful as a child and parent carer motivation tool The example below shows progression of mesial lesions in both of the maxillary second primary molars over 3 years based on which the management strategy was changed from prevention alone to Hall crowns Recording radiographic findings Currently no system of recording radiographic findings is in common use although UK regulations require a radiographic report to be entered in the patient s notes A significant difference however with assessing caries is that radiographs are available at subsequent visits unless they are mislaid If mounted sequentially they can be invaluable in monitoring caries progression
103. lusions to cover surface until the entire surface approximately a third of the is frosty incline of the cusp Do not allow resin to overflow into gingival sulcus as this will compromise the seal Check the sealant Wipe the air inhibited layer Check for flash and the integrity from the surface of the sealant of the sealant with a probe as children find the taste If the sealant can be picked off distressing with a probe then it is almost certainly leaking and needs to be removed Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 79 Reasons for failure e The most common reason for failure is inadequate moisture control Generally the mouth mirror should never leave the patient s mouth during the procedure in the maxilla it separates the tooth from the patient s tongue while in the mandible it does the same by stabilising the lingually placed cotton wool roll e The tooth surface must look frosty before applying the resin if not then there has been moisture contamination e The resin must not be allowed to flow distally into the gingival sulcus when the flash is removed it will invariably also take part of the sealant indicating an absence of bond in that area Children will be better served having no sealants placed than a leaky one Monitoring fissure sealants over time A fissure sealant is only effective when all the fissures are fully covered by a well bonded resin Fissures shoul
104. ly high failure rate If glass ionomer is used limit this to Class cavities e Inform the child and parent carer of the approach taken and record details in the patient s notes Avoiding latrogenic Damage when Preparing Class II Restorations When preparing Class II cavities iatrogenic damage to the approximal surface of the adjacent tooth is common This damage has been shown to occur in up to 60 of Class Il preparations and is associated with a significantly increased risk of subsequent caries development To reduce the risk a matrix band can be placed around the adjacent tooth prior to cavity preparation or the enamel margins of the box can be prepared with hand instruments alone as shown below Technique e Example shown Class II cavity preparation for a mesial cavity on an upper left 5 with u gingival margin trimmers alone being used to ad prepare the box e Access cavity prepared with a high speed handpiece leaving the approximal wall of enamel intact e Remove caries using a slow speed handpiece e Prepare approximal cavity margins using gingival margin trimmers only e Complete the restoration Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 112 Planning recall intervals Recall intervals will vary between patients and should be determined by e their caries risk e If operative treatment has been staged Maintaining momentum An approach to oral health care for c
105. m F given a brushing chart or recorded the reason for not doing so given dietary advice and completed a 24 hour recall diet diary or recorded the reason for not doing so applied sodium fluoride varnish 5 or recorded a valid reason not to fissure sealed all susceptible pits and fissures if the child is at increased caries risk or recorded a valid reason not to G agreed an action plan with the child and parent carer to improve compliance with preventive advice HOO o C as part of your Caries Management have you O managed caries in the pits or fissures of 6s and 7s appropriately managed enamel only approximal caries in 6s and 7s effectively considered the prognosis of any carious 6s and if this is poor considered planned loss selected an appropriate management option for any active carious lesions in the primary dentition that you assess as likely to cause the child pain or sepsis before exfoliation used appropriate behavioural management techniques to help the child to accept treatment or referred for further care the child who is unable to accept treatment despite behavioural management techniques oe cere A A N Oo E D D as part of your Decision Making and Shared Goal setting have you not only met your goals but also those outcome measures agreed with the child and parent carers agreed an appropriate recall interval with the parent carers and secured their commitment to attend S
106. me information about home care it is very likely to make the parent carer feel uncomfortable about the process Instead change a closed question into an open question by altering the beginning Closed question Open question How often do you brush his teeth How are you managing with his brushing How often does he get fizzy juice Tell me about what he likes to drink Who looks after him when you work Can you go through with me how you manage with working part time Communicating styles When the patient responds to you they will generally follow one of three main communicating styles Most oral health care workers will naturally follow the patients lead on style which is important for increasing rapport and empathy but the nuances are subtle and we may well rationalise with ourselves that that is what we do when actually we don t If there is a positive supportive relationship between two members of the OHC Team such a nurse and therapist carefully worded feedback after a consultation can be invaluable Styles of Example Comments communication Directing What can I give him that s Can be useful but only where there is good for his teeth really good rapport Following I feel awful that he s going to Patient takes the lead and you just need all those teeth out respond to them classically used in breaking bad news Guiding I know I should brush his Best for behaviour change teet
107. ments Try to have your notes written up so that you are turned to face them First impressions count Establishing a basic level of engagement to build on as an entree to building empathy Parent carers generally have a lot going on in their lives Acknowledging that you appreciate the effort they have made and will do what you can to reduce the inconvenience to them of further appointments will help build rapport Knowledge of regular overnight stays are important when planning brushing advice The answers here will give valuable information for Planning Treatment Medical histories usually involve closed questions so should be left till the final part of the History taking when rapport should be well established Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 22 OHA with gt Mstory amp Fa Tn ra examination Y pope ee preblem list ec eae plan Examination an overview key points e A thorough comprehensive and meticulous examination and diagnosis are the foundation of successful oral health care and must include both of the following factors An assessment of the oral health status of the child with respect to the presence or absence of dental disease and An assessment of the attitudes opinions and expectations of both the parent carers and the child regarding the child s oral health e Use of a standardised data recording form is essent
108. mply brings together techniques from a variety of areas of clinical practice many of which have been used in different parts of the world for many years e It does not involve learning a complete new set of skills and at most requires nothing more than the refinement of a few skills that experienced members of the OHC Team will already have Much of what is contained in the manual will be familiar to anyone involved in providing oral health care for children although the emphasis may be different e The approach to managing the carious primary dentition is not a simplified dumbed down version of specialist paediatric dental treatment for those who don t have access to such care a kind of second class dentistry for second class citizens Indeed it is every bit as intellectually and clinically challenging and satisfying as the classical surgical approach just less stressful for all the parties involved e Itis not exclusionist and is not proposed as the only model of child dental care the approaches may not suit every clinician every parent carer every child or every carious tooth in that child Clinicians may find some parts of the approach easier to integrate into their clinical practice than other parts and that is perfectly acceptable Clinicians share the same goal when providing care for their child patients even if they choose different routes to getting there e The approach does not involve writing off ignoring
109. n Occlusal Class lesions cavitated o If the patient unable to accept partial caries removal technique or conventional restoration Signs or symptoms of irreversible pulpitis or dental sepsis Clinical or radiographic signs of pulpal exposure or peri radicular pathology Crowns so broken down that they would normally be considered as unrestorable with conventional techniques Teeth with arrested caries Teeth close to exfoliation Child at risk of endocarditis or immunocompromised 98 No Caries Removal Prevention With or Without Self cleansing Aim to reduce the cariogenic potential of the lesion by altering the environment of the plaque biofilm overlying the carious lesion through brushing and dietary advice Making the lesion self cleansing by slice preparation may aid plaque control Advantages e The absence of operative intervention unless the lesion must be shaped to make it self cleansing makes this Disadvantages As yet there is no evidence base that this approach is effective Very reliant on parent carer and child approach acceptable to children changing their oral health behaviours with regard to oral health Technique for prevention alone Show the parent carer and the child the carious lesion Provide enhanced Prevention with particular emphasis on effective brushing of the lesion e g to brush a Class Il lesion may require the brush to be moved laterally Keep a record of the size col
110. n then there is evidence that provided the sealant is maintained the caries will not progress If there is uncertainty whether caries is present in an occlusal fissure the appropriate procedure is as follows e Thoroughly clean the fissures of all debris dry the tooth and view it with bright direct light e Drying allows any demineralisation in the enamel to be visualised in the same way that etched enamel only appears frosty when completely dry e View a good quality bitewing radiograph of the tooth If there is either shadowing visible under dentinal caries clearly visible micro cavitation or enamel adjacent to fissure radiographically i maks z then place a conventional composite restoration limited to the site of the carious lesion as described below and fissure seal the remaining fissure system e tis important to note that the two clinical examples shown above do not represent a failure of the fissure sealants they represent a failure to monitor and repair existing sealants possibly due to patient non attendance or on the part of the dental team Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 108 e If the fissure is discoloured or stained but none of the above applies and caries is not clearly undermining the enamel either visually or radiographically then place a fissure sealant and review at every recall visit Top up the sealant if it wears enough to expose fissures e f
111. nds on the 6 E contact 2 3 times a week e In addition if the distal of the E has a Class II lesion consider e a Hall crown on the E or a restoration If restoring take extreme care not to cause iatrogenic damage to the mesial of the 6 when if rotary instruments are used e Extraction of the E this will necessitate loss of the 5 for crowding relief in due course Earlv aovroximal enamel lesion on upper left 6 Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 110 Atraumatic Restorative Technique ART Aim To prepare cavities in a manner that is less stressful for the child than conventional techniques Advantages Disadvantages e Evidence that children find cavity e Requires the use of very sharp hand preparation with ART less stressful than instruments and is a very exacting conventional preparation technique for the clinician e Cavity preparation using ART may be advantageous where child behavioural management is an issue ART was developed for cavity preparation using hand instruments only without local anaesthesia in developing countries where there was no access to power Children perceive cavity preparation with ART to be less stressful than conventional techniques so dentists might consider using ART to prepare cavities Unfortunately ART has become synonymous with use of glass ionomer cement as the restorative material as it is the only material which can safely be hand mixed
112. ness of the following using a Motivational interviewing approach Tell me about e brush twice day for 2 mins Ya toothpaste 21000ppm F Y N e supervised toothbrushing lt 8 yrs Y e smear lt 2yrs pea 2 6 yrs Y N e spit don t rinse Yz e Nuthin after brushin at bedtime Y N Examination amp Diagnosis Extra oral any features of note intra oral Sinus Plaque score BPE 110 gt 12 yrs ANF CIEE ELUST TRAE OT NET anaa RT N EA Complete Caries chart overleaf Signs of erosion Non carious opacities Dental anomalies Caries risk low moderate high WERT PEREBA EA NEIE Second page of Oral Health Assessment sheet For the Carious Primary Dentition Existing pain sepsis Imminent risk pain sepsis Delayed risk pain Sepsis Indications for early orthodontic referral Y N if yes tick relevant box e Anterior X bite Upper 3s not palpable by age 10 e Missing or delayed eruption or impaction Ga peer prsgnasis _ displacement of permanent teeth Problem list oc seeeecesees ease nes ee enema mee sem cee m mne ec e Treatment plan Sign and date on completion Date Po Clinician s Signature c0c0 cen 117 Dental chart dao B10 je USPYsIpOIS MMM YSA OW WeIHOIg SSSUBAIISYA LHUD J USq YSS JO UOIssiwad Aq pey Judg EE E a NA a od re Bupu JUBADS 9I J3UjO Kuy Aum uoseel ree ee u ye SUOU i syudeiboipey uoHeousne 118 Post tr
113. ng Knowledge but also the skills and motivation to operationalise that knowledge put that knowledge into practice 2 Educating and motivating transferring knowledge and the skills and motivation to apply it Modern educational practice recognises a range of techniques that can be used in order to help the learner to achieve an educational goal and these can be applied to a toothbrushing instruction session Teaching strategies e Interaction e Transfer e Enactment Repetition of core ideas Practice Feedback Clarification In addition it is recognised that people have different learning styles which are listed as follows Learning styles e Visual Demonstration using visual prompts Learns by remembering images e Verbal Learns by talking through ideas and explaining things themselves Dialogue with the learner Reading writing Use of the written word and names Kinesthetic learns ideas by applying them practically Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 66 Speaking Although different people will favour different learning styles everyone will use a combination of all four It is easier to remember and recall information that was presented using a variety of modalities so all four learning styles should be included in your brushing instruction Learning outcomes What you want the learner to be able to achieve at the end of the session For brushing
114. ng caries in pits and fissures and to be more effective at this than fluoride varnishes However placing high quality sealants is demanding for the clinician and sometimes for the child as well An uncomfortable truth Fissure sealants are very effective at caries prevention If caries does develop in a tooth which has been sealed then it is likely for one of the following reasons e The sealant was poorly applied so that it was either lost entirely or the bond failed around part of the margin but the material retained on the tooth as a cantilever this is why sealants must be checked physically as well as visually e The sealant has worn the material is an unfilled resin it wears exposing fissures in a child at higher risk of caries this has not been managed by topping up and caries has developed e There was pre existing caries in the tooth before sealing which was not diagnosed Worn sealant with exposed fissures now carious If the child has attended regularly this is a failure of clinical care rather than failure of the fissure sealant It is difficult to see a situation where a child who has been regularly attending for dental care goes on to develop new pit and fissure caries as anything other than a failure of clinical care Fissure sealants where indicated need to be placed and maintained with the same attention to detail as any restoration Notes to supplement lecture series given in Tasmania and New Zealand 20
115. ng dietary advice and brushing advice in the same session risks overloading the parent carer It should be brushing first then diet later Be up beat and positive Give a brushing chart example in Appendix and stickers to complete it plus toothpaste and a brush if possible and agree and confirm on the brushing chart o an Action Plan o areward for completing the chart successfully o that the child signs to confirm the contract O as does the parent carer Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 71 Remember that if there is an older sibling they might be able to take on the role of supervising the evening brushing session Also some people have suggested that asking children to brush their teeth immediately before bedtime might make them associate it with punishment while it might be more constructive to have them brush half an hour before bedtime with then half an hour to do what they like reading play TV as a reward No snacks though Reinforcement At every visit ask about brushing and be supportive and encouraging Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 12 Summary of a practical toothbrushing session 1 Assessing the 2 Education amp motivation 3 Action 4 Habituation need planning Having Engaged by Stage 1 Use Close the It takes time and gaining O Open questions session by repetition Eye contact amp
116. nical situation where it is in the child s best interest to continue with an intervention if they are distressed and vocalising There will invariably be a way of managing the situation in a different way Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 83 The child must be clear then that they have the final say as to whether an intervention can continue e Saying to a child Let me know if you want me to stop is not adequate to give them control Giving control means making sure the child understands that they decide whether treatment continues or not and rehearsing a signal to stop such as raising their hand If the child gives the signal then stop treatment immediately Failing to do so may well result in the child developing mistrust phobia which can be very difficult to resolve e Be aware that young children may not yet be familiar with or able to readily grasp the concept of control look for other signs eyes are good so use clear safety specs of distress Teach relaxation It is not physiologically possible to be both anxious and physically relaxed at the same time so physical relaxation is an extremely powerful method of reducing anxiety However just telling a child to relax will not help them to relax but showing them how to breathe deeply using their diaphragm can _ Ask the child to place a hand on their tummy 2 Ask them to breath in slowly and deeply making the air fil
117. nt brushing practice attitude and experience of child and parent carer to treatment assess whether anxious and if so level and causes of anxiety Medical history to Identify any medical conditions which may influence oral health and the provision of oral health care The use of a structured form for recording the oral health assessment or at least a checklist is essential see Section Problem List Overview First establish communication then take ahistory Social history Dental history Medical history Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 16 Communication Communicate verb k mju nt kert to Share information with others by speaking writing moving your body or using other signals There is more to communicating effectively with patients than simply speaking very clearly and avoiding jargon This is of course a part of communication but only a relatively small part Good communication is a two way process which involves actually engaging with the person both at a verbal and a non verbal level listening to them hearing what they are telling you and responding to it Most members of the OHC Team are good with people otherwise they wouldn t be able to achieve the miracles of people management that are a part of every day dental practice The skills used to achieve this can be difficult to clearly describe with words Much of clinical practice is very ph
118. ny caries preventive programme will be compromised Younger children have a different perception of oral health compared to adults being very much less concerned if at all by poor aesthetics or loss of function It is pain and sepsis chronic infection that bothers them In addition most children have little sense of the benefit of investment now e g having a filling for future gain freedom from pain in a year or two The combination of these two factors coupled with children being at an early stage in their emotional development results in them having a limited capacity to tolerate dental treatment Dental interventions therefore have to be tailored to the child s capacity to cope with the imperative of always practising within the envelope of the child s ability to tolerate treatment To do otherwise when providing an intervention risks winning the battle but losing the war Unlike the permanent dentition the primary dentition is temporary and is shed This offers a significant opportunity for the OHC Team when managing dental caries in the primary dentition particularly if trying to meet the child s treatment objectives freedom from pain and sepsis rather than most adults treatment objectives freedom from pain and sepsis and good aesthetics and good function There are evidence based methods available for slowing or even arresting dental caries for long enough to allow the affected teeth to shed naturally without
119. odontic treatment later Around the ages of 9 and 10 the maxillary canines should be palpable high in the labial sulcus If they cannot be palpated by 10 years of age consider taking parallax radiographic views to determine if they are palatally placed If they are seek an urgent orthodontic opinion Early loss of maxillary primary canines can in some cases allow the permanent canines to realign to a normal eruption path These parallax views show the maxillary left permanent canine is palatally placed the AOMax beam angle is 45 degrees the DPT is horizontal the tooth has moved with the tube therefore its deep Increased overjet Current UK guidance based on recent research is that early treatment of increased overjets only offers the patient advantages if they are unhappy due to being teased at school Otherwise arrange for treatment if the patient wishes it when the permanent dentition has erupted Submerging primary molars The majority of these are eventually shed with little problems However if submerging to the extent that adjacent teeth are crowding over them consider extraction Submerging second primary molars may be associated with missing second premolars if so refer for specialist opinion Premature loss of maxillary primary canine with centre line shift If unilateral loss of a maxillary primary incisor is associated with a centre line shift to that side then current UK guidance is that the remaining maxillar
120. or orthodontic opinion before undertaking extractions Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 42 e lf there is pain or sepsis and the child accepts local anaesthesia consider extraction of the affected tooth only before referring for specialist paediatric or orthodontic opinion e f necessary consider temporising first permanent molars of poor prognosis in young children possibly using preformed metal crowns to keep them free from symptoms until the optimal age for extractions is reached e fin doubt at any stage temporise the teeth continue prevention and refer the child for specialist paediatric or orthodontic opinion Extraction of FPMs under local anaesthesia especially if more than one tooth needs to be extracted is a significant undertaking for the child and clinician Clinicians should use their judgement on a case by case basis as to whether the use of sedation or general anaesthesia might be indicated and refer as appropriate F a m oa i ey L a j af aut p i 7 P F a E aF Good buccal segment alignment as a result of loss of FPMs of poor prognosis at the optimum time Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 43 OHA with P ai Agreed history amp Diagnosis amp _ fin Agreed treatment die atin findings i problem list examination plan Although we all discuss treatment plans with our patients it is
121. ords Right brain Left brain Characteristics Characteristics Quick Relatively slow Effortless Requires mental effort Dental and medical students are trained to approach diagnosis and treatment planning in a logical structured sequential and analytical way This has been described as a Type 2 approach Crosskerry or a Left brain approach The problem is that once qualified they soon stop doing so It seems that once in practice most clinicians formulate their problem list and treatment plan intuitively as they progress through the history examination and diagnosis stage and then use the dental chart as their restorative treatment plan This is Type 1 intuitive non sequential decision making or a Right brain approach which can be reliable for the experienced clinician who regularly audits and critiques their own clinical practice Clinicians tend to revert to Type 1 thinking because e It s quick e It takes less mental effort than Type 1 thinking so it s easier It is the natural default position of the human mind when engaged in a familiar task even if it s complex such as driving a car or flying an airplane Unfortunately it is largely based on pattern recognition from previous experience and with the natural tendency of the human mind to look for best fit and rationalise away factors which interfere with that fit Type 1 decision making is prone to both repeating the same mistakes
122. ottom teeth on this side keeping scrubbing and only after quite a few scrubs do now move to the outside of the same teeth and clean them and Peter what can you hear Yes You can hear the schhh schhh of the teeth being really cleaned Now well done Peter You ve let me brush your bottom teeth on both sides at the back and then at the front How long did it take me to brush your bottom teeth Yes it took about a minute didn t it So how long will it take you to bruch all of your teeth Yes a couple of minutes good boy Comments seeking permission as above This also lets the mother know she s not going to be put on the spot by being required to demonstrate what she does at this stage and her autonomy is not being challenged A matter of personal preference and no right or wrong but allows you to fit in with the mother s preference so increasing engagement and empathy A method of getting the knowledge across that there are three surfaces to be cleaned and back teeth as well as the front ones without challenging either the mother s knowledge or her autonomy Which is best is again a matter of personal preference Demonstrate a modified Bass technique engaging with the child but also including the mother in your dialogue This is the opportunity to help the mother learn the need to include the back teeth see diffusion of fluoride in previous section and all three surfa
123. our and consistency of the lesion to enable monitoring and an alteration of the treatment plan if the lesion does not arrest Consider recording caries progression via radiographs photography or ICDAS Assess for the presence or absence of plaque biofilm on the surface of the lesion at each visit consider recording plaque scores If the child or parent carer cannot keep the lesion free from plaque consider an alternative management strategy Ensure the parent carer is made fully aware of their responsibility If caries progresses choose another option Consider whether making the lesion self cleansing would aid plaque control Inform the child and parent carer of the approach taken and record details in the patient s notes This carious lower E has been managed with a prevention alone strategy This has not been successful as plaque is visible four months later and the caries appears active rather than dark hard and inactive arrested Therefore a more restorative based approach is now required Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 99 Technique for making a lesion self cleansing As only enamel and carious dentine are removed the use of a local anaesthetic should not be necessary unless subgingival tooth preparation is required e Using a high speed handpiece or hand instruments remove undermined enamel adjacent to the carious lesion making the surface of the lesion accessib
124. ow regarded as unacceptable to leave dental sepsis in the mouth There are two treatment options extraction of the tooth or pulp therapy if feasible In exceptional circumstances it may be possible to monitor asymptomatic dental sepsis for up to three months while the child is acclimatised to the dental treatment necessary to manage the dental sepsis If within this time the child does not respond to anxiety management consider referral to a specialist centre Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 38 OHA with 5 sags Agreed history amp Diaminais i Ap sod treatment aii findings problem list examination plan Recording plaque levels Recording plaque levels at each visit and sharing this information with the child and their parent carer will help reinforce the importance of effective tooth brushing An example of a quick method of recording plaque levels and presenting the information in terms the child will understand is to give marks out of 10 as follows perfectly clean line of plaque cervical third of middle third tooth around the the crown covered cervical margin covered Record the worst score in each sextant for example 8 10 6 10 8 10 8 10 6 10 8 10 It is also important to assess the surface of open carious lesions for plaque that is visible or evident when an instrument is gently drawn across the surface of the lesion particularly if considering
125. pain or sepsis and without the child having to tolerate complete surgical excision of carious tissue followed by restoration of the tooth This manual is a practical guide to an effective caries preventive and management programme which works within the parameters outlined above and can be provided for children attending for dental care It is not aimed at undergraduates as it assumes a basic level of knowledge and skill but at members of the OHC Team who have some experience of clinical practice How the approach will be presented in this manual Providing child dental care is as complex multifactorial and non linear as playing a musical instrument or driving a car and using the written word alone to convey information about it has limitations With that proviso those areas which define the child friendly approach as being different from an adult model for dental care will be highlighted on the next page in the sequence they are likely to occur when a child is brought for dental care these areas will then be explored in more depth with sufficient practical information to allow them to be applied The evidence supporting them where available and information on further reading and resources will be itemised for each area in the Appendices and finally cases will be presented showing how some children were managed with this child friendly approach Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 7 The
126. plan Building communication and the first visit Engagement is the key not just talking at them Communication amp history taking key points Communication is a two way interactive process and is critical in moving the relationship between oral health worker and patient parent carer from the traditional Expert giver Passive receiver to a more empathic relationship which is an essential component of effective behaviour change This begins by warmly welcoming the parent carers as well as the child and beginning the engaging process through the two stages of a getting eye contact and b gaining a positive response to a verbal exchange making them smile Then building on the engagement through open questions matching the parent carers communication style being non judgemental and showing an appreciation of the efforts the parent carers have made to attend and a willingness to reduce the inconvenience by altering appointment times Include the child at every opportunity they intensely dislike being talked over and can be a valuable source of reliable information on brushing and diet Using the above techniques take a Social history to gain information about the care arrangements for the child particularly regular overnight stays to help develop an effective prevention programme the most convenient appointment times for the parent carers Dental history to help with diagnosis of any pain curre
127. progressing The level of risk will determine the intensity of the preventive programme Assessing the occlusion Details of a full orthodontic assessment are outside the scope of this manual It is incumbent on the clinician to monitor the developing occlusion for problems and if in doubt to seek specialist advice The following list is not exhaustive but includes some of the more common problems to be on the look out for and how they might be managed Impacting maxillary first permanent molars It may be possible to disimpact using orthodontic elastic separators but if still impacted after around 9 months then extract the second primary molar otherwise there is an increased risk of caries affecting the first permanent molar Premature loss of the second primary molar will inevitably lead to crowding in that quadrant so ensure the parent is advised and this is documented Anterior crossbite These are usually best corrected as soon as is possible using a removable appliance However if part of a developing Class III skeletal relationship then simple management with a URA is unlikely to be effective and the child should be referred for specialist advice Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 40 Impacting maxillary permanent canines It is very important that maxillary permanent canines which are moving palatally are identified early as prompt management may avoid protracted and difficult orth
128. ption Not all carious lesions require operative management To make this decision consider e proximity of the lesion to the dental pulp e activity of the lesion e time to exfoliation e whether the lesion is sufficiently cavitated to allow cleaning with brushing e anticipated cooperation of the child and parent carers with preventive interventions In short Assess carious primary tooth clinically and radiographically Risk of abscess before exfoliation High Low Prevention and monitor Imminent Delayed Manage now if possible manage later if necessary The clinician needs to use their skill and judgement when carrying out this risk assessment It should also be noted that caries activity can change With so many variables it is not possible to clearly define specific criteria that will accurately predict which carious lesions will or will not result in pain or abscess for the child The following is intended as a guide only Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 31 Clinical scenario Description Risk of abscess before exfoliation High Distal carious lesion Imminent risk Or delayed outer 1 3 of dentine lower first primary molar Delayed 5 year old child intervention can be planned for a follow up course of treatment manage within 12 months High Occlusal carious lesion Imminent risk Or delayed soft to probing lower second primary molar 5 Slightly delayed year ol
129. r core ideas there is very good research now that brushing teeth twice a day rather than just once gives a significant extra benefit with Nuthin after brushin at night to let the paste really strengthen his teeth And spitting out not rinsing out after brushing has the same effect Clarification properly and the need to spit out not rinse after brushing This is flagging up to the Mother that you will be shortly asking her to become actively involved This may not be your usual practice but it is probably important It needs however to be handled with great sensitivity to avoid the mother feeling this is a test or empathy will evaporate and with it your chances of changing behaviour Addressing the child and using the term Mum will help you should assist with avoiding problems You are now empowering the Mother by showing her that she can manage brushing and also the necessity for it by contrasting the child s attempts on his front teeth with your own Plenty of praise helps with adults as well as children Roll with resistance Mentioning research will reduce the risk of seeming authoritarian so that the mother perceives you as a conduit for information rather than you yourself telling her what to do which would reduce empathy The Summary part of OARS Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 69 Here is the brushing chart I d like to g
130. rceptions is there a preference for avoiding a certain kind of treatment for example preformed metal crowns if alternatives are available e the clinician shares different options for overall treatment goals as well as for each of the treatment components Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 44 for example for a lower right first primary molar with micro cavitated occlusal caries extending radiographically into dentine a resin or glass ionomer fissure sealant composite amalgam or glass ionomer filling and even a Hall crown might all reasonable treatment options in certain circumstances However some might appeal more to a particular clinician as being easier for them to deliver Also there might be a balance to be struck between a simple non invasive intervention that is suitable for the less cooperative child but is likely to need replaced regularly compared with a different intervention which might have a better longevity but be more invasive for a child ina family where there is difficulty getting to appointments It is usually the case that the clinician draws up the list of problems and issues based on the parent and child s histories and the clinical radiographic examinations However as can be seen from the above examples it may not be the case that the clinician parent and child s problem list and priorities completely coincide and so it is important to build in the step of disc
131. reparation at the same appointment e There is evidence that placing a PMC at the same appointment as the pulpotomy improves the prognosis of the tooth Aftercare e Advise the parent carer that the tooth might be a little uncomfortable for the child when the anaesthetic wears off and that the child may need analgesia e Conduct a radiographic review of pulpotomised primary molars annually Non vital Pulp Therapy It should be noted that there is currently no evidence base supporting the following approach or indeed any other approach to managing the non vital primary molar and some opinion is that these teeth should always be extracted However if it is specifically wished to avoid extractions then the following technique might prove useful Example shown pulp therapy of a lower second primary molar in a 6 year old e Give local anaesthetic e Cut a large access cavity using a high speed handpiece ensuring the entire roof of the chamber is cleared e Remove the contents of the pulp chamber using a slow speed handpiece or sharp excavator and remove as much necrotic tissue as is possible from the entrance to the root canals using a straight probe e Thoroughly irrigate the pulp chamber with water from the 3 in 1 syringe e Avoid the use of compressed air which could cause surgical emphysema e Consider gentle irrigation of root canals using local anaesthetic solution To facilitate access use a needle that ha
132. report 1 sheet A4 and a post treatment checklist 1 sheet A4 These are designed to be photocopied onto both sides of an A3 sheet of paper which is then folded to give a booklet with the assessment sheets on pages 1 and 3 while the chart is inside on page 2 and the post treatment checklist at the back on page 4 These sheets are also available for downloading as Word documents to allow them to be modified as required for the local situation The five Oral Health Assessment sheets and post treatment checklist challenge Members of the OHC Team who are dubious about the value of using the sheets or something similar are urged to try using the sheets on at least 5 patients At the end of this they should evaluate whether using the sheets allowed them to collect clinically useful information which they might otherwise have missed and so offer a better quality of care for their patients Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 50 ine N Agreed OHA with i diagnosis amp history amp a a findings with eenia treatment N5 examination 8 child amp parent P plan y carers Agreed Treatment plan Achieving success by following the right route Treatment planning key points The treatment plan Be guided by discussion with child and parent Follow the sequence Pain relief if necessary Prevention Planned treatment caries management e P
133. rious dentine in a permanent tooth are met then the tooth should be managed as follows e Give LA and isolate with rubber dam e Thoroughly clean all the fissure system e Use a high speed handpiece to access the carious dentine but do not extend for prevention e Remove all soft infected dentine unless pulpal exposure would result in which case place an indirect pulp cap e Place a lining if appropriate avoiding any Zinc Oxide Eugenol product e Etch the entire fissure system and cavity walls e Wash and dry e Once the enamel is frosty in appearance apply an appropriate bonding agent then blow thin with dry air from the triple syringe e Light cure e Restore the cavity with composite in increments if necessary light curing after each stage e Flow an unfilled resin sealant over remaining fissure systems and light cure e Remove rubber dam check the occlusion and discharge the patient Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 109 Management of the Enamel only Approximal Lesion in a Permanent Molar Aim to reduce the risk of permanent molars requiring a Class II restoration Advantages Disadvantages e Identification and appropriate e As yet few clinical studies in primary management of an early proximal lesion care have assessed the effectiveness may prevent the child entering the of interventions in arresting or restorative cycle unnecessarily reversing enamel only lesions on e
134. rm the child and parent carer of the approach taken and record details in the patient s notes Primary incisors managed by partial caries removal and restoration Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 95 No Caries Removal Seal With Restoration including Hall Technique Aim to completely seal a carious lesion from the oral environment so that the environment of the plaque biofilm is altered sufficiently to slow or even arrest caries progression Advantages Evidence including some research from Primary Care that this approach can be effective and is preferred to complete caries removal techniques by children their parent carer and dentists Avoids need for local anaesthesia and tooth preparation No risk of iatrogenic damage to adjacent teeth Technique using fissure sealant Place a fissure sealant over non cavitated pit or fissure caries to completely seal the fissure system If using this approach on a pre cooperative child consider using the press finger technique with a glass ionomer material as a temporary measure see Section 6 5 Aftercare Disadvantages e Dependent on the quality of the seal for success f the seal fails the caries will progress e Further clinical trials in Primary Care needed to consolidate evidence base Non cavitated caries before and after fissure sealing Check the integrity of the sealant with a probe at each recall vis
135. ry Teeth with no Clinical or Radiographic Signs of Pulpal Involvement For each type of lesions shown the possible treatment options are indicated Further details on each caries treatment technique are provided in the following sections No caries removal No caries removal Extraction seal seal provide make orteview caries caries prevention lesion with with with Hall alone self fissure cleansing sealant and provide prevention Occlusal non cavitated lesions Occlusal cavitated lesions POROGEN Approximal early dentinal lesions eae Approximal advanced lesions Complete Partial caries caries removal removal and and restoration restoration extraction if pain or sepsis develops Ano cavitaled esin P J gt Grossly carious unrestorable tooth without signs or symptoms of pain or sepsis due to a lack of supporting evidence these approaches are only appropriate for these lesions when no other approach is feasible Document the use of these approaches in the patients record Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 92 Partial caries removal and restoration Aim to remove sufficient carious tooth tissue to enable an effective marginal seal to be obtained with a bonded adhesive restorative material and thus inhibit further progression of residual caries Advantages Disadvantages e Evidence largely from secon
136. ry belongs 0 eowsracssonmen What have had to eat and drink Draw a ring around any food or drink which can cause decay More than 4 rings a day and you may get holes in your teeth 2 rings at the same time counts as 1 for example fizzy drink and a biscuit Action Plan To help stop my food and drink from damaging my teeth will ee example have a bottle of water and a piece of fruit for my mid morning snack Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 122
137. s been bent with tweezers Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 106 e Dry pulp chamber with cotton wool Place calcium hydroxide paste in coronal section of canals using either an applicator or a probe Alternatively use a mix of plain zinc oxide eugenol e Back fill with zinc oxide eugenol paste applied with firm pressure then at the same appointment place a conventional preformed metal crown PMC e lf the tooth remains symptomatic or a sinus is still present after three months extract the tooth e lf the child will accept the placement of rubber dam clinicians could consider a pulpectomy procedure where endodontic files and irrigation are used to clean the canals before filling them with a mix of plain zinc oxide eugenol cement Further information on this specialist technique is available Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 107 Management of the Suspicious Fissure in a Permanent Molar Aim to ensure the optimum management of possible fissure caries in permanent molars Advantages Disadvantages e Appropriate management of early e If a sealing in approach is adopted when carious lesions may prevent the child managing a suspicious fissure then entering the restorative cycle careful long term monitoring and repair unnecessarily of fissure sealants is essential e f early occlusal dentinal caries is inadvertently sealed i
138. s that high carbohydrate high fat foods are generally tasty immediately satisfying inexpensive and quick to prepare compared with high protein foods A packet of sweets or a sugary night time drink will often settle a distracting child Dietary modification should be approached with caution and a sense of realism Just as with brushing avoiding judgement and gaining empathy are everything if progress is to be made see section on Changing behaviour Couple those two and combine them with realistic expectations and some dietary modification might be achieved There is clear evidence that the key component of a cariogenic diet is sugars more than four times daily so the aim should be to reduce the frequency of sugar consumption to four times or less per day Being realistic and in view of all the barriers to dietary change it would seem sensible to concentrate on two areas e Between meals e The last hour before bedtime especially anything just before going to sleep Why concentrate on between meals eating Because of the amount of hidden sugars in many pre prepared meals and foodstuffs It may well be unrealistic to expect many families to prepare a full meal identifying and excluding foods and drinks with sugars And why is eating last thing at night so damaging Because the salivary flow rate drops to about one tenth of the daytime flow rate This results in a longer clearance time for sugars in the mouth and so encoura
139. se by non progression using a diagnostic system sensitive enough to detect progression Sequential radiographs photography ICDAS in early lesions 3 If present and active what s the risk of it causing pain sepsis before the affected tooth exfoliates e Assess this using the following criteria proximity of the lesion to the dental pulp activity of the lesion and time to exfoliation whether the lesion is sufficiently cavitated to allow cleaning with brushing anticipated cooperation of child and parent carers with preventive interventions e Asymptomatic dental infection Sepsis must be identified from History Inflammation sinus tenderness in peri alveolar tissues Pathological mobility Radiographs Clinical judgement based on extent of cavity Information must be recorded using a method that allows caries progression to be monitored and for different clinicians to be able to interpret the information about the same assessment in the same way Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 24 The management of dental caries in primary teeth is different from permanent teeth Introduction Primary teeth shed naturally and so a carious tooth might if the rate of progression of the disease can be slowed exfoliate before the child experiences pain or infection In addition children are generally little bothered by either the aesthetics or loss of function of carious primary teet
140. series given in Tasmania and New Zealand 2010 2011 9 after it It is relatively easy for the clinician to become focussed on obvious dental disease in the primary dentition and to take their eye off the ball regarding the permanent dentition For example have a look at the radiograph below and identify which pathology catches your attention first Was it the leaking restorations on the upper primary molars Or the distal caries on the upper second primary molar Or the cavity on the lower first primary molar which seems arrested or even the space loss already obvious following loss of the lower second primary molar Is it the buccal pit masquerading as occlusal caries on the lower first permanent molar its linearity gives it away but it will need to be sealed Arguably the most significant lesion of long term importance to the child s future oral health is the early enamel only lesion on the mesial of the upper first permanent molar Appropriate management of this lesion might avoid the necessity for a Class II restoration which when placed in a child has a poor prognosis The primary teeth with all their problems will be gone in three or four years the permanent dentition is for life Similarly with the maxillary dentition of this 6 year old child it is the poor state of the primary molars which catches the eye but the maxillary right first permanent molar is erupting into an environment where the caries is still uncontrolle
141. story amp examination treatment plan Agreed preblem list Caries diagnosis Presence or absence is only half the story Caries diagnosis key points e Primary teeth shed Therefore the principle aim of managing dental caries is to prevent the disease causing the child pain or abscess before the affected tooth is shed and this requires a different assessment of the disease from that for permanent teeth Assess caries in primary teeth using the following 3 criteria 1 Is caries present 2 If present is it active or inactive 3 If present and active what s the risk of it causing pain sepsis before the affected tooth exfoliates and is that risk imminent or delayed 1 Is caries present e Teeth must be clean and dry Bitewing radiographs will usually be an essential part of any examination repeated at subsequent intervals as determined by a risk assessment every 12 to 24 months if at increased caries risk e Dentine will be carious and infected if Shadowing opaque whiteness visible under enamel adjacent to pit or fissure Microcavitation present Dentinal caries visible on a radiograph 2 If present is it active or inactive e Enamel caries which is active feels rough to a probe gently stroked across the surface arrested caries feels smooth e Dentinal caries which is active is soft to probing arrested caries feels hard e Assume dentinal caries which is not accessible to probing is active unless proved otherwi
142. supplement lecture series given in Tasmania and New Zealand 2010 2011 17 provide see Helping children cope and provides the basis for changing behaviour in a positive way It must be remembered though that the level of engagement and its very close relative empathy see Changing behaviour are not fixed and can go down as well as up during a single treatment session or between appointments This must be identified if it occurs by the OHC Team and managed appropriately B Building communication This section draws from an excellent short book edited by Ramseier and Suvan Health Behaviour Change in the Dental Practice which is highly recommended see section on Further Reading for details Stimulating engagement sometimes referred to as rapport is the first step to building up good communication with the parent carer and child Having achieved it you will then settle the family group down in the surgery and will begin the process of history taking This is a good opportunity to begin to lay out what you expect the relationship between you and the parent carer to be which may well be different to that which they are used to or expecting Changing the balance The old model of clinical care is as follows Dentist Patient Expert Cooperative Active Passive Authoritative Unable to think for themselves Judgemental In need of guidance to differentiate between good and bad behaviour This model which many clinicians and the
143. tablets or fluoridated water The sites are the base of fissures and just below the contact points So how does fluoride reach these two sites By diffusion It is important to fully appreciate this because the rate of diffusion of fluoride through plaque to reach these two sites is significantly affected by a number of factors several of which are in the oral health team s control The rate and quantity of diffusion is directly related to Concentration gradient e Therefore use 1000 ppmF paste rather than 500 750 ppmF assists diffusion paste and 1 450 ppmF paste for children aged 7 years and over if at increased caries risk This is why F concentration is important and why giving a child a larger quantity of a lower F concentration paste is not as effective as using a small quantity smear lt 2 years pea sized lt 6 years of an adult paste e Consider 2 800 ppmF paste for children over 10 years of age if at increased caries risk Time e Spit not rinsing after brushing allows a film of paste to coat the assists diffusion teeth for a few hours particularly after the last brush at night when the salivary flow rates drop to about a tenth of daytime flow 393 e Nuthin after brushin also helps retain the film allowing more time for diffusion e nothing to eat for 30 minutes after varnish application allows more time for diffusion Notes to supplement lecture series given in Tasmania and New Zealand 2010 20
144. taken to identify any conditions which might either affect the child s oral health long term oral medication in syrups for example or the provision of oral health care Information on these is readily available in most standard textbooks It is however worth exploring here the issue of a child with congenital or acquired heart problems which places them at increased risk of infective endocarditis Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 20 Children at increased risk of bacterial endocarditis Guidance on the provision of oral health care in the UK to people who are at increased risk of infective endocarditis has recently changed Dental procedures which are known to cause a bacteremia need no longer be covered with antibiotic prophylaxis nor is it necessary to provide a pre treatment rinse with chlorhexidene It is important to note however that this is due to the evidence indicating that any benefit to the patient of antibiotic prophylaxis is outweighed by the disadvantages of the prophylaxis itself it does not mean that bacteremias of oral origin are no longer thought to increase the risk of bacterial endocarditis For child oral health care provision this means that primary teeth associated with a dental abscess or which are assessed as at increased risk of causing a dental abscess should be extracted promptly although there is no need to cover the extraction with antibiotic prophylaxis This means
145. that is capable of dropping the pH to the level at which mineral dissolution occurs This is why the great majority of dental caries begins on two sites which together make up less than 1 of the tooth surface e Base of pits and fissures e Just below the contact points on proximal surfaces High caries susceptibility Plaque is far from the bland homogenous material it appears to the naked eye Given time and a stable environment plaque will mature into a complex organised structure with channels and pores Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 88 Its bacterial population will shift and change in composition with symbiotic relationships developing between some species while other species will be gradually squeezed out by their neighbours In the deeper layers organic acids formed as a by product of bacterial metabolism will favour a shift in the bacterial composition from non cariogenic species such as Streptococcus oralis and Streptococcus Salivarius to more cariogenic species such as the mutans streptococci and lactobacilli Plaque has been described by Marsh as a city of slime This is a useful analogy because just as a city is a complex structure whose smooth functioning can be interrupted by a change in the supply of any number of factors food water oxygen power light so can the cariogenic potential of plaque be altered by changing the supply of carbohydrates oxygen or pH
146. the softened dentine will result in its loss Enamel overlying carious dentine loses its support and also has its dentinal surface demineralised As a result of its brittleness the enamel fractures under stress causing a cavity to form Cavitation can open up the plaque biofilm sufficiently to the oral environment to cause the caries to arrest m EREN RIGS Bo OA ND O 4 eS A Fd RT _ i ae y gt 4 Lower primary molars with Bitewing radiograph of the same teeth Arrested caries on an upper first arrested dentinal caries showing absence of radiographic primary molar which is light which is hard to probing signs of infection coloured and hard to probing e Active dentinal caries feels soft to the probe e Arrested dentinal caries feels hard and is often but not always dark in colour Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 30 Note e An arrested lesion can become active again if there is a change in the micro environment e The only certain criteria of an arrested lesion is that it does not progress over time Ideally therefore these lesions need to be recorded using a system that allows change over time to be identified 3 3 Is there a risk of pain or abscess before the tooth exfoliates When examining the carious primary dentition the clinician needs to assess the risk of each lesion progressing to pain or abscess in order to decide on the most appropriate management o
147. till need some support and encouragement from parents principal carers until they leave home Try to make appointments more convenient for them Bringing a child in for dental care frequently involves a greater commitment from parent carers than attending an appointment themselves The OHC Team should recognise this and show appreciation for their visit even if it is their first visit and only because the child is in pain This will also aid Communication see next section Ask which days and times are more convenient for them and attempt to meet their requests the child will be the one who benefits Managing suspected dental neglect Local protocols must be followed Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 13 Guiding principles Children are different from adults in how they perceive the value of dental care and this has largely been covered in previous sections When to start Children should be seen in the dental surgery with their parent carers from 1 year of age This is an ideal age to get the preventive message across and much easier for all than trying to manage a 3 year old presenting for the first time with established disease It is also an opportunity to begin the process of ensuring the parent carer appreciates that their child s oral health is their responsibility and not that of the Oral Health Care Team When parents bring older children for care enquiries should be made
148. ting the parent carers is fully described in the relevant sections in Prevention It is essential however that any educational intervention is delivered using the Motivational interviewing method of communication There may well be a need for advice but try to get the patient to request it If this doesn t happen try prefacing the advice with something like Some mothers tell me Research indicates Motivational Interviewing The following quotation from a paper by the two authors who first described the method gives a concise but comprehensive description of the method Motivational interviewing is a method of communication rather than a set of techniques It is not a bag of tricks for getting people to do what they dont want to do It is not something that one does to people rather it is a fundamental way of being with and for people a facilitative approach to communication that evokes natural change Miller amp Rollnick 2002 In essence the technique involves subtly guiding the patient to discover and strengthen their own motivation to change remembering e it s a collaborative process e the need to understand the patient s viewpoint if you want people to change you usually have to start from where they are not where you d like them to be e to resist the righting reflex correcting them early in the process e to listen with empathy and roll with resistance e to encourage the patient to be
149. to the toothbrushing Instruction Dialogue Now you told me that you brushed Peter s teeth every night before he goes to bed Now he ll also be brushing in the morning when is going to be the best time to do it When he uses the bathroom having just got up Or after his breakfast Oh so he uses the bathroom then dresses himself while you make breakfast Yes then straight after breakfast sounds a good time to brush that OK with you Peter Is there anything you re unsure about thought that was a good session and if you can both manage to stick at it it really will help reduce your visits in the future and you getting sore teeth again Peter Would it be OK for me to see you again in three weeks We ll have a look at helping you manage the amount of sweets Peter has then And Peter see if you can remember to bring your chart with you Closing the toothbrushing session Teaching strategy Comments Action planning is a key part of turning motivation into action see Changing behaviour If there are older siblings in the family they can sometimes be pressed into service with brushing if the Mother is struggling to get several children ready for school Praise again and highlighting benefits of compliance to both Parent carers do us the Oral Health Care Team the favour by coming to see us so recognise this by requesting rather than requiring further visits it aids empathy Mixi
150. truggling to cope risks alienating the child their parent carers and storing up attitudinal and behavioural problems in the future A classic example is a young child presenting for the first time at your surgery with a painful unrestorable tooth If they were an adult then making time in your schedule to extract the tooth at that visit would be the most appropriate management of the situation and if gaining adequate anaesthesia took a little time the adult would still be appreciative and feel positive about the experience This is not necessarily the case with a small child Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 10 It should also be remembered that as children grow their cognitive abilities change and develop with them and this should be capitalised on in helping children to take on responsibility for their own oral health care as young adults Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 11 Guiding principles The clinician The child Parent carers The route or barrier to success The Parent carers key points e Accept that parent carers have within limits autonomy over the care of their child Avoid coming across as judgemental at all costs e Key carers those who look after the child for significant periods of time can be many they need to be identified and ways found of including them within an individualised preventive programme e Bringing c
151. ts to the actively cariogenic plaque biofilm being extremely vulnerable to changes in its micro environment alter the micro environment and the carious process can stop These approaches are termed Biological to differentiate them from the classic surgical approach where all active caries is completely excised from a tooth and the resultant cavity restored Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 89 Biological approaches to managing active dental caries in primary teeth All of these approaches are aimed at disrupting the micro environment of the plaque biofilm so that it is no longer actively cariogenic and include Improving plaque control by the child and parent carer over the surface of an active lesion through brushing and flossing for proximal lesions Occasionally opening a lesion to facilitate the above Sealing in the lesion with a dental material restoration to isolate the lesion from the oral environment and dietary based nutrients Advantages of biological management of caries e Usually less demanding for the patient to accept and less demanding for the clinician to provide e Reduced risk of iatrogenic harm to the dental pulp Disadvantages of biological management of caries If based on plaque control alone very reliant on child parent carer compliance with advice If based on sealing in the seal s the deal A leaky seal will allow caries to progress
152. ussing with the child and the parent all of the findings from the oral health assessment before discussing treatment options The list of problems issues need to be agreed upon and then how these are prioritised does the aesthetics of an anterior tooth with Molar Incisor Hypomineralisation take precedence in an older child over restoring active caries in posterior primary molars Following this step for each problem issue a range of options can be discussed and by working together the child parent and clinician must come to some agreement on how each of these can be addressed a clinician e discuss findings e identify and discuss problems issues e prioritise these See section on assessing risk of pain sepsis from carious primary teeth to help with this but include the child s and parent carers priorities e discuss options for each problem issue and their pros and cons e work towards establishing a consensus treatment plan bearing in mind that a treatment plan should be A guide for a course of interventions for the problems issues that have been identified DYNAMIC it should be reviewed and updated regularly to meet any changing needs It should include an evaluation of progress for the child parent in meeting any specified goals and objectives for each problem issue Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 45 Steps involved in agreeing a treatment plan e from
153. were taken by Simon Scott of the Department of Medical Photography University of Dundee and the authors are grateful to him for his patience and Skill Effective oral health care for children is not easy and there is still a long way to go before we will have the answers to many of the clinical problems we face on a daily basis As we all face the same problems we can learn much from each other if we share information and ideas and keep an open mind about our own clinical practice We very much hope that members of the Oral Health Care Team who read this manual will contact us with their comments ideas and suggestions for improvements Dafydd Evans d j p evans dundee ac uk Nicola Innes n p innes dundee ac uk For the reader in a hurry It is recommended that the manual is read as a whole However the sections regarded as essential in order to have an understanding of the Child Friendly approach are e The summaries on the following two pages The summaries in the yellow boxes at the beginning of each section The Assessment form and post treatment checklist The toothbrushing charts The 24 hour diet analysis chart Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 2 The Child Friendly approach for the Oral Health Care Team OHC Team the one page summary Guiding principles e Begin early See children regularly from 1 year of age e Identify all principal carers find ways to include each of them in the c
154. y be associated with some of the root canals other root canals might be necrotic if signs or symptoms of abscess extract Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 34 Recording the caries assessment Recording the results of a caries assessment in a way that allows disease progression to be monitored is problematic For example below are three examples of occlusal caries becoming progressively more extensive and each with different management options on a lower second primary molar and how they would be recorded on a standard dental chart Similarly two distal lesions on an upper first primary molar one active and at high risk of causing pain abscess and one hard and arrested and needing a prevention alone approach and how both would be recorded on most charts In addition most charts are relatively crude schematics of tooth morphology with the following for a maxillary second primary molars and first and second maxillary permanent molars Instead of this schematic which allows for there being two distinct and separate sites for caries development on the occlusal surface the mesial fossa and the distopalatine fissure ni Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 35 Alternatives to standard dental charting 1 The most widely reported system is ICDAS International Caries Diagnostic and Assessment System www ICDAS org Here two
155. y molar in a 5 year old e Give local anaesthetic e Cut a large access cavity using a high speed handpiece ensuring the entire roof of the chamber is cleared e Remove the contents of the pulp chamber using a slow speed handpiece or sharp excavator e Thoroughly irrigate the pulp chamber with water from the 3 in 1 syringe e Avoid the use of compressed air which could cause surgical emphysema e Identify entrances to root canals which will be in the corners of the pulp chamber Maxillary primary molars have three canals two buccal and one palatal Mandibular primary molars have just two canals mesial and distal e If still bleeding arrest haemorrhage by placing a pledget of cotton wool dampened in ferric sulphate into the pulp chamber place another pledget on top and then have the child bite on a cotton wool roll placed over the tooth for 2 minutes e Use of formocresol is not recommended due to concerns about its safety e f haemorrhage cannot be arrested consider sealing in ferric sulphate in cotton wool until the next visit e Remove the cotton wool and place zinc oxide eugenol cement in the pulp chamber Alternatively setting calcium hydroxide cement Notes to supplement lecture series given in Tasmania and New Zealand 201 or MTA may first be placed on pulp stumps and the floor of the pulp chamber e Fill the cavity with zinc oxide eugenol cement then place a PMC following a conventional p
156. y primary incisor should be extracted Missing or impacted permanent teeth If a child is assessed as missing permanent teeth such as maxillary lateral incisors or second premolars or eruption of a permanent tooth is delayed more than 9 months after its antimere has erupted consider early referral for an orthodontic opinion Notes to supplement lecture series given in Tasmania and New Zealand 2010 2011 41 Management of first permanent molars of poor prognosis First permanent molars FPMs are the permanent teeth most vulnerable to caries in the school aged child In addition around 1 in 20 children are affected to varying degrees by Molar Incisor Hypomineralisation MIH This condition of unknown aetiology primarily affects FPMs but can also affect permanent incisors though usually much less severely The affected teeth have yellowish areas of hypomineralisation which often rapidly breaks down Extraction of FPMs of poor prognosis at around 9 years of age can allow the second permanent molars to erupt into an acceptable occlusion with the second premolars Molars of poor prognosis include those that have e an advanced occlusal lesion or an approximal Class II lesion e hypomineralisation that has caused breakdown and cavitation of enamel e lingual decalcification with cavitation Delaying loss of FPMs of poor prognosis can result in the child having to tolerate several restorative interventions before the tooth is finally
157. ysical and tangible with readily identifiable parameters For example soft active dentine caries is identified in a permanent tooth and removed until it s all gone calculus is detected on a root surface and instrumented until the root surface is clean and smooth problem identified problem managed The sections on Building Communication and Changing behaviour cover areas very different from these These sections use language and concepts that may be less familiar to the OHC Team Many of us may feel relatively comfortable with the rules of engagement of our routine day to day interactions with other people and see no need to break them down into their component parts However it is becoming increasingly accepted that there are real advantages for us and our patients in doing so A The welcome or laying the foundations With the practice based model of oral health care the standard in most countries most interactions between parent carers and children will take place in a dental surgery This is a unique environment for most people and they will enter it with all sorts of feelings Parent carers may well carry their own anxieties about dental care and children are bound to have chatted in the playground about dental treatment Much can be achieved in those all important first few seconds by a really warm straight forward welcome Avoid irony children don t understand it and it irritates the parents Parent carers will have gone

Child Friendly Dentistry - NZ Dental & Oral Health Therapists

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Child Friendly Dentistry - NZ Dental &amp; Oral Health Therapists

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Child Friendly Dentistry - NZ Dental & Oral Health Therapists