Illustrated Pediatric Dentistry - Part 3

The basis for safe permanent teeth in infants and teens is laid during the first years of childhood. Several studies have linked dental caries in children to insufficient diet, unhealthy eating habits, and insufficient toothbrushing habits during the first two years of childhood. The emergence of caries in primary teeth increases the chance of developing caries in permanent teeth. Once a tooth has decayed in young children, the paediatric dentist plays a crucial role to return the tooth to its full functioning potential. The technical advancements in dental products utilized in children over the last few decades are a necessary prerequisite because what was acceptable in the past is not necessarily the safest way to treat young patients nowadays. Several alternatives exist to restore carious teeth in paediatric patients, ranging from stainless steel crowns to aesthetic crowns such as strip crowns and zirconium crowns, which are gaining popularity. This chapter contains a description of the crowns in paediatric dentistry.

Prosthetic management is the healing part of the dentistry which plays a crucial role in rehabilitating the missing or damaged oral and maxillofacial structures. Dental aesthetics is a paramount important aspect in today’s society and is faced by many challenges like age, periodontal condition, occlusal adjustments, patient’s cooperation etc., to overcome this the dentist should have a thorough knowledge regarding prothesis before the fabrication and delivery. In this chapter, various prosthesis like removable partial denture, fixed partial denture, complete denture, implants, maxillofacial prostheses their types, advantages, disadvantages, indications, contraindications, fabrication etc., have been discussed in detail which will help in successfully understanding and treating the patient to obtain positive treatment outcome.

A correct finding of the ailment of the pulp in teeth conceded by caries, dental processes or other forms of injury is vital for arriving at a proper conclusion for the treatment. Essential evidence in this respect is whether the pulp is vital or necrotic. It is similarly important to be able to ascertain whether the pulp is reversibly or irreversibly inflamed, mainly in connection with a carious or traumatic exposure of the tissue. In other words, can the pulp heal and continue in a long‐term perception or is it scratched to the extent that it is not curable, and is a root canal treatment required? Diagnostic information is gained from the patient's history of pain or irritation, the experience of trauma or restorative techniques, clinical examinations, results of clinical tests and radiographic assessment of the teeth and the surrounding tissues. A diagnosis is rarely based on a single finding, but rather on a set of reflections. The clinical condition may be so complex that a proper diagnosis and treatment outcome requires a diagnostic process comprising several steps.

Pediatric endodontics is an integral part of dental practice that aims to preserve fully-functional primary teeth in the dental arch. Despite advances in the prevention of dental caries in pediatric dentistry, the occurrence of pulpal-involved primary teeth and their premature loss continue to be a common problem. The benefits of preserving primary teeth are of utmost importance. Primary teeth aid in mastication, phonation, and guidance of permanent tooth bud, harmonized temporal and spatial development of permanent teeth and prevent the detrimental psychological effects due to tooth loss. Despite the emphasis, prevention in primary teeth remains much talked about and rarely practiced. Restoration of a child’s dentition to a healthy, functional status is often complicated by the severity of dental caries, particularly in the primary dentition, which often falls prey to the ravages of decay. Moreover, primary dentition is often regarded as transient and hence, undeserving of much time or effort. The intervention is only sorted when the child experiences pain due to the decay. Unfortunately, the delay incurred due to dental caries renders the tooth non-restorable.

Traumatic injuries suffered by the anterior teeth mostly occur before completion of the root formation which may have consequences like inflammation or necrosis of the pulp. The most sensitive part of a young permanent tooth to trauma is the Hertwig’s epithelial root sheath (HERS). However, root formation can still continue to occur if there is a disruption of vascularity and cellularity in the apical region, even in the presence of pulpal inflammation and necrosis of the traumatized teeth. Hence, every effort should be made to maintain the viability of HERS as it acts as a source of undifferentiated cells which could give rise to the formation of the hard tissue and it also protects the tooth against the ingrowth of the cells of periodontal ligament into the root canal, which might result in intracanal bone formation and cessation of root development. In cases where complete destruction of Hertwig's epithelial root sheath occurs, the development of a normal root comes to a halt but, this does not mean that there is an end to the deposition of hard tissue in the region of the root apex. Although, once the sheath has been destroyed, there can be no further differentiation of odontoblasts but, the hard tissue can still be formed by cementoblasts which are present in the apical region or by fibroblasts of the dental follicle and periodontal ligament cells that undergo differentiation after the injury. This chapter is specifically oriented towards discussion of the viable methodology and treatment modalities of vital, nonvital immature young permanent teeth.

Pulpectomy is the treatment of choice for pulpally involved deciduous teeth, which potentially eliminates inflamed or necrotic pulp, bacteria, and toxins, relieving pain and promoting periradicular healing by cleaning and shaping the root canals. Over the years, cleaning and shaping of the root canals are done by manual endodontic instruments like files and reamers which are still considered to be the gold standard. With the advent and advances in Nickel Titanium rotary files, rotary endodontic instruments have been widely used for cleaning and shaping the root canals in Pediatric Dentistry. Of rotary files is less time-consuming thereby reducing stress to both the child and the dentist, giving consistent and predictable results even in narrow and curved root canals due to superelasticity and shape memory of nickel-titanium alloy.

Smile with beautiful natural teeth is one of the greatest assets of a person. Untreated fractured teeth can affect day to day activities of children in school which can have a psychological impact on children. Apart from dental caries and periodontal diseases, a traumatic dental injury is the third most common cause of tooth loss. Violence, accidents, falls and sport-related activities are the leading causes of traumatic dental injuries, that majorly involve anterior teeth. Epidemiological studies indicate that dental trauma is a significant problem in young people and that soon, it will be a major dental health care requirement. Prevalence of traumatic dental injury in primary and permanent dentition ranges from 9.4-41.6% and 1% to 58.6%, respectively. The management of traumatic injuries to anterior teeth is also changing with advances in materials sciences and understanding of the mechanism of traumatic injuries.

Traumatic injuries are commonly seen in children. There are various causes and factors that make an individual or a particular tooth more susceptible to traumatic injury. Owing to factors like early fine motor development of infants and toddlers, participation in sports and other physical activities, accidental and non-accidental injuries or common reasons, children may suffer from dental trauma. Many facial types like convex facial profiles, class malocclusions and malposition of teeth also make the teeth prone to trauma. This section describes the etiologic and predisposing factors and sketches an outline for a detailed examination of traumatic dental injuries.

Management of traumatic dental injuries has remained a problem for the dental surgeons due to the wide range of clinical presentations and the unpredictable nature of the pulpal response. Combined with the anxiety and fear at the time of the trauma. Trauma also makes the children apprehensive about any treatment. The approach to the management of traumatic dental injuries, must be customized according to age, general vital signs, systemic conditions, growth potential, and type of trauma to the individual tooth or supporting structures. Each type of traumatic injury has a unique approach and the evidence for their management is updated from time to time. Hence it is important to keep the latest recommendations in mind while adhering to the traditional time-tested methods in the management of traumatic injuries in children.

Sports dentistry is an emerging section of dentistry. All sports-associated persons must have knowledge about injuries during all sports-related events. Since the very beginning, it has been known that participation in sports carries an extensive risk of sustaining dental injuries, with the increased popularity of sports like contact sports, semi-contact sports, and more support for children to participate at an early age. Dental injuries have become one of the most recurrent types of orofacial injuries that may occur during involvement in various sports activities and have a high rate of incidence between sports-related injuries normally during school physical education classes and club activities. The commonest orofacial injuries involve both soft tissue and hard tissue injury i.e.: facial bones, tooth intrusions, luxation, crown and root fractures, complete avulsions, and Dento-facial fractures. Prevention is of utmost importance to aesthetics for reducing the psychological and economic consequences of traumatic injuries. The most substantial feature in averting sports-related orofacial injuries is wearing protective devices like face masks, mouth guards, and helmets. The use of these protective devices by athletes has been shown to provide an effective safeguard against suffering.

The mouth is a window to the body, and saliva plays an essential role in maintaining the integrity of oral structures. Saliva is that complex fluid that controls oral health through specific and nonspecific physical and chemical properties. The significance of saliva in our everyday activities and its medicinal properties are often taken for granted. However, when disruptions occur in the quality or quantity of saliva in an individual, he or she will likely experience detrimental effects on oral and systemic health. Often head and neck radiotherapy have serious and detrimental side effects on the oral cavity, including the loss of salivary gland function and a persistent complaint of a dry mouth (xerostomia). Thus, saliva has many beneficial functions that are essential to our well-being. Although saliva has been extensively investigated as a medium, few laboratories have further studied saliva’s role in maintaining oral and general health and found saliva as a fascinating biological fluid that possesses the features of a perfect diagnostic tool. The presence of microbial, immunologic and molecular biomarkers in saliva offers these unique opportunities. These biomarkers aid in the early diagnosis and monitoring of oral diseases such as, dental caries, oral malignancies, infectious diseases and many more. Saliva has proved to be a good substrate for the early detection of oral diseases to evaluate therapeutic responses.

Dental caries remains a significantly prevalent public health problem globally for both developing countries and deprived inhabitants in developed countries. The WHO Oral Health Programme persists in emphasizing the importance of public health methods for the effective use of fluorides in the prevention of dental caries. Early research and development were concerned with waterborne fluorides, both naturally occurring and their controlled addition, with emphasis on the effects of fluoridation on the prevalence and incidence of dental caries. More recently, systematic reviews summarizing these extensive databases have indicated that water fluoridation and fluoride toothpaste both substantially reduced dental caries. Fluoride must be present in the right place, namely in saliva and dental plaque at the right time to interfere with the tooth decay process. This process is a swing and balance affair between acid dissolution and remineralization of the tooth surfaces. In addition, in conditions where the incidence and prevalence of dental caries in the community are high to moderate, or when there are firm indications that the incidence of caries is increasing, a supplementary source of fluoride should be contemplated.

Fluoride is present in natural water sources and occurs as an ionic form of fluorine trace element. It is a safe and effective agent used primarily to prevent dental caries, especially in children. Fluoride can remineralize calcium hydroxyapatite crystals in enamel by forming acid-resistant calcium fluorapatite crystals. It can be administered topically as well as systemically. Topical fluorides form a vital part of preventive oral health programs and help promote enamel remineralization, inhibit bacterial metabolism, and reduce the growth of bacteria in plaque. Various methods for delivering topical fluorides include self-applied toothpaste, gels, mouthwashes, professionally applied varnishes, and other gel forms. This chapter provides an overview of the different topically applied fluoride agents, their mechanism of action and the recommendations for their use in children.

Silver diamine fluoride (SDF) is a colourless and odourless combination of silver and fluoride solution with caries arresting properties. Clinical and in-vitro trials have proven its preventive efficacy for caries in high-risk individuals, which is considered a minimally invasive approach for arresting caries progression in cavitated teeth. This chapter gives an overview of the rationale of caries management by SDF, the mechanism of action, and the current evidence for its effectiveness as an anti-caries agent. The safety of SDF use in humans and its various limitations are also explained in the chapter.

Newly erupted posterior teeth in both the primary and permanent dentitions are vulnerable to dental caries attack due to deep, uncoalesced, and not-so-soundly mineralized pits and fissures as compared to their matured counterparts. Therefore, it is more important to “catch them young” before it becomes too late to save them from the deleterious effects of dental caries. Sealing such immature morphological structures with an appropriate sealing material is one of the primary prevention strategies Though this therapy sounds and appears simple, when conducted improperly, it results in the failure of the treatment motto. Hence, there is a need to gain in-depth knowledge of the material, intricacies in the proper selection of the teeth, technique and the behavior of the therapy eventually.
This chapter provides an overview of the historic background and recent evidencebased clinical recommendations for the use of fissure sealants. It describes the different morphological variants of fissures and a wide range of commercially available products with their dispensing means. This writeup also enlightens the conceptual understanding of sealing non-cavitated fissures, therapeutic fissure sealing and smooth surface sealing. Troubleshooting in sealant therapy along with adverse reactions is also described.

Vaccination is an important measure that is undertaken to provide an individual with acquired immunity against a variety of diseases which may result in significant morbidity and sometimes, may even result in mortality. The vaccination program undertaken by Government has helped in containing many diseases which were responsible for many fatalities in the past. Like any other branch of science, vaccines are also evolving with continuous advancements in their mode of synthesis as well as the method of delivery.
Even though various approaches to caries prevention are available, dental caries is still considered to be an irreversible, and a prevalent disease among humans mankind. Mutans streptococci are responsible for such activity. Biofilm is formed on the tooth surface due to everyday diet consumption followed by the role of mutans streptococci through the entry into biofilm on the tooth surface. Most treatment options or medications work for the disposal or destruction of this microorganism. The concept of immunization can be the alternative that works on either inactive or passive grounds. Certain molecular determinants of mutans streptococci are studied and considered for caries formation. Therefore, their use in the preparation of the caries vaccine is widely researched.

Novel coronavirus disease (COVID-19) is one of the worst pandemics known to mankind. It affects people of all age groups. The children may present with milder symptoms and may also be asymptomatic. In the current scenario, pediatric dentists pose a high risk of the disease due to close contact with not just children but also with their parents. Additionally, the majority of pediatric dental procedures advocate the use of an air rotor that generates massive aerosol increasing the transmission risk by a manifold. This, necessitates a change in dental practice protocol to adapt to the new routine. It requires modification in behaviour management techniques, tele-triaging of patients, stringent infection control, minimization and replacement with minimally invasive techniques along with the use of adequate isolation.