Why is pediatric dentistry so important
Pediatric Dental Treatment - Requirements and Challenges
Specialization in children's dentistry
The need for specialists in pediatric dentistry is increasing significantly more than the number of appropriately qualified doctors. Pediatric dentistry is a specialty of dentistry in its own right, but there is still no advanced course of study that allows for a specialization, as is the case with orthodontists or oral and maxillofacial surgeons. The Universities of Gießen and Marburg are addressing this issue in a partner project. The three-year Master of Science degree in children's dentistry combines the specialist knowledge of both universities and international experts as teachers. The deficit that pediatrics has so far only been prescribed to a small extent in dental studies is thus remedied. Pediatric dentistry has so far only been taught in theoretical courses at most German universities. More extensive training and specialization would mean that children could receive much better dental and psychological care than the general dentist. The recognition of children's dentistry as a separate specialty would also have the advantage of a fairer billing option. So far, pediatric dentists have been compared with general dentists, although the range of treatments is much more limited. In addition to successful prophylaxis and treatment, the main goal of every dentist who wants to treat children should be a psychological claim: visits to the dentist can be a positive experience for children. Phobias due to disregard for age-appropriate treatment are common and sometimes have far-reaching consequences in adulthood. This can be prevented by observing the following basic rules. In many general dentist practices, this implementation is difficult because the concept of the children's dentist practice (KZP) has special requirements.
Requirements for children's dental treatment
In the premises of a practice specializing in children, the first differences become apparent when you register and in a spacious waiting area. Children love to explore, play and discover. This exploratory character can work wonders in the area of stress reduction before the treatment and thus initiate the upcoming medical contact in the best possible way. For this purpose, the practice should have an expansive play area that appeals to all the senses. Opportunities to discover things should be found as well as quieter retreats and enough toys for all small patients. Separate guidelines apply to time management in children's dental treatment. The average duration of treatment in adults is longer than in children. For general dentists, the waiting rooms are therefore often smaller because the appointments can be made more precisely. Behavior and willingness to cooperate can vary greatly from child to child. Flexibility must therefore also determine the timing. The average duration of treatment is between 10 and 30 minutes, depending on age and scope of treatment. As a result, there are more patients in the practice at the same time, including siblings. In order to take advantage of the decreasing attention paid to treatment in children during the course of the day, it makes sense to treat small children in the morning, as this is when the willingness to cooperate is greatest. School children can and should be treated in the afternoon. Your receptivity is still good even then. Strict rules ensure very good treatment successes here, but often encounter a lack of understanding when it comes to making an appointment with the parents.
Fig. 1: Treatment room with Pedolounger.
The distraction factor is also often underestimated in adult treatment. The design of the ceiling above the treatment area is important. If there is a screen for films, glittering crystals, a starry sky or a large picture puzzle, children are so interested that the treatment in the mouth becomes a minor matter.
In this situation, the dentist and assistant have to work more closely together than is the case with adults. They take turns telling the story and playing guessing games that the child is happy to join. In order not to disturb the distraction achieved in this way, the instruments are always handed over the child's chest or behind the head, which, however, also means additional expenditure of time.
The conclusion of every successful appointment is a reward from the dentist. In general, parents are advised not to promise the child a big gift. It is easy for children to feel pressured because they associate the reward with a previous accomplishment or something uncomfortable. Many children's dentists work very successfully with very small gifts. A child can choose a surprise from a treasure chest or receive a coin that can be exchanged for a present in the waiting area, where other children can see it. The latter variant has the advantage that the sometimes long search is no longer necessary and the treatment room can be used again more quickly. The often unconscious pressure exerted by parents is defused and the positive bond between dentist and child is promoted.
Fig. 2: Child-friendly registration counter.
There special communication patterns simplify the treatment. A child-friendly practice-specific vocabulary provides information and at the same time ties in with the play and discovery instinct of many children. The “Tell-Show-Do” method creates a communicative bridge between language and treatment. So there is no drill at the children's dentist, but a "brush" to tackle Karius & Baktus. It is not anesthetized, but one lets a tooth “fall asleep” before it is “wiggled out” and not pulled. The fact that the human subconscious does not know negation is particularly important. Just as every kindergarten teacher learns to say "hold on tight" instead of "don't fall down" to children climbing around trees, the practice staff should also be trained in the language. Point out something to the child Not is bad and that's why no Having to be afraid often leads to the opposite association, which can impair the building of trust between the dentist and the child. Parents need to be made aware of this very often. Pictorial and playful language moves the treatment away from medicine for the child and provides additional distraction. Approaches from hypnotherapy have also proven to be very useful. A linguistically trained practitioner can accompany and guide the child on a fairy tale or adventure journey from the moment they enter the room. It is important that there is a head of communication. At best, this is the dentist or the assistant. If the parents interfere too linguistically, the child can become confused, as in case of doubt it will always listen to the parents' familiar voice. Pediatric dentists are therefore faced with the challenge of looking after not only the patient but also those accompanying them, usually the parents, during treatment. Success can only be achieved if the patient and dentist can build a close relationship of trust. This is made easier if parents are familiar with the concept given by the dentist, such as B. telling a fairy tale. Many parents find it difficult to feel comfortable during treatment, v. a. if your child becomes restless, hold back or adopt the given practical vocabulary. In this case, it should be clearly signaled to the parents that this could adversely affect the treatment of their child. The focus is always on the child and not the parents. Here the dentist should also decisively urge the parents to exercise restraint if interference gets out of hand. Pediatric dental practices develop their own pedagogical concept, which for many parents becomes a decision-making criterion and which can also meet with rejection. Accepting this and still sticking to the practice philosophy is extremely important for the credibility of the practice and its employees. Communicating the practice guidelines often means an increased amount of advice for parents who are used to other treatment and work concepts.
Treatment spectrum in children's dentistry
Baby teeth are important placeholders for permanent teeth. Hence, it is ideal to keep as many as possible up to natural exfoliation. Again and again, children's dentists fall into disrepute here for wanting to treat every tooth of the little patient. It is not so. The developmental stages of children and consequently also those of their teeth are much more individual than those of adults. The treatment must take this into account. Apart from the physical conditions in the area of the jaw, the psyche of the child sets the framework for the entire treatment. Resilience and willingness to cooperate determine the progress plan. So it is not uncommon not to carry out the extraction of a milk tooth if it is going to fail in the foreseeable future.
The introduction to dental treatment takes place in a KZP in a very case-specific and pedagogical manner. An initial consultation is used to get to know each other, to get to know the practice and to assess a possible treatment. It is important for trauma prevention not to carry out any treatment when you first get to know each other (with the exception of patients with acute treatment needs).
The biggest difference to the general dentist is the desensitization appointment, which is carried out by the dental prophylaxis assistant. In doing so, one makes use of the child's natural curiosity and discovery behavior to test the child's cooperation (compliance). If treatment is necessary, the child is introduced gradually and playfully to some of the instruments that will be needed later at the desensitization appointment. The practice's own vocabulary is also learned during this appointment. Fears and insecurities as well as excessive demands are thus prevented. Such an appointment is also useful for children who have already had negative dental experience in order to rebuild the bond between doctor and child. It is a holistic, sensual and always positive experience. Due to time pressure, it is usually not possible to give such an introduction to the family dentist before a treatment. The large number of patients who are referred to the KZP by the family dentist because treatment has been discontinued clearly speaks for the value of this additional appointment. Just like a professional teeth cleaning, this appointment is not listed in the dental service catalog and is therefore one of the sessions that are billed privately. Fortunately, more and more parents are willing to do this - for good reason, as it turns out. Treatment discontinuations are far less common in patients who have made use of the pre-accession appointment. Of course, despite the best preparation, it can happen that a child does not manage a treatment to the end. It is then important not to force the treatment. Today it is no longer the standard in any children's dental practice to hold a child and continue working against his or her will. Unfortunately, some parents still expect this every now and then. Clear rules must be communicated here in order to prevent dental trauma and phobias. Pediatric dentists are allowed to be brave and correct their parents if necessary. The treatment spectrum of a KZP also includes additional private services that are repeatedly discussed with parents. Many assume that at least the medical care of milk teeth is completely covered. Although all health insurances ensure basic care, there are additional services in the field of aesthetics such as ceramic crowns, plastic fillings, etc., which, just like adults, are not covered by the health insurances.
Consequences of non-treatment
Regular checks are also extremely important for children. The German Society for Children's Dentistry (DGKiZ) recommends that the first check-up be carried out about six months after the first milk tooth has erupted. Due to the thinner hard tooth substance in milk teeth, carious spread occurs more quickly (Fig. 3). The result can be great pain. Most children are new to this feeling, which is why they rarely attribute it to their teeth. Parents then often recognize a change in the child's behavior, which they cannot specify more precisely. A professional look in the mouth can bring clarity. If caries remains undetected or untreated for a long time, acute nerve inflammation can result (Fig. 4). Trepanation by the general practitioner or emergency dentist is usually the method chosen. However, the risk of trauma is particularly high here, as the child has to be treated directly by the dentist in pain and without prior introduction. Regular and, above all, early controls prevent this.
- Fig. 3: Nursing bottle syndrome, ECC II.
- Fig. 4: Lingual involvement with deep deciduous tooth caries.
- Fig. 5: Bitewing image with approximal caries in a 3-year-old child.
Diagnostics and aids
Dentists, who also otherwise carry out comprehensive diagnostics before treating their patients, should not do without it in children either. Whether before extractions, for diagnosing approximal caries (Fig. 5), to secure the depth of the defect and to assess the tooth structure of the permanent successor, it makes sense to take X-rays. In adults, it is unthinkable to start treatment without prior assurance through appropriate admissions. These benefits should not be withheld from children. In order to keep children's exposure to radiation as low as possible, OPGs should only be made to check the tooth systems or the tooth eruption. Bitewing exposures are generally more suitable for all other indications. Intraoral X-rays in particular are often difficult for the general practitioner because X-ray films the size of children are seldom available. However, with a little practice and patience, the production of X-ray images with appropriate children's films is often successful for three-year-olds. The willingness of the child to cooperate in this completely painless procedure is always a good indicator for the practitioner: the better the cooperation in taking the images, the higher the probability that the child will cooperate just as well in the subsequent treatment.
Unfortunately, all too often patients are referred to the children's dentist, where the drastic consequences of false X-ray modesty become apparent. In the worst case, it is only during treatment that it becomes apparent that a caries extends deeper than can be seen intraorally. General dentists then occasionally place the filling too close to the nerve. The latter carries the risk of pulp teeth and later inflammation, especially in children. Previous X-rays provide information about deep caries or even deep caries complicata lesions and give the practitioner security for the necessary therapy.
If you want to gain the trust of your patient, you should be honest with him. Of course, this also applies to the treatment of children. It is essential to address the child directly during the entire time in the practice and thus make him a fully-fledged interlocutor. Additional bonding creates the ability to explain the next step to a child during treatment. Patients understand that it may tickle, press, or get cold in a moment and are prepared. The fact that this announcement actually arrives solidifies the basis between patient and practitioner.
Working with a rubber dam is practiced successfully in adults and should also be standard in the treatment of children. The cheek and especially the tongue, which the children often cannot hold still for a long time, do not have to be held, which not only simplifies the work, but also shortens the treatment time. In addition, injuries to the oral cavity are prevented, should the child move suddenly.
Many dentists also fail to see the value of local anesthesia. On the one hand, because it can be quite a challenge to set the anesthetic, and on the other hand because of the belief that milk teeth are less sensitive to pain. In children, it is advisable to use a nice smelling surface anesthetic that has to act for three to four minutes before the local anesthesia can be applied. In addition, nitrous oxide sedation (Fig. 6) is of inestimable value in children's dentistry. The harmless nitrous oxide-oxygen mixture is inhaled through a nasal mask and causes about 85% of the patients a feeling of deep relaxation and euphoria, which can increase the willingness to cooperate many times over. This so-called inhalation sedation can avoid many general anesthesia. If there is a lack of compliance, if the children are too young or if the need for treatment is too great, it makes sense to treat children under general anesthesia. Appropriate preparation as well as anesthetists and rooms are then requirements for the practice. Leaving trepanned milk teeth in the mouth is a constant burden on the child's immune system. In addition, these teeth are an ideal breeding ground for bacteria, which significantly intensifies care through to exfoliation. A trephined tooth left in the mouth for several months can cause damage to the permanent successor. So-called gymnasts' teeth (Fig. 7) can be the result. There are other ways to keep the space free for a permanent tooth that has already been created, e.g. B. fixed or removable placeholders (Fig. 8).
- Fig. 6: Aids, rubber dam and nitrous oxide.
- Fig. 7: Turner's tooth (tooth 44) as a result of a persistent milk tooth inflammation.
- Fig. 8: Removable aesthetic gap holder.
Doctors often incise intraoral swellings. However, a child's bones are still very susceptible to medication. Here it is better to give an antibiotic for at least six days as well as a pain reliever to bridge the first two days and to call in the little patients for the first few days to check the progress. Then the guilty tooth can be removed after it has faded. If there is massive extraoral swelling, a referral to a hospital is often the best treatment. Baby teeth must not be left untreated. The phase from primary dentition to complete development of the permanent dentition lasts around the first twelve years of life. During this time, a small, initially harmless defect in a milk tooth can also turn into a large, carious lesion (Fig. 9), which can cause pain in the affected child, make oral hygiene difficult at home and even lead to premature loss of the milk tooth. Well-informed parents know that milk teeth are important as placeholders, we dentists should support them in the fight against Karius & Baktus.
Fig. 9: Massive plaque and tartar formation (region 64, 65) due to inadequate oral hygiene due to pain.
In many practices, the above-mentioned basic rules will be difficult to implement. However, if it is important to the respective colleague to practice good children's dentistry, he will make it possible. Because one thing should be clear to everyone: Children cannot and should not just fill gaps in the appointment book or be dismissed as fun time. Good children's dentistry requires psychological knowledge as well as imagination, a lot of patience and strong nerves. It is therefore desirable that more colleagues refer children to specialists who are precisely trained in this. Parents will appreciate this as much as pediatric dentists, who are equally interested in the best possible treatment for small patients.
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