CHAPTER 14: EXAMINATION, DIAGNOSIS, TX PLANNING OF THE INFANT-TODDLER

sas + ppt

infant oral health

in 1986, the american academy of pediatric dentistry recommended that the first visit occur within 6 months of the eruption of the first primary tooth, since many children by age 3 had already experienced dental caries

Goals or pillars of INFANT ORAL HEALTH

Break the Cycle of Early Childhood Caries
-Early childhood caries progresses rapidly and by the time treatment is sought, the disease can be extensive enough to warrant the use of sedation or GA. -high cost

2. Disrupt the Acquisition of Harmful Microflora
- Vertical transmission of MS from caretakers,primarily mothers.
Can be prevented by:
- establishing a low-sugar diet
- adequate flouride exposure
-effective oral hygiene practices
Prenatal counseling coupled with maternal oral health and infant oral health form the chain in prevention of bacterial acquisition.

3. Manage the Risk/Benefit of Habits -Nonnutritive Sucking habits

The goal would be a gentle waning of the habit, which would negate the need to correct habit- related malocclusions.

4. Establish a Dental Home for Health or Harm
-The dental home should be established no later than 12 months of age and includes referral to dental specialist when appropriate(AAPD)

5. Impart Optimal Fluoride Protection
-Fluoride remains dentistry’s best preventive tool, and optimal fluoride exposure is the foundation of early intervention
-no more than a smear or rice-sized amount of toothpaste for children under age 3

6. Arming the Parents Through Anticipatory Guidance
-Parental involvement has become a cornerstone of child health care.

risk assessment

anticipates caries progressions or stabilization

fosters the treatment of the disease process instead of treating the outcome of the disease according to AAPD

individualizes, selects, determines frequency of preventive and restorative treatment for a patient

gives an understanding of the disease factors for a specific patient and aids in individualizing preventive discussions

fish-owns multifactorial model

time

child (host, teeth, biology)

family (socioeconomic status)

community (dental care system, physical environment)

anticipatory guidance

it is the complement to a risk assessment

defined as proactive counseling that addresses the significant physical, emotional, psychological, and developmental changes that will occur in children during the interval between health supervision visits

common topics discussed:

• teething

• caries prevention

anticipatory guidance of 6-9 months

the sitter/roller

rolls over, opens for a spoon, fear of separation

manage teething symptoms, transition to open cup begins, never sleep with a bottle

6 months → fear of separation (mawala siya ig 19 months)

anticipatory guidance of 12-13 months

the walker

stands/walks, feeds self, fear of strangers

extreme trauma, fall risk, transition off bottle completely, establish dental home

7-13 months (fear of strangers)

anticipatory guidance of 24 months

the toddler

3-4 word sentences, runs, kicks ball

limit snacking to 3 structured times/day

active habit management (prepare for cessation by 36 months)

teething

parents should be advised not to use teething products under 2yo that contain benzocaine because it can lead to methemoglobinemia (a condition which reduces the amount of oxygen carried in the bloodstream and can result to death)

safe, non-toxic teething toys, avoid homeopathic teething tables (associated with seizures and respiratory issues)

can cause a slight temp rise, but a true robust fever indicates a medical illness

symptoms:

• gingival irritation

• irritability

• drooling

oral examination and assessment triage of 0-3 years

use of dental chair is unnecessary and the least preferred approach

crying is a normal response and clinically useful as it affords a wide-open mouth for the exam

preferred approach to infant examination is the KNEE TO KNEE POSITION in which a parent and a dental provider sit facing each other

knee to knee position

knees should touch and create a flat surface on which the child can rest

the infant initially is held facing the parent and then reclined into the lap of the dentist

the parent is responsible for holding the child’s hand and the dentist stabilizes the child’s head

lift the lip technique

recommended periodically based on the child’s risk to developing caries.

instruct parents to check their child’s teeth for initial signs of early childhood caries by lifting the child’s lip to look for white spot lesions

establishing the normal clinical baseline

head/scalp → disproportionately large, open fontanels

temporomandibular joint → short condyles, flat fossae

neck → weak musculature, soft airway cartilage

oral cavity → high frenula placement on alveolus; prominent median raphe/rugae on palate

infant oral pathology and unusual clinical findings

ankyloglossia (tongue-tie)

natal or neonatal teeth

riga-fede disease

ankyloglossia (tongue-tie)

may be associated with breastfeeding difficulties

failure to thrive, swallow, articulation

tx: frenotomy

natal vs neonatal teeth

can be aspiration risk, nursing obstacle

90% are primary (left if not highly mobile)

10% supernumerary (extract)

85% occurs on the mandible

• natal → present at birth

• neonatal → present within 30 days of birth

riga-fede disease

traumatic ulcer of ventral surface of tongue from tooth

may cause active bleeding and discomfort

tx:

• observation

• cessation of breastfeeding

• smoothing/removal of the offending tooth

nonnutritive sucking habits

normal developmental characteristic

according to psychoanalytical theory, these habits (such as pacifier, thumb or finger sucking) arise out of erotic pleasure derived from oral simulation

persistence beyond oral phase (3y.o) reflects psychological disturbances suggestive of an inability to manage stress or anxiety → deleterious dental problems

effects of nonnutritive sucking habits

reduced overbite, increased overjet

protrusion of the maxillary incisors (anterior overbite)

narrowing of the maxillary posterior arch width (posterior crossbite)

digit sucking

weight of the arm applies upward/forward pressure on mx incisors & downward pressure on mn incisors

results to:

• increased overjet

• ant. open bite

• may produce greater severity of malocclusion

harder to break

pacifier habits

easier to discontinue, usually less severe effects

forces tongue down (outward pressure on lower arch)

sucking activates cheek muscles (medial squeezing force on upper arch)

results to:

• narrowed mx arch

• wider mn arch

• post. crossbite

• more associated with class II canine relationship

less likely to self-correct

malocclusion problems of nonnutritive sucking habits

anterior open bite

increased overjet

class II canine relationship

decreased maxillary arch width

increased mandibular arch with

recommendations for nonnutritive sucking habits

elimination of habits before 12 or 24 months is unrealistic

cessation of nonnutritive habits no later than 36 months of age to prevent lasting malocclusion

collaborative efforts and effective communication between medical and dental homes is essential to prevent oral disease and promote oral and overall health, especially among young high-risk children.

4 approaches to stop thumbsucking habits

counseling

• age 2-3 yo

• promoting spontaneous cessation

• substituting pacifier for a thumb if necessary

reminder therapy

• appropriate for those who want to stop the habit but need some help to stop completely

• an adhesive bondage taped to the offending finger can serve as a constant reminder not to place the finger in the mouth

reward therapy

• a contract is agreed upon between the child and parent or between the child and dentist. the contract simply states that the child will discontinue the habit for a specified period of time and in return he/she receive a reward if the requirements of the contract are met.

• the reward does not need to be extravagant but special enough to motivate the child

appliance therapy

• age 4-6 yo

• the child should be given an opportunity to stop the habit spontaneously before the permanent teeth erupt

• if treatment is selected as an alternative, it is generally undertaken between the ages 4 and 6 years.

• should only be used when reminder and reward therapy have failed

fluoride size for <3y.p

smear sized / rice-sized amount

brush twice daily, esp bedtime

fluoride size for >3y.o

pea sized

brush twice daily, esp bedtime

dietary transitions

limit juice to 4-6 oz daily at meals only

transition to an open cup as soon as motor skills allow

breastfeeding is optimal, but prolonged breastfeeding (>12mos) combined with other carbohydrates increases caries risk

abnormal oral habits

tongue thrusting

lip sucking

thumb sucking

[lip & thumb sucking can cause ant. open bite]

lip sucking

labioversion of mx anterior

thumb sucking

anteriors → mx incisor labially pushed and mn incisor lingually deepening of the palatal vault

[mx incisors have mamelons (lobes) [smallest is in the middle]

oral screen

appliance for cheek or lip biting

tongue guard (crib)

appliance for tongue thrusting (blue grass → spin bead roller)

bite block

appliance for class III

lip bumper (plumber)

appliance for hyperactive mentalis muscle

night guard / bite plate

appliance for bruxism

oral vestibule screen (shield)

appliance for mouth breathing

palatal crib

appliance for thumb sucking

appliances for abnormal oral habits

oral screen

tongue guard (crib)

bite block

lip bumper (plumber)

night guard / bite plate

oral vestibule screen (shield)

palatal crib

practice question in sas