My undergraduate exposure to paediatric dentistry was 'patchy' at best. I was the student assigned the child that failed to attend or the child that needed impressions for an orthodontic appliance. Three years ago, I would have described my paediatric specialities as the acclimatisation visit and the general anaesthetic consent form. Still, I passed my competencies and graduated, despite never having given a child an ID block nor taken out a tooth from a conscious patient.
In this article Kathryn discusses her thoughts and experience regarding choosing the correct treatment for children and rules that she follows.
My undergraduate exposure to paediatric dentistry was 'patchy' at best. I was the student assigned the child that failed to attend or the child that needed impressions for an orthodontic appliance. Three years ago, I would have described my paediatric specialities as the acclimatisation visit and the general anaesthetic consent form. Still, I passed my competencies and graduated, despite never having given a child an ID block nor taken out a tooth from a conscious patient.
My foundation training practice boasted five foundation dentists. The recalls all seemed to be booked in with one dentist and it wasn't me - I was safe up the corridor in surgery
5. My encounters with children were becoming rarer...and more traumatic. I soon realised that I was more scared of the appointment than the children.
In a moment of madness (I like to see it as bravery), I applied for a job in the Welsh Community Dental Service (which primarily treats under 16s) so I could face my fears. That was 2012. I write this having started my second rotation in the CDS, in shock to hear two separate nurses compliment me on how good I am with children. If I can do it, anyone can. Allow me to share some dilemmas I've faced and some of the golden rules I've learnt.
To monitor, restore or extract?
Currently a study named 'FiCTION' is trying to answer that very question so soon you can ask the authors. It is obviously very dependent on the size of the cavity, but here are my thoughts:
Saving teeth by placing restorations has multiple benefits - deciduous teeth are the best space maintainers, it teaches children that teeth are valuable and worth caring for and it can avoid extractions in young children until they are mature enough to cope. However, as long as a tooth remains, in a mouth that's obviously susceptible to caries, so does the potential for problems.
An extraction is a quick and effective treatment option. I am comforted by the thought that if a carious tooth is tucked under a patient's pillow, it can't hurt them again. My threshold for an extraction has certainly lowered since I first started in the Community Dental Service.
This is my opinion. Restore if the tooth is truly restorable (and with something that works - preformed metal crowns are simply better than Glass Ionomer Cement's), extract if the patient is in pain (and is co-operative) and only monitor if the tooth is mobile or the patient is untreatable.
Local Anaesthetic or no Local Anaesthetic?
Never has there been a truer dilemma because there is no right answer to this question. Some say 'not for deciduous teeth', others always administer it. I have done it both ways, regretted doing it both ways and had successes both ways.
First, consider this - if a deciduous molar requires restorative treatment, is the tooth going to remain symptom free until it exfoliates? Obviously, that is dependent on the age of the child and the extent of the cavity, but I was taught that if the marginal ridge is cavitated, the pulp is likely involved. So if at some stage, this tooth may need extracting, then why not get the patient used to local anaesthetic? This avoids introducing local anaesthetic for the first time when they are in pain, tired and somewhat hysterical.
I favour giving local anaesthetic for three main reasons. The child is less likely to jump, I feel more confident that I can go as deep as the caries goes and I'm continuing the acclimatisation process (as well as building my own confidence!). I have been repeatedly amazed by what children cope with. With a good story to explain what's happening ('if the tooth is snoring, no matter how much we tickle it, it won't mind), the 'magic jelly', endless chatter to distract them and hiding the syringe, then nine times out of ten, you will succeed.
General anaesthetic now or later?
Another question that is very much dependent on the age of the patient, the extent/number of cavities and the parental attitude. It is also worth researching the local protocol regarding paediatric exodontia under general anaesthetic, particularly the waiting time. The longer it is, the better a pre-emptive decision may be, because if a child is in pain, any wait is a long wait.
In a twelve month period 2012-2013, 9129 children had a general anaesthetic for extractions in Wales.1 Should you wait until a tooth becomes symptomatic to refer? That could be interpreted as supervised neglect but I have been on the ward after the operations and it's not a happy place - it's a mix of wailing from the children and comforting words from their parents. Sometimes I am happy to act (by doing nothing) to try and ensure my patient only goes through that once.
The potential for space loss (due to mesial migration of the 6s) and later crowding complicates the issue further. This is what now dictates my behaviour - 6s there? Show the parent the decay and explain the 'now or later' options. No 6s? Still show the parent, still explain the two options but be prepared to restore/extirpate teeth to tick along for the time being, at least until the 6s arrive. You never know, the patient might get to the age when they will have extractions without a general.
When is tooth decay neglect?
This is possibly the hardest of questions to answer as family life becomes ever more complicated. For example, diet isn't simply what a parent puts on the table each night - what are they eating in school? What are they eating at grandparents/friends' houses? As children age, what are they buying for themselves on the way from school?
I feel children with gross dental decay is too frequently considered a preventable disease. However, it is usually a lack of education or unwillingness to change from the perceived norm rather than anything malicious from the parents. The number of times I've referred a child for general anaesthetic only for Mum to say 'that's fine; his older brother/sister had the same'. In some areas, it is viewed as a natural event of childhood and it is our role to challenge this. So don't be afraid to speak up and say 'this isn't normal. How can I help you to prevent this happening again?'
With regards to neglect, it's a cliché but the best advice is to go with your instincts. Is what you have seen acceptable or does it make you feel uncomfortable? Two things I am particularly wary of are repeated general anaesthetic's (in the same child or the same family) or any unexplainable delay in seeking treatment for the child when they are in pain.
To finish, let me suggest seven rules that I personally follow:
- Ensure you have consent. Yes, it's awkward to ask Dad if he's married to Mum or on the birth certificate but it's better that than ending up in court. And you will definitely upset a grandparent who thinks they can give consent - don't worry about that one.
- Keep talking - silence is unnerving to children. Even if it doesn't make a huge amount of sense, the tone of your voice can be reassuring enough.
- 'Why?' is a very useful question. 'Why don't you like it?' 'Why won't you open your mouth?' 'Why are you crying?' I haven't heard many decent answers yet and it makes some children realise that you won't be taken in by them playing up.
- Withhold the sticker unless it's been earned. Jump on your nurse (and possibly receptionist too) to ensure they follow suit. If a child doesn't co-operate (even with the most minor thing) then I don't think they deserve a reward.
- Beware of unhelpful bribery. One ten year old told me he got a fiver every time he came. No wonder he needed several acclimatisation visits. Rewards for good behaviour yes, but in proportion with the achievement or progress made.
- Don't be afraid to stop if the child is uncooperative and making treatment dangerous - it'll be deemed your fault if something untoward happens. A bur-less fast hand piece trial run can be very telling.
- And lastly, NEVER say 'And is this Nan?' to the accompanying female. ALWAYS go for Mum (I have learned this the hard way. About six times).
Kathryn Hudson
Dental Core Trainee in South Wales
References:
1. Personal Communication from the Welsh Oral Health Information Unit
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