Childhood impairment and disability

An impairment becomes a disability for a child only if he/she is unable to carry out the normal activities of his/her peer group. For example, a child who has broken an arm is temporarily ‘disabled’ by not being able to eat and write in the normal way. However, impairment is a permanent feature in the lives of some children, although it may become a disability only if they are unable to take part in everyday activities, such as communicating with others, climbing stairs, and toothbrushing. A more contemporary view is one that moves away from the medicalization of impairment to a consideration of ability and functioning, enshrined in the World Health Organization’s International Classification of Functioning, Disability, and Impairment (ICF). In this definition, a number of domains are classified from body, individual, and societal perspectives. This approach is less stigmatizing and more enabling of children with impairments. There are a number of reasons why children with impairments merit special consideration for dental care. 1. The oral health of some children with disabilities is different from that of their healthy peers—for example, the greater prevalence of periodontal disease in people with Down syndrome and of tooth-wear in those with cerebral palsy. 2. The prevention of dental disease in disabled children needs to be a higher priority than for so-called normal peers because dental disease, its sequelae, or its treatment may be life-threatening—for example, the risk of infective endocarditis from oral organisms in children with significant congenital heart defects. 3. Treatment planning and the provision of dental care may need to be modified in view of the patient’s capabilities, likely future cooperation, and home care—for example, the feasibility of providing a resin-bonded bridge for a teenager with cerebral palsy, poorly controlled epilepsy, and inadequate home oral care. In the light of these considerations, do such children need special dental care? Most of the studies that have been undertaken on disabled children have indicated that the majority can in fact be treated in a dental surgery in the normal way, together with the rest of their family.

Traumatic injuries to the teeth

Dental trauma in childhood and adolescence is common. At 5 years of age 31–40% of boys and 16–30% of girls, and at 12 years of age 12–33% of boys and 4–19% of girls, will have suffered some dental trauma. Boys are affected almost twice as often as girls in both the primary and the permanent dentitions. The majority of dental injuries in the primary and permanent dentitions involve the anterior teeth, especially the maxillary central incisors. Concussion, subluxation, and luxation are the most common injuries in the primary dentition, while uncomplicated crown fractures are most common in the permanent dentition. Prognosis of traumatic injuries has improved significantly in the last 20 years. This has been largely due to a greater understanding of dental pulp reaction patterns and vital pulp therapies. Children are most accident prone between 2 and 4 years for the primary dentition and between 7 and 10 years for the permanent dentition. Coordination and judgement are incompletely developed in children during the primary dentition years, and the majority of injuries are due to falls in and around the home as the child becomes more adventurous and explores his/her surroundings. Most injuries in the permanent dentition are caused by falls and collisions while playing and running, although bicycles are a common accessory. The place of injury varies in different countries according to local customs, but accidents in the school playground remain common. Sports injuries usually occur in the teenage years and are commonly associated with contact sports. Injuries due to road traffic accidents and assaults are most commonly associated with the late teenage years and adulthood, and are often closely related to alcohol abuse. One form of injury in childhood that must never be forgotten is child physical abuse or non-accidental injury (NAI). More than 50% of these children will have orofacial injuries (see also Chapter 4, Safeguarding Children). Accidental dental injuries can result from direct or indirect trauma. Direct trauma occurs when a tooth receives a direct blow, making this sort of injury more common at the front of the mouth.

Introduction to the dental surgery

It is a common belief among many individuals that being ‘good with people’ is something you are born with and cannot be taught. It is true that some individuals have a more open disposition and can relate well to others. However, everyone can adopt approaches that put children and parents at ease. It is particularly important for dentists to learn how to help people relax, as failure to empathize and communicate will result in disappointed patients and an unsuccessful practising career. Communicating effectively with children is of great value, as ‘being good with younger patients’ is a practice-builder and can reduce the stress involved when offering clinical care. All dental training should include a thorough understanding of how children relate to an adult world, how the dental visit should be structured, and what strategies are available to help children cope with their apprehension about dental procedures. This chapter will consider these items, beginning with a discussion on the theories of psychological development and following this up with sections on parents and their influence on dental treatment, dentist–patient relationships, anxious and uncooperative children, and helping anxious patients to cope with dental care. The psychological development of children was originally viewed as a series of well-defined phases, but is now seen as a continuum. The phases of development may well differ from child to child, so cannot be rigidly applied, but for clarity are described as a series of psychological developmental milestones from infancy to adulthood. The most important theoretical perspective now influencing thinking about child development is John Bowlby’s attachment theory. Bowlby suggested that child development could best be understood within the framework of patterns of interaction between the infant and the primary caregiver. If there were problems in this interaction, the child was likely to develop insecure and/or anxious patterns that would affect the ability to form stable relationships with others, to develop a sense of self-worth, and to move towards independence. The other important concept to note is that development is a lifelong process—we do not switch off at 18—nor is it an even process. Development is uneven, influenced by periods of rapid bodily change.

Anomalies of tooth formation and eruption

Both the primary and permanent dentitions may be affected by variations in the number, size, and form of the teeth, as well as the structure of the dental hard tissues. These variations may be exclusively genetically determined, brought about by either local or systemically acting environmental factors, or possibly a combination of both genetic and environmental factors acting together. The same interplay of influences may affect the eruption and exfoliation of primary teeth, as well as the eruption of permanent teeth. This chapter considers a range of conditions involving abnormalities of the number, size, form, and structure of teeth and their eruption. It is important to be aware of the psychosocial aspect when meeting children and families affected by these conditions. We have too often heard stories of social isolation of even very young children as a result of their missing or discoloured teeth. In the case of discoloured teeth, parents and children have told us that they have been told off or teased for not looking after their teeth when the discolouration was intrinsic and unavoidable. Society’s preoccupation with ‘the perfect smile’ seems to increase; hence children denied access to aesthetic dental treatment may be genuinely disadvantaged. Wherever possible, we try to avoid the use of the word ‘normal’ in our clinical care, although the word will be used in this text. The vast majority of children with these conditions want to become ‘one of the crowd’. Thus we would speak, when offering restorative treatment for example, of making a smile ‘ordinary’ or ‘boring’. While investigating inherited conditions, it is important to make enquiries of both sides of the family tree equally. Not only does this ensure that the investigation is complete, but also it may help to alleviate any sense of ‘guilt’ felt by an affected parent. We have been questioned repeatedly about the possibility of genetic treatment for some of these inherited conditions. We are not aware of any progress in this direction at present. Hypodontia is the term most often applied to a situation where a patient has up to six missing teeth (excluding third permanent molars) as a result of their failure to develop.

Operative treatment of dental caries in the young permanent dentition

Caries is a chronic disease. If it starts to affect the permanent teeth the child patient is drawn into a cycle requiring ongoing care for the rest of his/her life. Therefore when treating the young permanent dentition we have to adopt an approach that considers and addresses the whole disease process and not just treat the outcome of the disease. Caries is still a considerable problem in children and adolescents. The 2013 Child Dental Health Survey for England, Wales, and Northern Ireland found that, on average, nearly half (46%) of 15-year-olds and a third (34%) of 12-year-olds had obvious decay experience. Although the proportion of children with untreated dentinal caries has improved from 2003, it remained high at 21% and 19% for 15-year-olds and 12-year-olds, respectively. These children are at high risk of pain and discomfort relating to their teeth. The 2013 survey also looked at the impact on daily life. On average, a fifth of 12- and 15-year-old children reported experiencing difficulty eating, and about half reported that their life had been affected by problems with their teeth or mouth within the previous 3 months (Steele et al. 2015). Caries prevalence declined in the later decades of the twentieth century. As it dropped, a concentration of the disease occurred, with a small percentage of the population experiencing most of the disease. Caries prevalence is greatest in the occlusal surfaces of the first permanent molars and buccal grooves of the lower first molars, and the prevalence in these sites has dropped by the smallest proportion. The least susceptible sites are the approximal surfaces of the incisors, so caries seen in these permanent teeth indicates more extensive disease (Sheiham and Sabbah 2010). The first permanent teeth erupt in the mouth at approximately 6 years of age, but may appear as early as 4 years of age. The eruption of the anterior teeth usually causes great excitement, as it is associated with ‘the fluttering of tooth fairy wings’. However, the eruption of the first permanent molars goes largely unnoticed until there is a problem.

Diagnosis and prevention of dental caries

Almost all research on the process of dental caries supports the chemoparasitic theory proposed by W.D. Miller in 1890. This is now more commonly known as the acidogenic theory of caries aetiology. The main features of the caries process are as follows. 1. Fermentation of carbohydrate to organic acids by micro-organisms in plaque on the tooth surface. 2. Acid production, which lowers the pH at the enamel surface below the level (the critical pH) at which enamel will dissolve. 3. When carbohydrate is no longer available to the plaque microorganisms, the pH within plaque will rise because of the outward diffusion of acids and their metabolism and neutralization in plaque, so that remineralization of enamel can occur; 4. Dental caries progresses only when the balance between demineralization and remineralization favours the former. The realization that demineralization and remineralization are in equilibrium is key to understanding the dynamics of the carious lesion and its prevention. One of the interesting features of an initial carious lesion of the enamel is that the lesion is subsurface, i.e. most of the mineral loss occurs beneath a relatively intact enamel surface. This contrasts strongly with the histological appearance of enamel after a clean tooth surface has been exposed to acid, where the surface is etched and there is no subsurface lesion. This dissolution of the surface of enamel, or etching, is a feature of enamel erosion caused, among other things, by dietary acids. Therefore the carious process and erosion differ completely, as erosion is a surface phenomenon. The explanation for the intact surface layer in enamel caries seems to lie in diffusion dynamics: the layer of dental plaque on the tooth surface acts as a partial barrier to diffusion. Further erosion occurs at much lower pH values (pH <4) than caries. Dental plaque forms on uncleaned tooth surfaces and is readily apparent if toothbrushing is stopped for 2–3 days. Contrary to popular opinion, plaque does not consist of food debris, but is a biofilm; 70% is comprised of micro-organisms—about 100 million organisms per milligram of plaque. When plaque is young cocci predominate, but as plaque ages the proportions of filamentous organisms and veillonellae increase.

Craniofacial growth and development

This chapter describes, in general terms, the prenatal development and postnatal growth of the craniofacial skeleton, and the occlusal development of the primary and permanent dentitions. Understanding of embryological development is essential for the dental practitioner who may frequently face patients with common craniofacial anomalies such as cleft lip and/or palate. For routine care, an understanding of their development and aetiology will bring insight to their likely presenting signs and symptoms. This section will include a brief summary of the development of the face, including the neural crest and pharyngeal arches. It is not the intention of this summary to be in any way a complete or thorough description but simply to describe some of the key cells/interactions and structures. Neural crest cells are derived from the neural fold, and are highly migratory and specialized cells capable of predetermined differentiation. The differentiation occurs after their migration and is essential for the normal development of face and teeth. By week 4 the primitive mouth or stomatodeum is bordered laterally and from the developing heart inferiorly by the pharyngeal or branchial arches. These are six bilateral cylindrical thickenings (although the fifth and sixth are small) which form in the pharyngeal wall and into which the neural crest cells migrate. They are separated externally by the branchial grooves and internally by the pharyngeal pouches. The first groove and pouches are involved in the formation of the auditory apparatus and the Eustachian tube. Each arch has a derived cartilage rod, muscular, nervous, and vascular component. The first two arches and their associated components are central to the development of the facial structures. This period is also characterized by the development of the organs for hearing, sight, and smell, namely the otic, optic, and nasal placodes. By the end of week 4, thickenings start to develop in the frontal process. The medial and lateral frontonasal processes develop from these, together with the nasal placodes. The maxillary process develops from the first pharyngeal arch and grows forward to meet the medial and nasal processes, from which it is separated by distinct grooves at week 7.

The paedodontic–orthodontic interface

The long-term management of a child’s developing occlusion often benefits greatly from a good working relationship between the paediatric dentist and the orthodontist. Typical problems range from minimizing damage to the occlusion caused by enforced extraction of poor-quality teeth, through the management of specific local abnormalities such as impacted teeth, to referral for comprehensive treatment of all aspects of the malocclusion. This chapter discusses the principles underlying when to refer to a specialist colleague, and looks at some common clinical situations where collaboration is often needed. From the age of 8 years all children should be screened for the presence of malocclusion when they attend for a routine dental examination. Although orthodontic treatment is usually carried out in the late mixed and early permanent dentition, some conditions benefit from treatment at an earlier stage. The screening need only be a brief clinical assessment, but it should be carried out systematically to ensure that no important findings are overlooked. An outline of a basic orthodontic assessment is given in Table 15.1. With practice this can be carried out quite quickly to give an overall impression of the nature and severity of a malocclusion. In essence, it comprises assessments of the following elements: • the patient’s awareness of their malocclusion (the complaint, if any) • their general level of dental awareness • an extra-oral examination of facial form (skeletal pattern and soft tissues) • general oral condition—oral hygiene, periodontal health, caries risk, and tooth quality • the presence or absence of all teeth • the alignment and form of each arch • the teeth in occlusion. Radiographs are not routinely used when screening for the presence of malocclusion and should only be taken when there is a clinical indication. A panoramic radiograph gives a useful general scan of the dentition and indicates the presence or absence of teeth. Modern digital panoramic radiographs are generally of good enough quality to assess for the presence of any abnormalities or gross caries. Intra-oral views may be indicated if specifically indicated by the history/examination (e.g. dental trauma) or for further investigation of pathology found on a panoramic image. A radiographic assessment must always be made when considering any extractions.

Periodontal diseases in children

Periodontal diseases comprise a group of infections that affect the supporting structures of the teeth: marginal and attached gingiva, periodontal ligament, cementum, and alveolar bone. Acute gingival diseases—primarily herpetic gingivostomatitis and necrotizing gingivitis—are ulcerative conditions that result from specific viral and bacterial infection. Chronic gingivitis, however, is a non-specific inflammatory lesion of the marginal gingiva which reflects the bacterial challenge to the host when dental plaque accumulates in the gingival crevice. The development of chronic gingivitis is enhanced when routine oral hygiene practices are impaired. Chronic gingivitis is reversible if effective plaque control measures are introduced. If left untreated, the condition invariably converts to chronic periodontitis, which is characterized by resorption of the supporting connective tissue attachment and apical migration of the junctional epithelia. Slowly progressing, chronic periodontitis affects most of the adult population to a greater or lesser extent, although the early stages of the disease are detected in adolescents. Children are also susceptible to aggressive periodontal diseases that involve the primary and permanent dentitions, and present in localized or generalized forms. These conditions, which are distinct clinical entities affecting otherwise healthy children, must be differentiated from the extensive periodontal destruction that is associated with certain systemic diseases, degenerative disorders, and congenital syndromes. Periodontal tissues are also susceptible to changes that are not, primarily, of an infectious nature. Factitious stomatitis is characterized by self-inflicted trauma to oral soft tissues and the gingiva are invariably involved. Drug-induced gingival enlargement is becoming increasingly prevalent with the widespread use of organ transplant procedures and long-term immunosuppressant therapy. Localized enlargement may occur as a gingival complication of orthodontic treatment. A classification of periodontal diseases in children is given in Table 12.1. Marginal gingival tissues around the primary dentition are more highly vascular and contain fewer connective tissue fibres than tissues around the permanent teeth. The epithelia are thinner with a lesser degree of keratinization, giving an appearance of increased redness that may be interpreted as mild inflammation. Furthermore, the localized hyperaemia that accompanies eruption of the primary dentition can persist, leading to swollen and rounded interproximal papillae and a depth of gingival sulcus exceeding 3mm.

Advanced restorative dentistry

The aim of this chapter is to cover the management of more complicated clinical problems associated with children and adolescents: tooth discolouration, inherited enamel and dentine defects, hypodontia, and tooth surface loss. As there is considerable overlap in the application of the various restorative techniques, the chapter is divided into two parts. The first outlines the clinical steps involved in the various procedures, while the second covers the more general principles of management of particular dental problems. It is not the remit of this chapter to cover advanced restorative dentistry in detail, but many of the techniques and indications used in children are the same as those for adults (Boxes 11.1 and 11.2). With the aid of some clinical examples, eight of the restorative procedures will be described in simple stages. Omitted from this list are the stages involved in the provision of full crown restorations and bridgework, which are the specific remit of a restorative dentistry textbook. However, the provision of porcelain veneers, more commonly associated with adult patients, will be mentioned briefly. This technique involves the daily placement of carbamide peroxide gel into a custom-fitted tray on either the upper or the lower arch. As the name suggests, it is carried out by the patient at home and is initially done on a daily basis. • Mild fluorosis. • Moderate fluorosis as an adjunct to hydrochloric acid–pumice micro-abrasion. • Yellowing of ageing. • Single teeth with sclerosed pulp chambers and canals. • Selective bleaching for aesthetic purposes. • Upper impression and working model. • Soft mouthguard—avoiding the gingival tissues. • 10% carbamide peroxide gel. 1. Take an alginate impression of the arch to be treated and cast a working model in stone. 2. Relieve the labial surfaces of the teeth by about 0.5mm and make an acrylic pull-down vacuum-formed splint as a mouthguard with or without reservoirs for bleaching agent on the teeth requiring lightening. The splint should be no more than 2mm thick and should not cover the gingival tissues. It is only a vehicle for the bleaching gel and is not intended to protect the gingivae.