- Definition of Pediatric Dentistry
- Pedodontics in India
- Aims and Objectives of Pediatric Dental Practice
- Scope of Pedodontics
- Specific Differences Between Child and Adult Patients
- General Principles of Pediatric Pharmacology
- Responsibilities of the Pedodontist
A young child is definitely more than just a miniature adult. Managing and convincing a child as a patient for any dental procedure requires extra effort. Pedodontists as specialists should master these skills and be in a position to manage children. It is a challenging venture where only few dare to go.
Pediatric dentistry as it is also referred to, in the beginning was mainly concerned with extraction and restorations. The trend changed from extractions to preservation. Presently the concept of pediatric practice is prevention and concentrating on minimal invasion.
Pedodontist is in an excellent position to alter the growth pattern and improve the resistance to diseases, as he or she deals with children during their formative periods.
DEFINITION OF PEDIATRIC DENTISTRY
According to Stewart, Barber, Troutman and Wei (1982)
“Pediatric dentistry is the practice and teaching of comprehensive preventive and therapeutic oral health care of child from birth through adolescence. It is constructed to include care for special patients who demonstrate mental, physical or emotional problems”.
According to the American Association of Pediatric Dentistry (1999)
“Pediatric dentistry is an age defined specialty that provides both primary and specialty, comprehensive, preventive and therapeutic oral health care for infants and children through adolescence including those with special health care needs”.
PEDODONTICS IN INDIA
- First dental college began as “Calcutta Dental College and Hospital in the year 1920, by Dr R Ahmed which was later renamed as Dr R Ahmed Dental College and Hospital.
- Initially pedodontics as a subject was combined with orthodontics and only in the year 1978 was introduced as a separate subject for undergraduates.
- Pedodontics became a separate specialty much before it was introduced as a separate subject for the undergraduates in the year 1950 at Government Dental College, Amritsar.
- Indian Society of Pedodontics and Preventive Dentistry began functioning in the year 1979.
AIMS AND OBJECTIVES OF PEDIATRIC DENTAL PRACTICE
- The services rendered to the child must be focused from the point what is best of the child at that moment and also for the adult into whom the child will eventually grow.
- The child should be treated as a whole. Effort must be made for the general and oral health to be in accordance with each other.
- Prevention of oral diseases must be the prime motive and should begin if possible from before the birth, directing the expectant mothers.
- Educating parents regarding importance of deciduous teeth, dental treatment and preservation of teeth.
- Developing dentition and jaws should be observed regularly so that any developing malocclusion can be intervened at the right time.
- Relief of pain and sepsis forms one of the main theme of a care provider.
- To achieve and maintain esthetics.
SCOPE OF PEDODONTICS
- Pedodontics encompasses a variety of disciplines, techniques, procedures and skills, all which are aimed, adapted and targeted to achieve healthy oral health to children.
- Pediatric dentistry is an age specific specialty and not a technique specific or disease specific specialty.
- Since it deals with children, pedodontist is in an excellent position to monitor growth and accordingly deal with the arising problems.
- Pediatric dentists have extended services to fulfill the needs of the special child, including physically, medically and mentally handicapped.
- They also form team members in the management of cleft lip and palate patients.
SPECIFIC DIFFERENCES BETWEEN CHILD AND ADULT PATIENTS
Child is in a dynamic state of growth and development and is thus a changing person.
Three general areas in which pediatric patients are unique compared to the adults are:
- Physiologic and anatomic differences
- Pharmacokinetics
- Emotional differences
Physiologic and Anatomic Differences
These differences can be discussed based on body size, body fluids, respiratory system, cardiovascular system and the urinary system.
Body Size
- Less drug is needed to reach an effective plasma level but less is also needed to produce toxicity in children due to small body size.
- Height and weight of children are less than that of adults, their proportions also differ from adults.
- Ratio of body surface area (BSA) to body weight is about seven times greater for neonates than for adults. Many physiologic functions are proportional to BSA, which may be the reasons why some professionals advocate the use of body surface area.
- Smaller the patient, the higher is the basal metabolic rate, oxygen consumption and fluid requirement per hour.
Body Fluids
- Children have larger volume of total body water (TBW). Child's TBW is 80% of body weight and that of an adult's is 50–60%. This has direct bearing on pharmacokinetics of water soluble medications. Because these drugs are distributed to a relatively larger volume once absorbed, a larger dose is necessary to achieve therapeutic effect in a small child.
- Total body fat also varies.
Fat content in a premature infant is about 1% of the body weight, whereas a full term infant's body fat is about 16% of the body weight. In an one-year-old it forms 22% of body weight, four-year-old 12% and in 10–11 years it forms 18–20% of body weight.
The child with the smaller percentage of body fat thus requires a smaller dose of a lipid soluble drug. Lipid soluble drugs such as barbiturates and diazepam may require higher dosage in an obese child as most of it will be distributed to fat tissues, therefore decreasing their effective plasma levels.
Respiratory System
- Relatively large head, narrow nasal passage, smaller diameter of glottis and trachea predisposes the child to increased risk of airway obstruction. Tongue is proportionally larger, larger mass of lymphoid tissues, more copious secretions and loose glottic areolar tissue further compromises the airway. This makes it difficult to manage the child during sedation, general anesthesia or respiratory emergency.
- A child cannot compensate as readily as an adult by increasing ventilatory volumes by increasing chest expansion. So a child is more dependent on the diaphragm as the primary muscle of respiration. Thus care should be taken not to impede diaphragm movement, which might occur when the child is made to lie supine or with head low because the abdominal contents will place gravitational forces on the diaphragm
- Respiratory rate of the child is higher due to higher metabolic rate.
- Basal metabolic rate (BMR) in children is double that of an adult thus requiring greater oxygen consumption and carbon dioxide production.
Cardiovascular System
- Relative blood volume in children is greatest at birth and decreases with age.In a newborn it is 85 ml/kg and in adult it is 70 ml/kg.
- Heart rate is highest in infants.
- Parasympathetic tone (vagal) is more pronounced in infants due to immaturity of sympathetic nervous system. Any vagal stimulation may cause a decrease in heart rate, as seen with manipulation of the airway (endotracheal intubation), bladder distension and pressure on eyes. For these reason children undergoing treatment under general anesthesia should be given parasympathetic blockers such as atropine.
- In a newborn peripheral circulation is very much poorly developed. This is important as uptake of intramuscular injections are low.
- About 40% of the cardiac output in children contributes to the cerebral blood flow, compared to only about 29% in adult.
Urinary System
- Level of urine concentration by the kidneys is very much low in neonates. Therefore infants require more free water per day. Infant and young child may become rapidly dehydrated.
- Glomerular filteration rate (GFR) of an infant is 30–50% of an adult which may be due to less mature glomeruli and lower blood pressure. So drugs that are excreted primarily by glomerular filtration have longer half lives (upto 50% longer) in a child. Example of such drugs are aminoglycoside antibiotics, digoxin and curare. GFR reaches adult level by 3–6 months.
- Tubular reabsorption and tubular secretion also vary and mature to adult levels during the first few months of life.
Pharmacokinetics
It is a dynamic process of drug turnover in the body, which includes absorption, distribution, biotransformation and elimination. It determines a drugs plasma concentration, duration of action and its effectiveness and toxicity.
Uptake of the Drug and Absorption
- Topical medications are absorbed more rapidly and completely in children, due to greater permeability and relatively inactive sebaceous glands.
- Gastric emptying time in a newborn is 6–8 hours compared to 2 hours in an older child and adult. Younger children have a lower gastric pH, promoting greater absorption of weakly acidic drugs such as penicillin, while delaying absorption of weakly basic drugs such as diazepam and theophyllin. Irregular peristalsis slows down the transit time in the bowel in young infants causing net effect of slower drug absorption. Active transport mechanisms in the bowel mucosa aiding in drug absorption is deficient in infants.
Drug Distribution
- Neonates and infants have decreased plasma protein concentration especially albumin. This reduces the binding sites of the drug and they remain unbound or in the free form making it available to produce its pharmacological effect. Drugs that are highly protein bound, displace other protein bound drugs. Compounds like bilirubin, Sulfonamides, vitamin K are known to displace protein bound bilirubin leading to hyperbilirubinemia and resultant kernicterus (brain damage).
- Drugs penetrate blood-brain barrier more easily in children than in adults, due to lack of myelination of the nervous tissue and greater membrane permeability. This can be advantages, when it is needed for the antibiotics to reach the CNS, but may be disadvantages owing to the greater sensitivity to CNS depressant like narcotics.
- Children require higher concentration of inhalation anesthetics due to decreased receptor site sensitivity to drug. This sensitivity changes with the child's development. Other than this notable exception, children are more sensitive and are therefore more prone to drug toxicity.
Drug Metabolism
- In children liver enzyme production that is responsible for biotransformation of drugs may be almost absent, reduced or even overproduced at various stages of development.
- Poor oxidative rates in infants results in prolonged effects of diazepam, phenytoin and other drugs.
- Poor conjugation results in prolonged effects of amphetamines and phenacetin.
- Low levels of glucuronyl transferase in newborn, results in an inability to detoxify the antibiotic chloramphenicol, morphine and steroids and thus increasing their sensitivity. Glucuronyl transferase reaches normal levels by 1 month of age.
- Pseudocholinesterase levels are only 60% of normal for several months after birth.
Drug Excretion
At birth, the ability of the kidneys to clear drugs and concentrate urine is greatly reduced leading to prolongation of the effects of drug that are primarily excreted by the kidneys such as ampicillin, etc.
Emotional Differences
- The major difference between the treatment of children and an adult is the treatment relationship. Treatment relationship between the dentist and the adult patient is one to one whereas in case of a child patient there is a one to two relationship, with the child being the focus of attention of the dentist as well as the parent. This is represented by the pedodontic treatment triangle as given by Wright (Figs 1.1 and 1.2). The child occupies the apex of the triangle and is the focus of attention of both the dentist and the parent. All the three are interrelated. Recently society has been added, meaning that the influence of the society on the child has to be considered affecting the treatment modalities.
- Children exhibit a fear of the unknown.
- They do not know to rationalize.
- Behavior management modalities differ, depending on the age and understanding.
- Treatment appointments should be preferably given during the morning time and avoided during their nap time.
- Adult patient seeks treatment by his own will, but the child patient visits the dentist usually by the will of his parents.
RESPONSIBILITIES OF THE PEDODONTIST
FURTHER READING
- American Academy of Pediatric Dentistry Council on Clinical Affairs: Policy on the role of pediatric dentists as both primary and specialty care providers. Pediatr Dent 2005–2006;27(7 Reference Manual):60.
- American Academy of Pediatric Dentistry Council on Clinical Affairs: Policy on the ethics of failure to treat or refer. Pediatr Dent 2005–2006;27(7 Reference Manual):61.
- Brennan DS, Spencer AJ. The role of dentist, practice and patient factors in the provision of dental services. Community Dent Oral Epidemiol 2005; 33(3): 181–95.
- Goldman HM, Guernsey LH. The role of the dental specialist in the hospital. Dent Clin North Am 1975; 19(4): 665–74.
- Jessee SA. Risk factors as determinants of dental neglect in children. ASDC J Dent Child 1998; 65(1): 17–20.
- Konig KG. The role of the dentist in prevention of dental disease. Int Dent J. 1974; 24(4): 443–7.
- Mouradian WE. Ethical principles and the delivery of children's oral health care. Ambul Pediatr 2002; 2(2 Suppl): 162–8.
- Nainar SM. Pediatric dental practice: reconstruction or disintermediation. ASDC J Dent Child 2000; 67(2): 107–11, 82.
- Pinkham JR. An analysis of the phenomenon of increased parental participation during the child's dental experience. ASDC J Dent Child 1991; 58(6): 458–63.
- Rich JP 3rd, Straffon L, Inglehart MR. General dentists and pediatric dental patients: the role of dental education. J Dent Educ 2006; 70(12): 1308–15.
- Ryan KJ. The role of the voluntary dental association and the private practitioner. J Dent Child 1967; 34(2): 74–9.