Essentials of Pediatric Dentistry Kanchan Harikishan Asnani
Chapter Notes

Save Clear

1Fundamentals of Pediatric Dentistry
  1. The Practical Importance of Pediatric Dentistry
  2. Pain Reaction Control: Sedation
  3. Antimicrobials in Pediatric Dentistry
  4. Dental Public Health Issues in Pediatric Dentistry
zoom view

The Practical Importance of Pediatric DentistryChapter 1

American Academy of Pediatric Dentistry (1985)
“Pediatric dentistry also known as pedodontics and as Dentistry for adolescents and children, is the area of dentistry concerned with preventive and therapeutic oral health care for children from birth through adolescence. It also includes special care for special patients beyond the age of adolescence who demonstrate mental, physical or emotional problem”.
American Academy of Pediatric Dentistry (1999)
“Pediatric dentistry is age-defined speciality that provides both primary and comprehensive, preventive and therapeutic oral health care for infants and children through adolescence including those with special health care needs”.
Pediatric Dentistry Incorporates Various Branches of Dentistry within Itself. It is shown as in Figure 1.1.
zoom view
Fig. 1.1: Various branches of dentistry
What is Practical Importance of Pedodontics?
Various evidences reports the importance of study in field of paediatric dentistry.
  • Evidence of child abuse and neglect
  • Evidence of oral burns
  • Bitemarks evidence.
These all evidences could be considered in general under a single title of “forensic pedodontics”.
Let us discuss all these evidences one by one.
Child neglect is generally characterized by omissions in care resulting in significant harm or risk of significant harm. Neglect is frequently defined in terms of a failure to provide for the child‗s basic needs, such as adequate food, clothing, shelter, supervision or medical care.
Types of Neglect
  • Emotional neglect
  • Educational neglect
  • Physical neglect.
Emotional neglect is defined in following words:
  1. Inadequate nurturing or affection: Marked inattention to the child‗s need for affection, emotional support or attention.
  2. Chronic or extreme spouse abuse: Exposure of the child to chronic or extreme spouse abuse or other domestic violence.
  3. Permitted drug or alcohol abuse: Encouragement or permission of drug or alcohol use by the child.
  4. Permitted other maladaptive behavior: Encouragement or permission of other maladaptive behavior (e.g. chronic delinquency, severe assault) under circumstances where the parent and caregiver has reason to be aware of the existence and seriousness of the problem but does not intervene.
  5. Refusal of psychological care: Refusal to allow needed and available treatment for a child‗s emotional or behavioral impairment or problem in accordance with a competent professional recommendation.
  6. Delay in psychological care: Failure to seek or provide needed treatment for a child‗s emotional or behavioral impairment or problem that any reasonable layperson would have recognized as needing professional psychological attention (ego suicide attempt).
Educational neglect is defined in following words:
  1. Permitted chronic truancy: Habitual absenteeism from school averaging at least 5 days a month if the parent or guardian is informed of the problem and does not attempt to intervene.
  2. Failure to enroll or other truancy: Failure to register or enroll a child of mandatory School age, causing the child to miss at least 1 month of school, or a pattern of keeping a school-aged child home without valid reasons.
  3. Inattention to special education need: Refusal to allow or failure to obtain recommended remedial education services or neglect in obtaining or following through with treatment for a child‗s diagnosed learning disorder or other special education need without reasonable cause.5
Physical neglect is defined in following words:
  1. Refusal of health care: Failure to provide or allow needed care in accordance with recommendations of a competent health care professional for a physical injury, illness, medical condition or impairment.
  2. Delay in health care: Failure to seek timely and appropriate medical care for a serious health problem that any reasonable layperson would have recognized as needing professional medical attention.
  3. Abandonment: Desertion of a child without arranging for reasonable care and supervision.
  4. Expulsion: Other blatant refusals of custody, such as permanent or indefinite expulsion of a child from the home without adequate arrangement for care by others or refusal to accept custody of a returned runway.
  5. Inadequate supervision: Leaving a child unsupervised or inadequately supervised for extended periods of time, or allowing the child to remain away from home overnight without knowing or attempting to determine the child‗s where abouts.
  6. Other physical neglect: May include inadequate nutrition, clothing, or hygiene, conspicuous inattention to avoidable hazards in the home and other forms of reckless disregard for the child‗s safety and welfare.
    For example,
    • – Driving with the child while intoxicated
    • – Leaving a young child unattended in a car.
CHILD ABUSE (Fig. 1.2)
Types, Signs, Symptoms, Causes and Help
The first step in helping abused or neglected children is learning to recognize the signs of child abuse and neglect.
(To report abuse, call the National Child Abuse Hotline : 1-800-4-A-CHILD).
Child abuse is both shocking and commonplace. Child abusers inflict physical, sexual, and emotional trauma on defenseless children every day. The scars can be deep and long-lasting. Unfortunately, the more subtle forms of child abuse such as neglect and emotional abuse can be even more traumatizing than violent physical abuse.
What is Child Abuse?
Child abuse consists of any act, or failure to act, that endangers a child‗s physical or emotional health and development. Someone is abusive if he or she fails to nurture the child, physically injures the child, or relates sexually to the child.
zoom view
Fig. 1.2: Abused child
What are the Types of Child Abuse?
The four major types of child abuse are:
  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Neglect.
What is Physical Child Abuse?
Physical child abuse is an injury resulting from physical aggression. Even if the injury was not intended, the act is considered physical abuse.
The injury from physical child abuse may be the result of:
  • Beating, slapping, or hitting
  • Pushing, shaking, kicking, or throwing
  • Pinching, biting, choking, or hair-pulling
  • Burning with cigarettes, scalding water, or other hot objects
  • Severe physical punishment.
Is Physical Punishment the Same as Physical Abuse?
Physical abuse is an injury resulting from physical aggression. Physical punishment is the use of physical force with the intent of inflicting bodily pain, but not injury, for the purpose of correction or control. As you can see, physical punishment can easily get out of control and become physical abuse.
Some other specific types of physical child abuse are:
  • Shaken Baby Syndrome: Shaking a baby or toddler can cause serious head injuries.
  • Munchausen by Proxy Syndrome: Inducing medical illness in a child or wrongly convincing others that a child is sick is both dangerous and abusive.
  • Drug use during pregnancy: Drug and alcohol use during pregnancy or lactation can be harmful to your child, leading to problems such as Fetal Alcohol Syndrome.
Hundreds of thousands of children are physically abused each year by someone close to them, and thousands of children die from the injuries. For those who survive, the emotional scars are deeper than the physical scars.
What is Sexual Child Abuse?
Sexual abuse of a child is any sexual act between an adult and a child, including penetration, intercourse, incest, oral sex, and sodomy. Other examples include—
  • Fondling: Touching child‗s genitals, making a child fondle an adult‗s genitals.
  • Violations of bodily privacy: Forcing a child to undress, spying on a child in the bathroom or bedroom.
  • Exposing children to adult sexuality: Performing sexual acts in front of a child, exposing genitals, showing pornography to a child.
  • Commercial exploitation: Sexual exploitation through child prostitution or child pornography.
Regardless of the child‗s behaviour or reactions, it is the responsibility of the adult not to engage in sexual acts with children. Sexual abuse is never the child‗s fault.
Sexual child abusers can be:
  • Fathers, mothers, siblings, or other relatives
  • Childcare professionals or babysitters
  • Clergy, teachers, or athletic coaches.
  • Foster parents or host families of foreigns exchange students
  • Neighbors or friends
  • Strangers.7
What is Emotional Child Abuse?
Emotional child abuse is any attitude, behavior, or failure to act that interferes with a child‗s mental health or social development. It can range from a simple verbal insult to an extreme form of punishment. Emotional abuse is almost always present when another form of abuse is found. Surprisingly, emotional abuse can have more long-lasting negative psychiatric effects than either physical abuse or sexual abuse.
Other names for emotional abuse are:
  • Verbal abuse
  • Mental abuse
  • Psychological maltreatment or psychological abuse.
Examples of Emotional Child Abuse
Yelling, screaming, threatening, frightening, or bullying.
Belitting or shaming
Humiliating the child, name-calling, making negative comparisons to others. Telling the child he or she is “no good”, “worthless”, “bad”, or “a mistake”.
Lack of affection and warmth
Showing little to no physical affection (such as hugs) or words of affection (praise, saying “I love you”).
Habitual blaming
Telling the child that everything is his or her fault.
Ignoring or rejecting
Withdrawing attention, giving “the cold shoulder”, disregarding.
Extreme punishment
Confinement to a closet or darkroom, tying to a chair for long periods of time, or terrorizing a child.
Exposure to violence
Witnessing violent behavior, including the physical abuse of others.
Child exploitation
Taking advantage of a child, including child labor.
Child abduction
The trauma of being kidnapped, including kidnapping by a parent, amounts to abuse.
Emotional child abuse can come from adults or from other children:
  • Parents or caregivers
  • Teachers or athletic coaches
  • Siblings
  • Bullies at school or elsewhere
  • Middle and high school girls in social cliques.
What is Neglect?
Neglect is a very common type of child abuse. According to Child Welfare Information Gateway, more children suffer from neglect than from physical and sexual abuse combined. Yet victims are not often identified, primarily because neglect is a type of child abuse that is an act of omission—of not doing something.
Some overlap exists between the definitions of emotional abuse and emotional neglect. However, neglect is a pattern of failing to provide for a child‗s basic needs. A single act of neglect might not be considered child abuse, but repeated neglect is definitely child abuse. There are three basic types of neglect; physical neglect, educational neglect, and emotional neglect.8
Types of Neglect
  • Physical neglect: Failure to provide foods, clothing appropriate for the weather, supervision, a home that is hygienic and safe, and/or medical care, as needed.
  • Educational neglect: Failure to enroll a school-age child in school or to provide necessary special education. This includes allowing excessive absences from school.
  • Emotional neglect: Failure to provide emotional support, love, and affection. This includes neglect of the child‗s emotional needs and failure to provide psychological care, as needed.
What are the Warning Signs and Symptoms of Child Abuse?
Signs of Physical Child Abuse
  • Burns, bitemarks, cuts, bruises, or welts in the shape of an object
  • Resistance to going home
  • Fear of adults.
Signs of Emotional Child Abuse
  • Apathy, depression
  • Hostility
  • Difficult concentrating.
Signs of Sexual Child Abuse
  • Inappropriate interest in or knowledge of sexual acts
  • Seductiveness
  • Avoidance of things related to sexuality, or rejection of own genitals or body
  • Either overcompliance or excessive aggression
  • Fear of a particular person or family members.
Warning Signs of Online Sexual Child Abuse
  • your child spends large amounts of time online, especially at night
  • you find pornography on your child‗s computer
  • your child receives phone calls from men you don‗t know, or is making calls, sometimes long distance, to numbers you don‗t recognize.
  • your child receives mail, gifts or packages from someone you don‗t know
  • your child turns the computer monitor off or quickly changes the screen on the monitor when you come into the room
  • your child becomes withdrawn from the family
  • your child is using an online account belonging to someone else.
Signs of Child Neglect
  • Clothing unsuited to the weather
  • Being dirty or unbathed
  • Extreme hunger
  • Apparent lack of supervision.
What are the Causes of Child Abuse?
Why would someone abuse a defenseless child? What kind of person abuses a child? Not all child abuse is deliberate or intended. Several factors in a person‗s life may combine to cause them to abuse a child:
  • Stress, including the stress of caring for children, or the stress of caring for a child with a disability, special needs, or difficult behaviors
  • Lack of nurturing qualities necessary for caring for a child
  • Difficulty controlling anger9
  • Personal history of being abused
  • Isolation from the family or community
  • Physical or mental health problems, such as depression and anxiety
  • Alcohol or drug abuse
  • Personal problems such as marital conflict, unemployment, or financial difficulties.
No one has been able to predict which of these factors will cause someone to abuse a child. A significant factor is that abuse tends to be intergenerational—those who were abused as children are more likely to repeat the act when they become parents or caretakers.
In addition, many forms of child abuse arise from ignorance, isolation, or benign neglect. Sometimes a cultural tradition leads to abuse. For example, such beliefs as :
  • Children are property
  • Parents (especially males) have the right to control their children in any way they wish
  • Children need to be toughened up to face the hardships of life
  • Girls need to be genitally mutilated to assure virginity and later marriage.
What are the Results of Child Abuse?
Child abuse can have dire consequences, during both childhood and adulthood. The effects of being abused as a child vary according to the severity of the abuse and the surrounding environment of the child. If the family or school environment is nurturing and supportive, the child will probably have a healthier outcome.
Emotional Effects
  • Low self-esteem
  • Depression and anxiety
  • Eating disorders
  • Relationship difficulties
  • Alienation and withdrawal
  • Personality disorders.
Physical Effects
  • Injury
  • Death
  • Lifelong health problems
  • Cognitive difficulties.
Behavioral Effects
  • Problems in school and work
  • Delinquency
  • Teen pregnancy
  • Suicide attempts
  • Criminal or antisocial behavior
  • Substance abuse
  • Aggressive behavior
  • Spousal and child abuse
Note: For more details on the results of child abuse, see the Long-term consequences of child abuse and neglect, from the Child Welfare Information Gateway of the US Department of Health and Human Services.
You may be afraid to report child abuse because of possible repercussions to the child or yourself. You probably will be relieved to know that :
  • 10The child abuse will be confirmed before the child is removed from the home. The authorities will investigate, and if your suspicions of abuse are correct, the child will then be removed from the home and placed in safe care.
  • Reporting is anonymous. In most states, you do not have to give your name when you report child abuse. The child abuser cannot find out who made the report of child abuse.
Remember that suspected child abuse is sufficient reason to make a report to authorities. You do not need proof. Your call may save the life of a child.
How can Child Abuse be Prevented or Stopped?
Tips for preventing or stopping child abuse
What you want to accomplish?
Where you can get help?
To keep from physically hurting your child when you are angry…
Twelve alternatives to Lashing out at your child and Disciplining Children without spanking or other physical abuse.
To console a crying baby….
Some suggestions for coping with a crying baby
To intervene when you witness child abuse in a public place…
What can I do to stop child abuse in a public place?
To report suspected child abuse…
How do I report suspected child abuse?
To protect your child from abuse..
Following simple rules to prevent child abuse
To keep your children safe on the internet…
About…Kid‗s Safety and Protection from child abuse on the internet
To prepare your children to defend themselves…
Self-defense (for teens) and self-defense resources (a worldwide list of IMPACT style self-defense workshops
To identify paroled sex offenders who live in your neighborhood…
National Sex Offender Public Registry and Federal Bureau of Investigation‗s Investigative
Programs : Crimes Against (individual state databases)
To deal with bullies, at school or elsewhere…
Dealing with bullies (for kids) and Bullying and your child
To deal with possible child kidnapping…
When your child is missing : A family survival guide
To deal with abusive coaches…
Parenting: Dealing with abusive coaches.
Child abuse tends to be cyclical, repeated generation after generation. A child who has experienced the trauma of child abuse may repeat the pattern by growing into an adult who delivers abuse to the next generation. The only way to stop such a cycle is to work with parents, prospective parents, and other caregivers who seek help or who are referred for help.
Mental health professionals and others can prevent child abuse by:
  • Establishing educational programs to teach caregivers good parenting and coping skills.
  • Making people aware of alternatives to abusive behaviors so that they seek help for their own abusive tendencies.
  • Educating the public about abuse so that people report abuse early enough for intervention.
  • Establishing relationships of trust with children so that they feel comfortable disclosing abuse. Then someone can intervene early on.
Finkelstein et al have reported that children less than 5 years of age are particularly prone to injury.
11The etiology may be varied such as thermal (Flame and Scald), chemical, electrical and radiation. Boys of all age groups are more prone to burn injury as compared to girls. Health et al. have reported that 10 percent of all cases with Battered children involve burns.
As a result of secondary wound healing and scar contracture, burns involving the perioral and intraoral tissues can cause varying degree of microstomia in age between— 6 months to 3 years.
Electrical Burns
  • Oral electrical burns most commonly occurs when the child places the female end of a line extension cord into the mouth
  • The child sucks or chews on exposed or poorly insulated line wires.
One possible theory is that electric arc is produced between a source of the current such as the female end of an extension cord and oral tissues. The electrolyte rich saliva provides a short circuit between the cord terminal and oral tissues resulting in arc phenomenon. This type of burn involves production of intense heat, causing coagulation tissue necrosis (Fig. 1.3).
Nature of Injury
Clinical manifestation depends on several factors: (i) Degree and duration of contact, (ii) The source and magnitude of electric current, (iii) The state of grounding, (iv) Relative degree of resistance at the point of contact.
zoom view
Fig. 1.3: Baby with oral electric burn
  1. The wound may be superficial including only the vermillion border of one or both lips or it may be very destructive, full thickness, third degree burn.
  2. The severe burns to the mouth generally involve not only a portion of the upper and lower lip, but the commissures as well.
  3. Damage associated with more serious burns may extend intraorally to the tongue, labial vestibule, floor of mouth or the buccal mucosa.
  4. There have been reports of damage to hard tissues such as mandible and the primary and permanent teeth.
  5. With 3rd degree burn, subcutaneous tissues may be damaged. The tissue destruction may be more extensive than is initially evident since nerves are frequently damaged the patient will probably have paresthesia or anesthesia.
  6. Arterial bleeding may occur during first 3 weeks of healing.
  7. Bleeding can also occur with sloughing of necrotic tissue that overlies regenerating granulation tissue.12
  8. The clinical appearance of an electrical burns including lips and commissure reflects the fact that wound is caused by intense and localized heat as much as 300°C.
  9. The wound is characteristic of coagulation necrosis in which there is heat induced coagulation of proteins, liquefaction of fats and vaporization of tissue fluids.
  10. During the first few days after the accident, the centre of lesion is generally composed of grayish or yellowish tissue that may be depressed relatively and has slightly elevated narrow erythematous margin of tissue that surrounds.
  11. Within few hours after the injury there may be great increase in edema. The margins of the wound may be become ill-defined and the lips protrubent. In 7-10 days the edema begin to subside. The delineation between the central nonviable tissue and the surrounding viable tissue become more apparent. The necrotic tissue eschar appear and begin to separate from surrounding viable tissues.
    The eschar slough off 1-3 weeks after the burn. Healing occurs by secondary intention as granulation tissue proliferates and matures.
  1. Assess the general health of patient.
  2. Local measures are undertaken such as control of minor hemorrhage, conservative debridement of non-viable tissue.
  3. Immunization of patient by tetanus toxoid or DPT.
  4. If bleeding persists place firm pressure with gauze for 10 mins.
  5. Acrylic prosthetic appliance should be given.
When in place the appliance has a static base from which the wings extends laterally to provide contact with both commissure.
  • The shape and location of the wings are important not only in preventing contracture or cohesion of lips during healing but also in shaping the affected commissure.
  • The proper size of wing will enhance acceptance and compliance by the child and parent.
  • After delivery of appliance patient is usually seen at 2 days, 1 week, 3 weeks, 7 weeks during this period, if required modification of wings are made.
  • Infants and toddlers who do not have primary molars that can be used for intraoral anchorage should given headgear type of extraoral anchorage appliance.
  • Patient who did not have access to burns appliance therapy may require a commissurotomy to re-establish the original dimension and symmetry of mouth.
The American burn association injury severity grading system has classified burns in children as—
Minor: I and II degree burn less than 10 percent of body surface area in children.
Moderate: II degree of burn 10-20 percent body surface area.
III degree burn less than 10 percent of body surface area.
Major: II degree of burn more than 20 percent, III degree burn at least 10 percent of body surface area, inhalational burns or electrical burns, all burns in infants, and burn which the patient is at poor risk due to preconditions.13
Is to tear or seize with the teeth.
A mark caused by teeth alone or is combination with other oral parts or consists of teeth marks produced by antagonists teeth can be as two opposing arch marks.
Classification of Bitemarks
  • Depending on biting agent
    1. Humans—Children, adult
    2. Animals—Mammals, reptiles, fishes
    3. Mechanical—Full denture
      • — Sawblade tooth marks, electric cord, bicycle chain, belt marks, etc.
  • Depending on material bitten
    1. Skin-Humans, animals
    2. Perishable items—Food items like cheese, apple, etc.
    3. Nonperishable items—Undrimated objects like pipes, pen, pencils.
  • Depending on degree of biting
    1. Definite bitemarks: Tooth pressure marks are formed when a direct application of pressure by the biting edges has caused tissue damage, other marks are caused by tongue pressing tissues between necks of teeth.
    2. Amorous bitemarks: These marks, made in amorous circumstances, tend to made slowly with the absence of movement between teeth and tissue. Lower teeth marks are formed when teeth are pressed into tissue with a gradually increasing pressure on contrast, upper teeth form a series of arches where the tissue is sucked into the mouth and pressed against the back of tooth with tongue.
    3. Aggressive bitemarks: These marks may show evidence of scraping, tearing and avulsion of the tissue. This usually involves ears, nose or nipples. Such bites may be difficult to interpret.
Tooth Pressure
Marks are caused by direct application of incisal edges of anterior teeth or occlusal surfaces of posterior teeth.
  • The mark will depend on
    • – Force applied
    • – Duration of force applied
    • – Movement between teeth and tissue.
  • The pale area represents the incisal edges and bruising represents the margin of incisal edge.
  • Shape of the mark may be useful in identification of specific tooth.
  • Tooth bitemark as “attack” or “defensive” bitemark is commonly seen in battered child syndrome.
Tongue Pressure
  • Is caused when material is taken into mouth and pressed by tongue against teeth or palatal rugae.
  • This leave a distinctive mark due to mechanism of suckling, a combination of sucking and tongue thrusting.
  • Suck mark has a radiating linear abrasion pattern surrounding the central area and resembling a sunburst. These are mostly found in sexually associated assault.14
Tooth Scrape
  • May caused by teeth scrapping across the surface skin.
  • These marks are usually inflicted by the anterior teeth.
  • May appear as scratches or abrasion.
  • If scratches, they might indicate a peculiarity of incisal edges and assist in identification.
Factors Affecting Bitemarks Injury
  1. Inherent skin factor: Loose skin at the site of injury (i.e. around the eye) will bruise easily and extensively where excess of subcutaneous fat is present as compared to skin supported by fibrous tissue with a good muscular tone.
  2. Age: Infants and old people tends to bruise easily and extensively. Infants because of delicate, loosely attached skin and presence of subcutaneous fat. Old people because of decreased elasticity of skin and lost subcutaneous fat.
  3. Sex: Females tend to bruise more easily than males and also bruise marks persists longer in females because of more subcutaneous fat and delicate skin.
  4. Time: The duration of bitemark depends onforce applied and amount of tissue damage. Thinner area retain the marks longer.
  5. Vascularity: The intensity of discoloration depends on vascularity. Bruises will occur and last on a more vascular area like face than in the site which is less vascular like bite on hand or foot.