Principles and Practice of Pedodontics Arathi Rao
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IntroductionChapter 1

CHAPTER OUTLINE
  • • Definition
  • • Pedodontics in India
  • • Aims and Objectives of Pedodontic Practice
  • • Scope of Pedodontics
  • • Specific Differences between Child and Adult Patients
  • • Responsibilities of the Pedodontist
 
INTRODUCTION
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. Pedodontics is a specialized subject that deals with the management of oral and dental problems in children. Pedodontists are specialists who have mastered these skills and are 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 in pedodontic practice has changed from extractions to preservation, concentrating on minimal invasion.
Pedodontists are 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
According to Stewart, Barber, Troutman and Wei (1982)1
“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 Academy of Pediatric Dentistry (AAPD) and Approved by the Council on Dental Education, American Dental Association (1995) –
“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.”
It, therefore, emphasizes the importance of initiating professional oral health intervention in infancy and continuing through adolescence and beyond.
 
PEDODONTICS IN INDIA
  1. 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. He is called as the ‘The Grand Old Man of Dentistry in India’.
  2. Initially, pedodontics as a subject, was combined with orthodontics and only in the year 1978 was introduced as a separate subject for undergraduates.
  3. 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.
  4. Indian Society of Pedodontics and Preventive Dentistry began functioning in the year 1979.
  5. November 14th was declared as the ‘Pedodontists Day’ by the Indian Society of Pedodontics and Preventive Dentistry at their annual meeting in 2010.
 
AIMS AND OBJECTIVES OF PEDODONTIC PRACTICE
  1. The services rendered to the child must be focused from the point what is best for the child at that moment and also for the adult into whom the child will eventually grow.
  2. 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.
  3. Prevention of oral diseases must be the prime motive and should begin if possible from before the birth, directing the expectant mothers.
  4. Educating parents regarding importance of deciduous teeth, dental treatment and preservation of teeth.
  5. Developing dentition and jaws should be observed regularly so that any developing malocclusion can be intervened at the right time.
  6. Relief of pain and sepsis forms one of the main theme of a care provider.
  7. To achieve and maintain esthetics.
  8. Improving personal information data bank is very important and can be done thorough updating of both clinical and theoretical knowledge on a regular basis.
 
SCOPE OF PEDODONTICS
  1. Pedodontics encompasses a variety of disciplines, techniques, procedures and skills, all which are aimed, adapted and targeted to achieve healthy oral health to children.
  2. Pediatric dentistry is an age specific specialty. It is not just a technique or disease specific specialty and thus covers a wide range of treatment procedures that can be provided to a child patient.
  3. Since it deals with children, pedodontists are in an excellent position to monitor growth and accordingly deal with the arising problems.
  4. Pediatric dentists have extended services to fulfill the needs of the special child, including physically, medically and mentally handicapped.
  5. 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. The differences between a child and an adult are obvious. But there also exists significant difference between a 2-year and a 13-year-old child. Therefore, a child is unique and different at each stage of his or her pediatric life.
Three general areas in which pediatric patients are unique compared to the adults are:
  1. Physiologic and anatomic differences
  2. Pharmacokinetics
  3. Emotional differences
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Physiologic and Anatomic Differences25
These differences can be discussed based on body size, body fluids, respiratory system, cardiovascular system and the urinary system.
 
Body Size
  1. Less amount of drug is needed to reach an effective plasma level but less is also needed to produce toxicity in children due to small body size.
  2. Height and weight of children are less than that of adults; their proportions also differ from adults.
  3. 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 to calculate drug dose.
  4. Smaller the patient, the higher is the basal metabolic rate, oxygen consumption and fluid requirement per hour.
 
Body Fluids
  1. 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.
  2. 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 a 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
  1. 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.
  2. In a child smaller bony thorax and soft sternum provide a less stable base for the ribs and intercostal muscles. Ribs are more horizontal than in adults and do not allow as much chest expansion as do the more vertically curved adult ribs.
  3. 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.
  4. Respiratory rate of the child is higher due to higher metabolic rate.
  5. Basal metabolic rate (BMR) in children is double that of an adult thus requiring greater oxygen consumption and carbon dioxide production.
 
Cardiovascular System
  1. 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.
  2. Heart rate is highest in infants.
  3. 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 reasons children undergoing treatment under general anesthesia should be given parasympathetic blockers such as atropine.
  4. In a newborn, peripheral circulation is very much poorly developed. This is important as uptake of intramuscular injections are low.
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  5. About 40% of the cardiac output in children contributes to the cerebral blood flow, compared to only about 29% in adult.
 
Urinary System
  1. 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.
  2. 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 (up to 50% longer) in a child. Example of such drugs are aminoglycoside antibiotics, digoxin and curare. GFR reaches adult level by 3–6 months.
  3. Tubular reabsorption and tubular secretion also vary and mature to adult levels during the first few months of life.
 
Pharmacokinetics68
It is a dynamic process of drug turnover in the body, which includes absorption, distribution, biotrans-formation and elimination. It determines a drug plasma concentration, duration of action and its effectiveness and toxicity.
 
Uptake of the Drug and Absorption
  1. Pulmonary uptake of nitrous oxide is more rapid in infants due to higher cardiac output, good alveolar ventilation and higher percentage of richly perfused visceral tissues.
  2. Topical medications are absorbed more rapidly and completely in children, due to greater permeability and relatively inactive sebaceous glands.
  3. 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 are deficient in infants.
 
Drug Distribution
  1. 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).
  2. 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.
  3. 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
  1. 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.
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  2. Poor oxidative rates in infants result in prolonged effects of diazepam, phenytoin and other drugs.
  3. Poor conjugation results in prolonged effects of amphetamines and phenacetin.
  4. Low levels of glucuronyl transferase in newborn, results in an inability to detoxify the antibiotic chloramphenicol, sulfisoxazole, morphine and steroids and thus increasing their sensitivity. Glucoronyl transferase reaches normal levels by 1 month of age.
  5. Psuedocholinesterase 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
  1. 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 Wright9 (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 and the arrows denote that the communication is reciprocal. Recently society has been added, meaning that the influence of the society on the child has to be considered affecting the treatment modalities.
  2. Children exhibit a fear of the unknown.
  3. They do not know to rationalize.
  4. Behavior management modalities differ, depending on the age and understanding.
  5. Children have less concentration time. Therefore, treatment time should be restricted to not more than 20–30 minutes.
  6. Treatment appointments should be preferably given during the morning time and avoided during their nap time.
  7. Adult patient seeks treatment by his own will, but the child patient visits the dentist usually by the will of his parents.
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Fig. 1.1: The pedodontic treatment triangle
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Fig. 1.2: Operatory area where the positioning of the child, operator and the parent resembles triangle and helps in proper communication
 
RESPONSIBILITIES OF THE PEDODONTIST
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REFERENCES
  1. Stewart RE, Barber TK, Troutman KC, Wei SHY. Pediatric dentistry, CV Mosby Co  1982.
  1. Howry LB, Bindler RM, Tso Y. Physiologic considerations in pediatric medications. JB Lippincott Co.  Philadelphia,  1981;3–17.
  1. Campbell RL, Weiner M, Stewart LM. General anesthesia for the pediatric patient. J Oral Maxillofacial Surg 1982; 40:497–506.
  1. Crawford JD, et al. Simplification of drug dosage calculation by applications of the surface area principle. Pediatrics 1950;5:783–9.
  1. Johnson TR. Moore WM, Jeffries JE. Children are different: Developmental Physiology. Ross Laboratories  Columbus, Ohio,  1978.
  1. Salanitre E, Rockow H. The pulmonary exchange of nitrous oxide and halothane in infants and children. Anesthesiology 1969;30:388.
  1. Morselli P. Clinical pharmacokinetics in neonates. Clin Pharmacokinet 1976;1:81–98.
  1. Anderson JA. Physiologic principles in pediatric dentistry, in Pinkham's pediatric dentistry infancy through adolescence, WB Saunders  1994.
  1. Wright GZ, Stigers JI. Nonpharmacologic management of children's behaviors. Dentistry for the child and adolescent, 9th Ed, Elsevier Mosby  2011;27–40.
FURTHER READING
  1. 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
  1. 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.
  1. 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.
  1. Goldman HM, Guernsey LH. The role of the dental specialist in the hospital. Dent Clin North Am 1975; 19(4):665–74.
  1. Jessee SA. Risk factors as determinants of dental neglect in children. ASDC J Dent Child 1998;65(1):17–20.
  1. Konig KG. The role of the dentist in prevention of dental disease. Int Dent J 1974;24(4):443–7.
  1. Mouradian WE. Ethical principles and the delivery of children's oral health care. Ambul Pediatr 2002;2(2 Suppl):162–8.
  1. Nainar SM. Pediatric dental practice: reconstruction or disintermediation. ASDC J Dent Child 2000;67(2):107–11, 82.
  1. 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.
  1. 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.
  1. Ryan KJ. The role of the voluntary dental association and the private practitioner. J Dent Child 1967;34(2):74–9.
 
QUESTIONS
  1. Give the American Academy of Pediatric Dentistry (AAPD) definition of Pediatric Dentistry.
  2. What are the aims and objectives of pedodontic practice?
  3. Explain the scope of pedodontics.
  4. Give the specific differences between child and adult patients.
  5. Explain the physiologic and anatomic differences.
  6. Write in detail the uptake of the drug and absorption and distribution in children.
  7. Explain the emotional differences between a child and an adult.
  8. What is a pedodontic treatment triangle?
  9. Give the general principles of pediatric pharmacology.