Pearls or Eureka Moments

Transcription

1 2011 Pediatric Dental Pearls SOUTH CAROLINA DENTAL ASSOCIATION Thursday April 28, :30 am 12:00 pm Martha Ann Keels DDS PhD Pearls or Eureka Moments 1. The First Visit 2. Caries Risk Assessment 3. Fluoride Issues 4. Recall Talk 5. Habit Breakers 6. Parents in Operatory 7. Staff Meeting Pearls 8. Eruption Problems 9. Anterior Crossbites 10. Primary Trauma Pearls The First Visit Pearls AAP Oral Health Policy May 2003 Infants at risk for caries should have a dental home by age 1 or by 6 months after eruption of the first tooth. Infant Pearls Getting to kids early! What do providers say? AAPD Dental Home 2001 ADA Oral Health Policy 2006 BRIGHT FUTURES 2007 Infants should have a dental home by age 1 or by 6 months after eruption of the first tooth (irrespective of risk). AAPD 1986 Age 1 visit ADA 2005 Dental Home ADA 2007 Age 1 visit AAPD 2009 Perinatal AAP NY Refer at age 1 if high risk Perinatal Bright Futures Refer all unless limited workforce Practitioner Type Do you care for infants? Recommend the Age 1 Visit Pditii Pediatricians 100% 5% General Dentist 45% 12% Pediatric Dentists 100% 37% Brickhouse TH et al. Infant oral health care: A survey of general dentist, pediatric dentists, and pediatricians in Virginia. Pediatr Dent 2008;30: Physician and Oral Health Pediatrician s office provides an excellent opportunity to begin timely preventive oral health interventions, particularly for children unable to establish a dental home. Physician visits outnumber dental visits 250 to 1 for infants and 1-year-olds. The Mayo Brothers 1928: ADA presentation: The practice of medicine includes dentistry and dentistry is the practice of a special branch of medicine, as is ophthalmology. It may be going too far to say that all dentists should be doctors of medicine, but certainly all dentists should know much about the practice of medicine as a whole; and, conversely, all physicians should know more about dentistry, its importance and possibilities. 1

2 Physicians in Dentistry Do physician based preventive programs work? preventive services? prevalence of ECC and related treatment/cost? Anticipatory Guidance 1) Establish relationship w/ family 2) Caries Risk Assessment 3) Periodontal Risk Assessment 4) Orthodontic Risk Assessment 5) Trauma Risk Assessment 6) Oral Hygiene Education 7) Diet / Feeding Behaviors 8) Habits (Pacifier, Digits) 9) Teething advice 10) Plan for acute dental trauma 11) Plan for next visit NEW ADA CODES D0145 -> 0-3yo D1206 -> Fl varnish Caries Risk Assessment PEARLS Who is High, Medium or Low? Goal prevent the heart attack of the caries process! Goal prevent the heart attack of the caries process! What is the Best Predictor of Caries in Permanent Teeth? Children having caries in their primary teeth are 3 times more likely to develop caries in their permanent teeth! Enamel decalcification Abscess Li and Wang 2002 J Dent Res 81: How do we do Caries Risk Assess? Fisher- Owens S Child, family, & community influences 2

3 The Caries (ECC) Balance Featherstone s Protective Factors Pathologic Factors FAVOR REMINERALIZATION FAVOR DEMINERALIZATION No Caries Caries Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42, The ECC Balance Protective Factors FAVOR REMINERALIZATION * Good Salivary Flow * Adequate Fluoride, Vitamin D, Calcium, Phosphate * Good Oral Hygiene & Diet * Antibacterials --- Iodine, CHX * Others Xylitol? Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42, The ECC Balance Pathological Factors FAVOR DEMINERALIZATION Acidogenic bacteria Increased frequency of ingestion of fermentable carbohydrate Reduced salivary function Deficient calcium, deficient Vitamin D Others? Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42, AAPD CAT Caries Risk Assessment Tool Clinical Conditions Visible plaque, demineralization, caries, gingivitis Environmental Conditions Fluoride exposure, sugar exposure, SES, established dental home General Health Conditions Special Needs, reduced saliva TIGHT TEETH Sippy cup with juice Enamel Defects Chronic liquid meds Determine if LOW, MED, HIGH risk for caries The Caries (ECC) Balance what is missing? Protective Factors Pathologic Factors No Caries Caries Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42, Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History 8. Child s Personality Potential Risk Factor for ECC? 1. TOOTH INTEGRITY 1) Early Eruption = prior to age 6 months Risk period increased Teeth are safe underground 2) Dental Crowding Tight Teeth / Overlapping Missing the GAPS Lacks natural saliva cleansing 3

4 Eruption Concerns Potential CommonSense Risk Factors for ECC? Early eruption times! First tooth at 3 months versus 6 months Great Spaces vs Hoover Dam Which mouth is more self- cleansing? dynamic vs stagnant 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History Potential Risk Factor for ECC? 2. ENAMEL INTEGRITY (hypoplasia) Defective / Porous Enamel / Shape of tooth Upper incisor concavity / lower canines defect Enamel Quality & Spacing Multiple Births look for enamel defects Potential Risk Factors for ECC? 2. ENAMEL INTEGRITY (hypoplasia) Etiologies --- for the enamel defects Hypoxia (multiple births, premature births) Stress (fever) in 3 rd Trimester of Pregnancy Pressure intubation Congenital Heart Defect (esp if cyanotic) Vitamin D deficiency Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History Risk Factor for ECC 3. Intraoral Anatomy FRENAL ATTACHMENTS Shallow Vestibules (includes constricted maxillary frenum) Constricted Lingual Frenum SALIVA ph level Stagnant at night (no swallowing) 4

5 Maxillary Frenum constricted Lower Lingual Frenum constricted Lower Lingual Frenum constricted Does he pack food in his upper pouches? Can he clean his teeth with his tongue? Meet Jake 4y4m Forked tongue = tight lower lingual frenum Lower Lingual Frenum constricted Lower Lingual Frenum constricted Lower Lingual Frenum constricted Caries at CEJ on right and left sides Restricted movement laterally Can he clean his vestibules? FOOD HOLDING Caries at CEJ on right and left sides INTRAORAL ANATOMY * Frenums * Salivary Flow Feeding during the night can be problematic why? - lack swallowing and natural saliva cleansing Salivary Dysfunction Limited salivary flow is a major risk factor for ECC. Reduced salivary flow: impairs the delivery of beneficial minerals: calcium, phosphate and fluoride reduces remineralization potential sustains lower ph level diminishes neutralization *** Mouthbreathing = tenancious plaque (spin brush) Saliva with low ph and Demineralization Low ph ACID (ph<5.5) 5

6 Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History 8. Child s Personality Risk Factors for ECC? FEEDING PRACTICES Breastfeeding vs Bottlefeeding Scheduled d vs Unscheduled d Feeding ESPECIALLY RISKY NIGHT TIME FEEDING Slow Swallowing / Food Holding / Dysphagia Infant Regurgitation / GERD AAPD Policy on Breastfeeding Endorses the AAP Policy best possible nutrition for infants Revised Ruta Valaitis, et al Canadian Paper Systemic Review of the Relationship between BF and ECC 151 articles (only 28 met Cochrane Criteria) Relationship is equivocal (lacks Risk Analysis) Human Breast Milk Is it cariogenic? Dr. PAMELA ERICKSON STUDY * Plaque ph after 5minutes BF not significantly different from H 2 O * HBM alone (without bacteria) did not dissolve enamel after 12 weeks * HBM supported moderate bacterial growth of Strep Sobrinus after 3 hours Ref P Erickson and E Mazhri. Pediatr Dent 21: 86-90, Human Breast Milk Is it cariogenic? ERICKSON STUDY * HBM has poor buffering capacity * HBM plus 10% sucrose caused dentinal caries w/in 3.2 weeks *** KEY FINDING Ref P Erickson and E Mazhri. Pediatr Dent 21: 86-90, Infant Bulimia? CHIPMUNK EFFECT slow swallowing food holding pediatric dysphagia Prasse JE, Kikano GE. An Overview of Pediatric Dysphagia. Clin Pediatr Phil 2009; 48: HER RISK FACTORS Chronic Meds Holding pattern Slow Swallowing Excessive regurgitation Could it play a synergistic role in ECC? Demineralizes the upper incisors? Greater synergy with crowded upper incisors 6

7 Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History 8. Child s Personality MEDICATIONS Medications: - Check sucrose content - Evaluate meds taken for chronic conditions 1. Ear infections 2. Constipation 3. Reactive Airway Vitamin Warning Gummi Bears Sourz Vitamin taste like Sour Patch Kids 4 bears = 100% RDA for 12 nutrients & 5 grams of sugar ph 2 Flintstones 1 vitamin = 100% RDA for 12 nutrients & 0.34 gram sugar Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake (in detail later) 7. Family History 8. Child s Personality Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History 8. Child s Personality Family History Bacterial Load Vertical Transmission (~30% maternal) Oral Hygiene Rituals Psychological Factors Mother s Untreated Caries OR = doubled the odds of increased child s severity of caries by ~ 3 surfaces J. Weintraub et al. J Dent Res 89(9): , 2010 Potential CommonSense Risk Factors for ECC? 1. Tooth Integrity 2. Enamel Integrity 3. Intraoral Anatomy 4. Feeding Practices 5. Medications 6. Fluoride Intake 7. Family History 8. Child s Personality Psychosocial Risks Fit Models Unconsolable child Passive Parenting Poor Fit Make feeding and toothbrushing difficult 7

8 Caries Risk Factors - summary 1. Dental Spacing crowded 2. Enamel Integrity - defects 3. Intraoral Anatomy constricted frenums 4. Feeding Practices 5. Medications sugar based 6. Fluoride Intake not brushing 7. Family History mom has untreated caries 8. Parent-Child Personality Fit Overall Goal --- A Healthy Child with a Healthy Smile Fluoride 2011 A Decade of Changes Review of how FLUORIDE works What is FLUOROSIS 2001 CDC Fluoride Guidelines 2006 ADA Topical Fluoride Recommendation 2007 ADA Infant Formula & Non-fluoridated H 2 O 2008 JADA Systematic review of Fluoride Supplements Fluoride 2011 A Decade of Changes 2010 JADA Causes of Fluorosis in Permanent Incisors Iowa Study Steve Levy 2011 ADA Evidence-Based Clinical Recommendations regarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis 2011 Dept of Human and Health Services and EPA recommendation for fluoride level in public water systems Mechanism of Action of Fluoride KEY CONCEPT --- primarily a topical action (even when given systemically): Reduces enamel solubility Promotes remineralization of enamel, and may arrest or reverse early caries Inhibits the growth of cariogenic organisms thus decreasing acid production Demineralization Low ph Ca++ Fluoride mechanism H+ PO - 4 H+ H+ F - H+ H+ Protein? Ca++ Remineralization Increased ph PO - 4 F F - - F F - - F - F - Concentrated in saliva Sources of Fluoride Systemic fluoride works topically Community water fluoridation Bottled water with fluoride added Fluoride supplements Swallowed toothpaste Topical fluoride works topically Fluoride toothpastes Professionally-applied: gels, foams, rinses, and varnishes like sodium too little - caries risk too much - fluorosis risk The Fluoride Zone Amount of FLUOROSIS depends on 1) Amount of exposure 2) Duration of exposure 3) Timing within Enamel Maturation 4) Individual id susceptibility ~ genetic predisposition i i? ** if too much fluoride is ingested before age 5 risk FLUOROSIS 8

9 Risk Period for fluorosis = while Perm Teeth are developing Critical Risk Period for Fluorosis 3 mos 5 years of age Tooth Hard Tissue Formation Begins Enamel Complete Eruption Permanent Dentition Maxillary Central incisor 3-4 mo 4-5 yr 7-8 yr Lateral incisor mo 4-5 yr 8-9 yr Issue of Fluorosis Anteriors -> 3months 5 years of age Enamel Maturation for all Permanent Teeth complete by age 8 Mandibular Central incisor 3-4 mo 4-5 yr 6-7 yr Lateral incisor 3-4 mo 4-5 yr 7-8 yr Fluorosis is treatable 1) Cool Dam 2) 37% HCL and pumice Fluorotic Incisors & Molars SYSTEMIC EFFECT Review of how FLUORIDE works What is FLUOROSIS 2001 CDC Fluoride Guidelines Fluoride When and Where ADA Topical Fluoride Recommendation 2007 ADA Infant Formula & Non-fluoridated H 2 O 2008 JADA Systematic review of Fluoride Supplements CDC Fluoride Recommendations Weigh the risk before Rx fluoride Select a fluoride modality according to: a caries risk assessment ( high or low ) recognize that an individual s risk can change over time change from low to high be familiar with the quality of the evidence of each fluoride modality Protective Factors FAVOR REMINERALIZATION No Caries Pathologic Factors FAVOR DEMINERALIZATION Caries Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42,

10 CDC Fluoride Recommendations Public Health and Clinical Practice promote community water fluoridation counsel parents regarding the risk of swallowing toothpaste, especially <2yo target mouthrinsing to high risk judiciously Rx fluoride supplements apply high-concentration Fl - products to high risk Community water fluoridation 61.5% of US population receiving fluoridated water (2006, CDC Statistics) 69.2% of US population on public water system receiving fluoridated water. #1 Kentucky 99.8% # 49 New Jersey 22.6%. CDC Tooth Brushing Recommendations Toothpaste No longer the pea, now the smear Age Tooth Brushing Recommendations (CDC, 2001) < 1 year ~ clean teeth with soft toothbrush 1-2 ~ parent performs brushing years 2-6 ~ pea-sized amount of fluoridecontaining toothpaste 2x/day years ~ parent performs or supervises > 6 ~ brush with fluoridated toothpaste years 2x/day Fluoride FREE Contain 0.15% fluoride ion SAME AS ADULT TOOTHPASTE 0.11 mg F 0.44 mg F Fluoride rinses Recommended to begin after age 6 years. CDC Fluoride Recommendations -Self Care know the fluoride content of your drinking water frequently use small amounts of fluoride *** drink Fl - water and brush BID supervise children <6yo use of toothpaste consider additional fluoride modalities if you are at high risk for caries use alternative water if >2ppm & child <8yo CDC Fluoride Recommendations Consumer Product Industry & Health Agencies label bottled water promote use of small amounts of toothpaste with children develop a low-fluoride toothpaste for children ~ 500 ppm collaborate to educate public and healthcare professionals 10

11 Fluoride 2011 A Decade of Changes Review of how FLUORIDE works What is FLUOROSIS 2001 CDC Fluoride Guidelines 2006 ADA Topical Fluoride Recommendation 2007 ADA Infant Formula & Non-fluoridated H 2 O 2008 JADA Systematic review of Fluoride Supplements Fluoride 2011 A Decade of Changes 2006 ADA Topical Fluoride Recommendation Fluoride Gels Fluoride Foams Fluoride Varnish What should we use in our offices? What is the best topical fluoride treatment for our patients? VARNISH > 4 minute GEL > 4 minute FOAM Use of any topical fluoride tx should be based on a caries risk assessment ADA 2006 Topical Fluoride Recommendations JADA 137: , Fluoride Varnish the preferred topical 22,600 ppm Shown to be 30-63% effective in preventing ECCs* Available in singledose disposable packets 3M or Colegate White Fluoride Varnish Improved taste for children! Cherry or Melon Preventive Role of Fluoride Varnish Dr. Jane Weintraub et al Fluoride Varnish Efficacy in Preventing Early Childhood Caries J Dent Res 85(2): , ,2,3 and 4 applications of fluoride varnish & parental counseling were efficacious in preventing ECC Note similar findings in NC Gary Rozier study 39% reduction in anterior caries Treatment Scenarios 1. White spots treat chemically 2. Beyond white spots Beginning breakdown ART plus Fluoride Varnish or ART w/ Glass Ionomer (Fuji IX or Ketac Nano) 3. Frank caries mechanical tx 11

12 Role of MDs in Oral Health TARGET POPULATION = Medicaid population AGE first tooth -> age 3 COORDINATE with VACCINES 3 Treatment Scenarios 1. White spots treat chemically by MD or DDS 2. Beyond white spots SMALL HOLES ART plus Fluoride Varnish by DDS 3. BIG HOLES mechanical tx by DDS *Bader JD, Rozier RG, Lohr KN, Frame PS. Physicians roles in preventing dental caries in preschool children. Am J Prev Med. 2004;26: Fluoride When and Where 2011 Baby Formula Fluoride Levels Review of how FLUORIDE works What is FLUOROSIS 2001 CDC Fluoride Guidelines 2006 ADA Topical Fluoride Recommendation 2007 ADA Infant Formula & Non-fluoridated H 2 O 2008 JADA Systematic review of Fluoride Supplements ADA News ADA Interim Statement Infant feeding 0 12 months 1st choice = breastfeeding 2 nd choice = Ready-to-feed (premixed) 3 rd choice = Liquid concentrate or powered formula MIX with FLUORIDE FREE WATER 2007 ADA Interim Statement Infant feeding 0 12 months ISSUE volume of liquid being consumed AAP ounces per day FORMULA 8 ounces of fluoridated water = 0.25mg fluoride EQUALS 0.75mg -1mg of fluoride per day Variable F in Drinking Water 12

13 Fluoride Content After Water Filtration ADA News 2000 JB 8yo *Had infant formula from 6-12 months *1 st tooth erupted around 10 months old *Now seeing Fluorosis on #K, #T, #8, #9, #19, and #30 Fluoride When and Where 2011 JB 8yo *Had infant formula from 6-12 months *1 st tooth erupted around 10 months old *Now seeing Fluorosis on #K, #T, #8, #9, #19, and #30 Review of how FLUORIDE works What is FLUOROSIS 2001 CDC Fluoride Guidelines 2006 ADA Topical Fluoride Recommendation 2007 ADA Infant Formula & Non-fluoridated H 2 O 2008 JADA Systematic review of Fluoride Supplements Only Rx Supplements if 1) NO Fluoride in Water AND 2) HIGH Caries Risk Limited Supply??? Testing H20 for fluoride Weigh the risk before Rx fluoride Fluoride Dosing Recommendations It is Complicated If content unknown and child is at high risk for dental caries, test water source. Protective Factors FAVOR REMINERALIZATION Pathologic Factors FAVOR DEMINERALIZATION Dietary Fluoride Supplementation No Caries Caries Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42, MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the U.S.: 13

14 Fluoride When and Where 2011 Fluoride When and Where JADA Causes of Fluorosis in Permanent Incisors Iowa Study Steve Levy 2011 ADA Evidence-Based Clinical Recommendations regarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis 2011 Dept of Human and Health Services and EPA recommendation for fluoride level in public water systems 2010 JADA Causes of Fluorosis in Permanent Incisors Iowa Study Steve Levy WHAT INCREASES RISK OF FLUOROSIS 1) reconstituted infant formula with fluoridated water ages 3-9 months 2) water added beverages using fluoridated water ages 3-9 months 3) higher fluoride toothpaste intake ages months Fluoride When and Where 2011 Fluoride When and Where 2011 Fluoride When and Where JADA Causes of Fluorosis in Permanent Incisors Iowa Study Steve Levy 2011 ADA Evidence-Based Clinical Recommendations regarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis 2011 Dept of Human and Health Services and EPA recommendation for fluoride level in public water systems 2011 ADA Evidence-Based Clinical Recommendations regarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis okay to mix with fluoridated water JUST advise parents of risk Why okay because the risk of fluorosis is MINIMAL 2010 JADA Causes of Fluorosis in Permanent Incisors Iowa Study Steve Levy 2011 ADA Evidence-Based Clinical Recommendations regarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis 2011 Dept of Human and Health Services and EPA recommendation for fluoride level in public water systems Fluoride When and Where Dept of Human and Health Services and EPA recommendation for fluoride level in public water systems Previous 0.7 to 1.2 mg of fluoride per liter of water *** Now recommend 0.7 mg of fluoride per liter of water We do NOT need a range of values any more Risks for fluorosis in young children RISK BEHAVIOR PREVENTION Infant feeding caution mixing with fluoridated water Swallowing Fluoride Toothpaste delay independent toothbrushing until child can spit out toothpaste Fluoride Rinse wait until child is >6yo Fluoride Supplements ck risk & water sources before Rx need to be HIGH RISK Water with >1.2ppm fluoride drink other water Prevention Pearls Recall Talk Tongues and Floss 14

15 Window/Mirror Marker Make sure to customize your OHI recommendations Brushing Routines Trying not to set up families to fail Brush when you are in the Bathroom Before Breakfast and Before Bed Disrupt plaque every 12 hours Lower Lingual Frenum constricted Lower Lingual Frenum constricted Oral Hygiene Routines ASK How do you clean your teeth after lunch? TEACH SELF-SUFFICIENCY And BODY AWARENESS Meet Spenzi 12y9m Note moderate to severe decalcification at CEJ on maxillary incisors Can she clean her teeth? Lower Lingual Frenum constricted Caries Risk Assessment After breakfast and lunch tongue brush Protective Factors Pathologic Factors Restricted tongue movement Forked tongue No Caries Caries Ref JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, C42,

16 Make sure each CHILD knows how to use their tongue to make sure their teeth are SLICK Flossing. Chicken Pearl Flossing. Flossing House Story Flossing. Flossing. Customizing your Care Flossing. Customizing your Care Chicken Pearl No flossing needed Mandibular teeth are tight -- Emphasize flossing between all the tight areas Jana 5y4m Tight = flossing needed Jana 5y4m **Diastemas forming due to maxillary enlargement -- Flossing only between tight teeth Flossing. Customizing your Care Pearls for Tackling Habits Tackling Habits Maxillary anterior teeth are tight Importance of flossing! Pacifiers okay until age 1 (AAP guideline 10/2005) Nadia 4y7m Pacifiers & SIDS prevention 16

17 AAP POLICY AAP Policy Task Force on Sudden Infant Death Syndrome The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics 116(5): November 5, 2005 Paci helps build a bear! Meet Jamie - 4y2m Gave her paci to her new Build-A-Bear kitty Positive Action: Giving her pacifier to her new friend v. Parent taking the pacifier away Google Stop Thumbsucking Tackling Habits tongue thruster MAVALA TIP Amazon.com $8-$10 Problem poor tongue retraction 1. Purposeful swallowing 2. Clucking 3. Talk with teeth together 4. Jar with quarters 5. Maxillary Hawley with hole in acrylic Tackling Habits tongue thruster Tackling Habits tongue thruster Elise age 4 Practicing tongue RETRACTION 17

18 Problem poor tongue retraction 1. Purposeful swallowing 2. Clucking 3. Talk with teeth together 4. Jar with quarters 5. Maxillary Hawley with hole in acrylic Tongue Thruster Remedy DOUBLE LIPS lip lickers Lick within the lines! Parent Pearls Parents in the Operatory. WHAT I HAVE LEARNED Parents in the Operatory. WHAT I HAVE LEARNED Parents in the Operatory What we have learned Research shows that parents want to be with their children during procedures, even for a lifesaving code. References: Ann Emerg Med 2002 Aug 40(2): Arch Pediatr Adolesc Med 1999 Sept 153(9): Research shows that there is a LOW prevalence of negative outcomes associated with family presence during a trauma assessment CHOP 136 cases References: Pediatrics 2007 Sept 120(3):e565-e575. MORAL of the STORY.. Treat dental chair as an operating room table Parents must remain seated unless requested to come closer to see the mouth Parents in the Operatory. WHAT I HAVE LEARNED #1 set rules limit number of family members #2 helpful words to use #3 explain scary machines pulse ox, etc #4 give parent a job --- massage the leg, breathing coach Understanding Parents 5 Stages of Accepting a Diagnosis Stage 1: Denial g Stage 2: Anger Stage 3: Bargaining Stage 4: Depression Stage 5: Acceptance 18

19 Understanding Parents We love the parents who progress through the 5 stages in 30 seconds ** The best treatment can take place when the parent is in acceptance of his/her child s needs = the dentist and the parent are on the same page ** Pedo Pearl Parents don t care how much you know until They know how much you care about their child. STAFF MEETING PEARLS 1) Practice CONSISTENT MESSAGING --- BPA, Xylitol 2) Read Books Together Chapter reports Beyond Basketball Coach K s Keys for Success 3) Norman Rockwell Painting Golden Rule STAFF MEETINGS 4) Duke Children s Bill of Rights A BILL OF RIGHTS FOR KEEPING KIDS COMFORTABLE REMEMBER KIDS HAVE THE RIGHT TO: Communicate when they have pain. (We understand that children may do this differently than adults) Have a parent or supportive adult stay with them during procedures. ( We understand that separation is difficult and a parent s presence is comforting and healing). STAFF MEETINGS Receive medication to relieve pain, in a timely fashion. (We want children to be free of pain whenever possible). Cry, Laugh, or be mad if it helps them feel better. (We understand how children communicate on different age levels). Have a blanket, favorite music, or a familiar toy to help comfort them. (We understand children have special comfort needs). To receive praise for going through difficult situations. (We encourage positive reinforcement for children). STAFF MEETINGS Have pain prevented whenver possible. (We encourage patients and families to ask about pain prevention.) Have a plan for pain management following discharge. (We know that pain can come and go.) Coach K on Team Building Excellent teams use pleural pronouns! Coach K on Team Building Excellent teams use PLEASE and THANK YOU a lot! 19

20 PLEASE: KID S BILL OF RIGHTS PLEASE: KID S BILL OF RIGHTS Crossbite Management Pearls Look at me and talk to me in a way I can understand Introduce yourself Be honest with me.. Always Offer me a choice whenever possible Communicate with my parents. If they feel less anxious it will help me a lot Tell me what you are going to do.. Before you do it PLEASE DON T: Tell me It won t hurt if it will. Or Don t cry Forget to listen when I have something to say Forget I want my favorite toy and my parents with me KEY to Successful Anterior Crossbite Tx Our Job Monitor Eruption Infant Talk for Primary Dentition Eruption Basics for parents Timing & Vigilance Own the Eruption Time Table NOAH s Ark Teeth erupt in pairs SYMMETRY is KEY 20 Baby Teeth in Total 8 fall out around first to third grade Last 12 fall out around age What if 1) TOO EARLY before 6 months 2) UNUSUAL Eruption Pattern know the correct order incisors, then molars, canines, molars 3) DELAYED one side is in and the other is delayed What if TOO EARLY? Born with teeth UNUSUAL Eruption Pattern? Baby Molar first TOO LATE? Delayed eruption TOO EARLY What if the first tooth is a neonatal incisor? Neonatal --- within 30 days of birth 20

21 A newborn with a tooth. The traditional neonatal incisor The Traditional Neonatal Incisor The Traditional Neonatal Incisor Tooth #O Mandibular suture Mandibular suture One day old baby anterior view The Traditional Neonatal Incisor TREATMENT OPTIONS UNUSUAL ERUPTION PATTERN What if the first tooth is a neonatal molar? First tooth -> Neonatal Molar 1) Extract to avoid aspiration risk 1) Observe Neonatal --- within 30 days of birth Vanika one day old Maxillary arch First tooth -> Neonatal Molar Puzzler - Neonatal Molar Puzzler - Neonatal Molar EM study Mandibular arch Vanika one day old Vanika one day old Gingival biopsy SMA 100 stain 21

22 Puzzler - Neonatal Molar Puzzler - Neonatal Molar lesson learned What if DELAYED eruption? Diagnosis Langerhan Cell Histiocytosis X Treatment Chemotherapy Vincristine Prednisone Neonatal Molars --- ominous sign Need to Rule out NEOPLASTIC DISEASES Langerhan Cell Histiocytosis X Avery #G is unerupted at 2y10m Puzzler What if delayed? Meet Avery #G is unerupted at 2y10m Puzzler What if delayed? Avery 3y11m Anterior Crossbite in Primary Dentition Consequences: 1) Erupts eventually or 2) Requires extraction if effecting eruption of #9 or #10 Is it 1) pseudo Class III or 2) real Class III? Class I, II and III bites Anterior Crossbite Treat early to avoid: 1. Enamel loss on facial of upper incisors 2. Potential jaw surgery Treat Class III occlusions early and often STABILITY ---- adequate OVERBITE! See enamel loss on maxillary incisors 22

23 Tx Options Anterior Crossbites Anterior Crossbites --- understanding functional shift 1) No tx 2) Recontour lower canines 3) Resin Bite block 4) Removeable Hawley w/ advancing screw 5) Fixed Appliance w/ advancing springs NEED FAMILY HX Meet Morrigan 4y2m Her normal bite: edge-to-edge With molars together Normal bite: edge-to-edge Anterior Crossbites Starting treatment once Morrigan was cooperative Anterior Crossbite - corrected KJ 2yr old Anterior Crossbite & ECC Morrigan 4y8m Her corrected bite in 4 weeks w/ mom losing the key for 1 week TX time = 3 weeks Tight Teeth Low Frenum No Flossing Sippy Cup w/ Juice Prevent wear of Crowns 23

24 Complete Crossbite anterior & posterior May take 2 appliances to fix anterior and posterior x-bite Anterior Correction Face mask Anterior Functional Shift Primary maxillary incisors are mobile 5y10m Plan to wait on eruption of permanent incisors Mara 5y10m LOVE the DEEP BITE Posterior correction Quad-helix Wait for exfoliation almost 2yrs Mixed Dentition complete crossbite Complete Orthodontic work-up Mara 7y8m Initial Right Lateral No room for #7 Initial Left Lateral Ceph 7y4m (great if there is a deep bite tendency) Panorex 7y4m Both crossbites corrected in 6 months! Friendly Face Mask Phase One finished Crossbites corrected in 6 months Mara 8y6m Right Lateral Left lateral 24

25 Primary Tooth Trauma Pearl Monroe s teeth Imagination is more important tthan intelligence. e e Avulsion pearl Albert Einstein Socket Depth Shallow / Splinting How??? Primary Teeth Avulsion Pearls Do we need to hold space? Usually do NOT replant Do you need a space maintainer? How did we lose space? Tackling Habits U arch versus V arch Do we need to hold space? The Great Masseter Muscle versus Maxilla spongy bone marrow PEARL --- Hold space when the child has a active digit habit 25

26 Thank you for your time! Any questions? 26