___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
SEALANTS As discussed, the use and efficacy of pit and fissure sealants can decrease the risk of caries associated with anatomical features in deciduous and permanent teeth. Parents may be unaware of this preventive option, especially if sealants were never used for their own teeth. The benefits of this approach should be discussed with the parents, but it is important that they know that pit and fissure sealants are not a substitute for good oral hygiene. Parents should also understand that the cost of pit and fissure sealants is per tooth and that insurance company reimbursement is variable. FLUORIDE TREATMENT Fluoride is the negatively charged ionic form of the element fluorine, and it is able to form stable bonds with positively charged ions, such as sodium and calcium, to promote reminer- alization of teeth. Virtually all water naturally contains fluoride, but usually at a concentration that is not sufficient to prevent tooth decay. The use of community water fluoridation began in late 1940s [25]. In 2010, the U.S. Department of Health and Human Services decreased the recommended optimal concentration of fluoride in drinking water for reduction of dental caries from 0.7–1.2 mg per liter of water to 0.7 mg per liter [30]. This change was the result of the widespread avail- ability of fluoride-containing foods, water, beverages, tooth- pastes, and mouth rinses and to some degree was a response to concerns of overexposure to fluoride, which is neurotoxic at higher doses and can also cause dental and skeletal fluorosis [72]. This recommendation was finalized in 2015, with stud- ies showing that 0.7 mg per liter of fluoride in drinking water maintained decreases of up to 35% of caries in children, while minimizing the risk of skeletal fluorosis [30; 81]. Fluoride is slightly more toxic than lead and slightly less toxic than arsenic and has a narrow therapeutic window that can be difficult to control when all potential sources are considered [74]. Exces- sive ingestion of fluoride can cause dental fluorosis, a condition in which the enamel exhibits subtle changes (e.g., white spots) and potentially extensive areas of pitting and discoloration. Swallowed fluoridated toothpaste and drinking water are the primary sources of excessive fluoride intake and are considered the leading causes of fluorosis [71]. To prevent this, parents should receive instructions regarding toothbrushing technique and tvhe amount of toothpaste that is appropriate for children to minimize the unnecessary ingestion of fluoride. Fluoride’s preventive effects are principally topical, rather than systemic, as was previously thought. Fluoride disrupts the activity of cariogenic bacteria (e.g., Streptococcus mutans ) by decreasing its metabolism of carbohydrates in dental plaque, the action responsible for acidification of the oral environ- ment that causes the demineralization [27]. Acid excreted by cariogenic bacteria stimulates the release of fluoride that is then incorporated into enamel that has undergone initial demineralization. However, mutated strains of Streptococcus
The initial appointment consists of the debridement and removal of the necrotic remnants of the pulpal tissue. A thick paste of calcium hydroxide is placed into the cleansed and debrided canal to stimulate the formation of the calcified stop in the apical region of the root. Whether calcium hydroxide is placed during the initial or second appointment, it is covered with a temporary filling material and left within the canal for approximately six months. If a calcified stop near the apical region of the tooth is confirmed by radiographs and is tactilely encountered by endodontic instruments such as files or ream- ers, conventional endodontic treatment can be completed [22]. If the stop is not encountered, the canal is retreated with calcium hydroxide paste. The complete loss of pulpal tissue in an immature permanent tooth precludes the continued thickening and developing of the root canal walls even if the apexification technique and subsequent endodontic therapy are successful [23]. This makes the tooth more susceptible to fractures of the crown or the root. A full-coverage crown can decrease, but not eliminate, the potential for coronal fractures. Patients should be reminded to minimize pressure to treated teeth and should be instructed to wear protective mouth guards during athletic activities. Procedures such as pulpotomies of deciduous and immature permanent teeth and apexification should only be performed by clinicians who have had adequate training. Referral to a pedodontist or endodontist should be considered if the required clinical techniques are beyond the capabilities of the general practitioner. PREVENTIVE DENTISTRY FOR CHILDREN AND ADOLESCENTS Of course, the ultimate goal for each child and adolescent is avoidance of dental caries. Unfortunately, many patients in this age range have one or more carious lesions. Infants and children are dependent upon their parents/caregivers to brush and floss their teeth, to bring them to the dental office for exams and routine prophylaxis appointments, and to provide nutrition that is conducive to good oral and general health. There are general guidelines for the prevention of dental caries in children and adolescents that may be helpful for clinicians and parents/patients. Oral problems that are diagnosed early can be treated conser- vatively and inexpensively. As such, the American Academy of Pediatric Dentistry has recommended an initial dental examination as early as the first tooth eruption and no later than 12 months, which would include a caries risk assessment, oral hygiene instructions for the parent(s), and a general assess- ment of the child’s oral health [24].
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