Pediatric Dentistry

Pediatric DentistryA clinical approachSecond edition

Editors

Göran KochSven Poulsen

This edition fi rst published 2009© 2009 by Blackwell Publishing Ltd© 2001 by Munksgaard, Copenhagen

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Library of Congress Cataloging-in-Publication DataPediatric dentistry : a clinical approach / editors, Göran Koch, Sven Poulsen. -- 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-6100-8 (hardback : alk. paper) 1. Pedodontics. I. Koch, Göran. II. Poulsen, Sven. [DNLM: 1. Pediatric Dentistry. 2. Dental Care for Children--methods. WU 480 P36983 2009] RK55.C5P447 2009 617.6’45--dc22 2008030047

A catalogue record for this book is available from the British Library.

1 2009

Preface to the second edition xiii

Contributors xiv

1 Pediatric oral health care: the perspectives 1

Sven Poulsen and Göran Koch

How it began: the historical perspective 1 Community responsibility: the population

perspective 1 From birth to adolescence: the oral health

perspective 1 UN Convention on the Rights of the Child:

the ethical perspective 2 Pediatric dentistry: the clinical perspective 3 References 4

2 Growth and pubertal development 5 Anders Juul, Sven Kreiborg and

Katharina M. Main

Measurement of growth in different phases of life 5

Prenatal growth 5 Postnatal growth 5 Infancy 6 Childhood 7 Puberty 7 Growing pains 8 Evaluation of growth charts 8 Bone age determination 10 Final height prediction 10 Dental age determination 10 Disorders of growth and puberty 11 Intrauterine growth restriction 11 Postnatal growth failure 11 Tall stature and growth acceleration 13 Early puberty 15 Late puberty 15 Disorders with deviations in dental maturity 15 Conclusion 15 References 16

3 Child and adolescent psychological development 17

Anders G. Broberg and Gunilla Klingberg

Perspectives on psychological development 17 A biopsychosocial approach 17 Aspects of psychological development 18 Cognitive development 18 Emotional development 21 Developmental tasks 23 Man is a social animal 24 Attachment theory 24 Social ecology 25 A holistic description of children of

different ages 25 The preschool years (3–5 years) 25 The elementary school years (6–12 years) 26 Adolescence (13–18 years) 27 Developmental psychopathology 28 The biopsychosocial model 29 Resilience and protective factors 29 Developmental lines 29 Summary 30 References 30

4 Dental fear and behavior management problems 32

Gunilla Klingberg, Magne Raadal and Kristina Arnrup

Defi nitions and prevalence of dental fear and anxiety 32

Etiology 33 Personal factors 34 External factors 35 Dental factors 36 Principles of management 37 Creating a safe environment for the child 37 Behavior shaping 38 Desensitization 39 Behavioral techniques in combination with

sedatives 41 Emergency situations 42 Specialized pediatric dentists 42 References 43

5 Pain, pain control, and sedation 44 Magne Raadal, Stefan Lundeberg and

Gro Haukali

Methods of pain control 46

Contents

Local analgesia and pain control 47 Intraoral topical analgesics 47 Local analgesic solutions 47 Methods of administration 47 Contraindications 51 Complications 51 Toxicity 51 Preparation of the patient 52 General analgesia 53 Conscious sedation 53 Indications and contraindications 54 Oral and rectal administration of

benzodiazepines 54 Routes and doses 55 Clinical considerations 56 General anesthesia 58 References 59

6 Dental caries in children and adolescents 61

Marit Slåttelid Skeie, Lill-Kari Wendt and Sven Poulsen

Childhood dental caries as a health problem 61

Epidemiology of dental caries in children and adolescents 62

Epidemiological data on dental caries 63 Dental caries in the primary dentition of

preschool children 64 Caries in the permanent dentition 66 Caries in children and adolescents in a

changing society 67 References 68

7 Case history and clinical examination 71 Sven Poulsen and Lars Matsson

Case history 71 The family history 72 General medical history 72 Dental history 73 Clinical examination 73 General appearance 73 Examination of the head and neck 73 Intraoral examination 74 Examination of the oral mucosa 74 Examination of periodontal tissues 75 Examination of teeth 75 Examination for temporomandibular joint

problems 77 Examination of occlusion 77 Records 77 References 78

8 Radiographic examination and diagnosis 79 Hanne Hintze and Ivar Espelid

Indications for radiographs in children and adolescents 79

Principles for interpretation of radiographs 79 Radiographic anomalies and pathologies in

children and adolescents 80 Caries and its sequela 80 Intervals between bitewing examinations 81 Trauma to teeth and supporting tissue 82 Developmental and acquired dental anomalies 82 Systemic diseases and syndromes 83 Treatment planning prior to orthodontics 83 Treatment planning prior to surgery 83 Intraoral radiographic techniques 83 Periapical radiographs 83 Bitewing radiographs 84 Three-dimensional object localization

radiographs 85 Extraoral radiographic techniques 86 Panoramic examination 86 Scanography 87 Computed tomography 87 Radiation protection 89 Patient protection in general 89 Image receptor sensitivity 89 Beam collimation 89 Lead protection 89 Patient cooperation 90 References 90

9 Caries prevention 91 Göran Koch, Sven Poulsen and

Svante Twetman

The importance and concepts of caries prevention 91

How does caries develop? 92 Evidence-based prevention 94 The randomized controlled trial 94 Where to fi nd the evidence 95 Basics of caries prevention 96 Diet 96 Plaque control 98 Fluoride 99 Fissure sealing 102 Preventive strategies 103 High-risk and population strategies 103 Evaluation of caries risk in individuals 105 Background data and clinical evaluation

of caries risk 105 Risk ages 107

vi Contents

Preventive and operative care: a coordinated approach 108

References 108

10 Diagnosis and management of dental caries 110

Ingegerd Mejàre, Magne Raadal and Ivar Espelid

The concept of caries diagnosis 110 Detection and assessment of the caries lesion

(caries diagnosis) 110 Assessing and grading lesion severity 111 Assessing and grading lesion activity 111 Diagnostic tools 111 Visual–tactile and radiographic

examination 111 Occlusal surfaces (pit and fi ssures) 113 Free smooth surfaces 115 Approximal surfaces 115 Alternative/supplementary diagnostic tools 116 The concept of caries treatment 116 Nonoperative treatment 116 Operative (restorative) treatment 117 Indications for operative (restorative)

treatment of primary teeth 118 Treatment planning 118 Restorative procedures 120 Restorative materials: basic principles and

handling 120 Specifi c conditions for different age groups 121 0–3 years 121 3–6 years (primary teeth) 124 6–12 years 128 12–19 years 131 References 137

11 Dental erosion 141 Ann-Katrin Johansson, Göran Koch and

Sven Poulsen

Epidemiology 141 Etiology 142 Gastroesophageal refl ux (disease) 143 Asthma 143 Eating disorders 143 Other factors associated with dental erosion 144 Drinking habits 144 Salivary factors 144 Oral hygiene practices 144 Lifestyle 144 Case history and clinical examination 145 Case history 145 Clinical examination 146

Indices for dental erosion 147 Follow-up of patients with erosions 147 Preventive policies 148 General aspects 148 Elimination of etiological factors 148 Population-based prevention 149 Restorative treatment 150 References 151

12 Pedodontic endodontics 153 Ulla Schröder

Diagnosis of pulp lesions in primary and immature permanent teeth 153

Should endodontic interventions be carried out in the primary dentition? 154

Endodontic techniques in primary teeth 154 Stepwise excavation 155 Direct pulp capping 156 Partial pulpotomy 156 Pulpotomy 157 Pulpectomy and root canal therapy 157 Wound dressings and tissue reactions 157 Calcium hydroxide and MTA 157 Formocresol 158 Ferric sulfate 158 Complications (primary teeth) 159 Follow-up and long-term prognosis

(primary dentition) 159 Pulp therapy in immature permanent

teeth 159 Stepwise excavation 159 Partial pulpotomy 159 Pulpotomy 160 Pulpectomy 160 Root canal treatment 160 Bleaching of nonvital discolored permanent

teeth 161 Handling the emergency child patient 163 Pain at food intake 163 Toothache at night 163 Use of antibiotics 164 References 165

13 Periodontal conditions 166 Bengt Sjödin and Lars Matsson

Normal periodontal conditions 166 Primary dentition 166 Permanent dentition 166 Bacteria-induced infl ammatory periodontal

diseases 167 Gingivitis 167 Clinical picture 167

Contents vii

Age-related differences 167 Etiology 168 Treatment 170 Periodontitis 170 Clinical picture 170 Classifi cation and epidemiology 171 Chronic periodontitis 172 Aggressive periodontitis 172 Etiology and risk factors 173 Screening and treatment 177 Prevention of bacteria-induced infl ammatory

periodontal diseases 178 Mechanical plaque control 178 Chemical plaque control 179 Gingival recession 179 Gingival enlargements 179 Drug-induced gingival overgrowth 179 Gingival fi bromatosis 180 Necrotizing periodontal diseases 180 Traumatic ulcerative gingival lesions 180 Streptococcal gingivitis 181 References 181

14 Tooth development and disturbances in number and shape of teeth 183

Göran Koch, Irma Thesleff and Sven Kreiborg

Mechanisms of normal and abnormal tooth development 183

Principles of tooth development 183 Molecules regulating tooth development 183 Disturbances in tooth development 186 Genetic causes of disturbed tooth

development 186 Hypodontia and abnormal tooth shape 187 Hyperdontia 187 Clinical aspects 187 Chronology of dental development 187 Dental age estimation 188 Terminology and defi nitions 188 Numerical variations in the primary

dentition 188 Numerical variations in the permanent

dentition 189 Syndromes involving congenitally missing

teeth 189 Treatment of children with missing teeth

or hyperdontia 189 Morphologic abnormalities 190 Odontomas 195 Background literature 196 References 196

15 Eruption and shedding of teeth 197 Göran Koch, Sven Kreiborg and

Jens O. Andreasen

Chronology of normal tooth eruption 197 Primary dentition 197 Permanent dentition 197 Mechanism and theories of tooth eruption 197 Mechanism of shedding of primary teeth 200 Systemic disturbances affecting tooth

eruption and shedding 200 Premature tooth eruption 201 Delayed tooth eruption 201 Premature shedding of primary teeth 202 Local disturbances affecting tooth eruption

and shedding 203 Local aberrations in primary dentition 203 Natal and neonatal tooth eruption 203 Symptoms associated with “teething” 203 Fibrotic mucosa and eruption cysts 204 Infraocclusion of primary molars 204 Retention of primary teeth 206 Local aberrations in permanent dentition 206 Ectopic eruption 206 Ectopic malpositions 207 Sequelae to trauma 208 Supernumerary teeth, mesiodentes, and

odontomas 208 Ankylosis 208 Developmental disturbances 210 Background literature 211 References 211

16 Occlusal development, preventive, and interceptive orthodontics 212

Jüri Kurol and Bengt Mohlin

Occlusal development of the primary dentition 213

Malocclusions in the primary dentition 214 Etiology of malocclusion in the primary

dentition 214 Prevalence of malocclusions in the primary

dentition 214 Space conditions 215 Malocclusion in the vertical plane 215 Malocclusions in the sagittal plane 215 Malocclusions in the transversal plane 217 Treatment need and cost-benefi t for

treatment of posterior cross bites 218 Treatment of posterior cross bites 218 Occlusal development through the mixed to

permanent dentition 219 Front teeth 220

viii Contents

Lateral segment 220 Malocclusions in the mixed (and permanent)

dentition 221 Etiology of malocclusions 221 The pediatric dentist’s approach to

orthodontic problems 223 Prevention of malocclusions 223 Interceptive orthodontics 226 Supervising occlusal development in the

primary and mixed dentition 227 The primary dentition 227 Early mixed dentition (6–9 years) 227 Late mixed dentition (9–12 years) 229 Young permanent dentition (12–15 years) 230 General decisions for orthodontic treatment 230 Dissatisfaction with appearance 230 Caries and periodontitis 2310 Speech 231 Chewing function 231 Temporomandibular disorders 231 The selection of orthodontic patients 231 References 231

17 Developmental defects of the dental hard tissues and their treatment 233

Ivar Espelid, Dorte Haubek and Birgitta Jälevik

Aspects related to tooth development 233 Etiology of developmental dental defects 234 Collection of information and treatment

planning 235 Anamnestic information 235 Extraoral examination 235 Clinical characteristics of developmental

dental defects 235 Diagnosis 236 Classifi cation 236 General treatment principles 237 Treatment planning 237 Environmentally determined dental defects 239 Localized defects of the dental hard

tissues 239 Generalized defects of the dental hard

tissues 240 Inherited defects of the enamel 244 Amelogenesis imperfecta 244 Inherited defects of the dentin 246 Dentinogenesis imperfecta 246 Disturbances in calcium/phosphate

metabolism with relevance to mineralization of teeth 251

Rickets 251

Vitamin D-resistant rickets (familial hypophatasia) 252

Celiac disease 253 Treatment 253 Fluorosis 253 Tetracycline defects 254 Molar–incisor hypomineralization 254 Amelogenesis perfecta 256 Dentinogenesis imperfecta 258 References 262

18 Traumatic injuries: examination, diagnosis, and immediate care 264

Ingeborg Jacobsen and Jens O. Andreasen

Epidemiology 264 Etiology 264 Examination 264 History 264 Medical history 266 Extraoral examination 266 Intraoral examination 266 Radiographic examination 267 Diagnosis 267 Injuries to the hard dental tissues and

the pulp 267 Injuries to the hard dental tissues, the pulp

and the alveolar process 267 Injuries to the periodontal tissues 268 Injuries to gingiva or oral mucosa 268 Immediate care: primary teeth 269 Enamel and enamel–dentin fracture 269 Complicated crown fracture 269 Crown-root fracture 269 Root fracture 269 Concussion, subluxation, and luxation

injuries 269 Immediate care: permanent teeth 273 Crown fractures 273 Crown-root fracture 275 Root fracture 276 Concussion 277 Subluxation 278 Extrusive luxation 278 Lateral luxation 278 Intrusive luxation 278 Avulsion 279 Injuries to the alveolar process 281 Injuries to the gingiva and the oral mucosa 282 Prevention of traumatic injuries 282 Use of mouth guards 282 Face masks 283 References 283

Contents ix

19 Traumatic injuries: follow-up and long-term prognosis 284

Jens O. Andreasen and Ingeborg Jacobsen

Wound healing events 284 Primary teeth: follow-up and prognosis 286 Pulpal and periodontal complications

following trauma to primary teeth 286 Injuries to developing permanent teeth 287 Permanent teeth: follow-up and prognosis 287 Prognosis following infraction and

uncomplicated crown fracture 288 Prognosis following a complicated fracture 289 Prognosis following crown-root fracture 289 Prognosis following root fracture 289 Prognosis following luxation injuries 290 Prognosis following replantation 295 Treatment methods following loss of

permanent incisors 295 Predictors for healing complications 296 Development of an interactive

Internet-based dental trauma guide 296 References 296

20 Oral mucous lesions and minor oral surgery 298

Göran Koch

Oral mucous lesions 298 Herpetic gingivostomatitis 298 Impetigo contagiosa 299 Aphthous ulcers 299 Oral candidiasis 300 Traumatic lesions 300 Bohn’s nodules 300 Mucous retention cysts (mucocele) 300 Epulides 301 Hemangioma 301 Lesions connected with common infectious

diseases in children 302 Surgical procedures 303 Extraction of teeth 303 Treatment of impacted teeth 303 Cysts 306 Frenuloplasty 306 Background literature 307

21 Temporomandibular disorders 308 Tomas Magnusson and Martti Helkimo

Defi nitions 308 Epidemiology 308 Bruxism 309 TMD and orthodontics 309

Taking the history in children and adolescents with suspected TMD 309

Clinical functional examination of the masticatory system 310

Radiographic imaging of the TMJs 311 Treatment of TMD in children and

adolescents 311 Summary 314 References 314

22 Children with chronic health conditions: implications for oral health 315

Göran Dahllöf and Luc Martens

Defi nition of CHCs 315 Prevalence 315 Increased risk for oral diseases in children

with CHCs 316 CHCs 316 Asthma 316 Cardiovascular disorders 319 Chronic renal failure 320 Renal transplant 320 Diabetes mellitus 321 Gastroesophageal refl ux 321 Eating disorders 321 Malabsorption 322 Celiac disease 323 Cystic fi brosis 323 Primary and secondary immunodefi ciency

states 323 Juvenile chronic arthritis 325 Epidermolysis bullosa 325 Bleeding disorders 326 Malignant disease in children 327 Epilepsy 328 Preventive strategies in children with CHCs 329 References 329

23 Dental care for the child and adolescent with disabilities 331

June Nunn and Gunilla Klingberg

Context 331 Prevalence 332 Oral health and disability 333 Consent 334 Neuropsychiatric disorders 334 Autism spectrum disorders: autism,

Asperger syndrome 334 Attention defi cit hyperactivity disorder 336 Tourette syndrome 336 Other disorders 337 Learning disability/mental retardation 337

x Contents

22q11 deletion syndrome 337 Fragile X syndrome 338 Down syndrome 338 Cerebral palsy 339 Spina bifi da 340 Muscular dystrophy 342 Cleft lip and palate 342 Preventive dental care 343 Diet 343 Fluorides 343

Pit and fi ssure sealants 344 Oral hygiene aids 344 Chlorhexidine 344 Dental visits 345 Behavior management 345 Body posture 346 Oral motor function 346 References 347

Index 349

Contents xi

To Anna-Lena Hallonsten

xiii

Preface to the second edition

Pediatric Dentistry: A Clinical Approach was fi rst pub-lished in 2001 with the aim of providing a comprehen-sive review of pediatric dentistry with special emphasis on evidence-based oral health care for the child and adolescent. In this second edition of this textbook, we have built upon the earlier volume by thoroughly updat-ing the text, as well as replacing chapters and adding new ones as necessary. The sciences behind pediatric dentistry, as well as strategies of clinical approaches, have developed rapidly over the past few decades. These advances have been refl ected in the considerable work undertaken by the many clinicians and scientists who have contributed to this textbook. Pediatric dentistry aims to improve the oral health of children and adolescents through health promotion, prevention and systematic and comprehensive oral care. It is concerned with the expression of, and interventions against, the major dental diseases as well as with a number of dental and oral conditions specifi c to child-

hood and adolescence. These comprise all aspects of dental and occlusal developmental disturbances, traumatic injuries to the teeth, periodontal conditions, oral pathological conditions, pain control, dental need and treatment of handicapped and medically compro-mised children. Pediatric dentistry applies principles from other clinical disciplines, medical and behavioral sciences and adapts them to the special needs of the growing and developing individual from birth through infancy and childhood to adolescent late teens. Our objective is that this book will serve not only as a basis for undergraduate training in pediatric dentistry but will also be of relevance to postgraduate students and dental practitioners who want to increase their knowledge and skills in order to deliver up-to-date pediatric dental care.

Göran Koch and Sven PoulsenEditors

xiv

Contributors

Jens O. AndreasenDepartment of Oral and Maxillofacial SurgeryCopenhagen University Hospital (Rigshospitalet)CopenhagenDenmark

Kristina ArnrupDepartment of Pediatric DentistryPostgraduate Dental Education CentrePublic Dental ServiceÖrebroSwedenandSchool of Health and Medical SciencesÖrebro UniversityÖrebroSweden

Anders G. BrobergDepartment of PsychologyUniversity of GothenburgGöteborgSweden

Ivar EspelidDepartment of Paediatric Dentistry and Behavioral ScienceInstitute of Clinical DentistryUniversity of OsloOsloNorway

Göran DahllöfDepartment of Pediatric DentistryDepartment of OdontologyKarolinska InstitutetHuddingeSweden

Dorte HaubekDepartment of Pediatric DentistrySchool of DentistryFaculty of Health SciencesUniversity of AarhusAarhusDenmark

Gro HaukaliDepartment of Pediatric DentistrySchool of DentistryFaculty of Health SciencesUniversity of AarhusAarhusDenmarkandMunicipal Child Dental Service of AarhusAarhusDenmark

Martti HelkimoDepartment of Stomatognathic PhysiologyThe Institute for Postgraduate Dental EducationJönköpingSweden

Hanne HintzeDepartment of Oral RadiologySchool of DentistryFaculty of Health SciencesUniversity of AarhusAarhus Denmark

Ingeborg JacobsenDepartment of Paediatric Dentistry and Behavioral ScienceInstitute of Clinical DentistryUniversity of OsloOsloNorway

Birgitta Jälevik Department of Paediatric DentistrySahlgrenska University Hospital/MölndalMölndalSweden

Ann-Katrin Johansson Department of Clinical DentistryFaculty of Medicine and DentistryUniversity of BergenBergenNorway

Anders JuulDepartment of Growth and Reproduction Copenhagen University Hospital (Rigshospitalet)CopenhagenDenmark

Gunilla KlingbergDepartment of Paediatric DentistryFaculty of OdontologyMalmö UniversityMalmöSwedenandMun-H-Center, National Orofacial Resource Centre for Rare DisordersGothenburgSweden

Göran Koch Department of Paediatric DentistryThe Institute for Postgraduate Dental EducationJönköping Sweden

Sven KreiborgDepartment of Pediatric Dentistry and Clinical GeneticsSchool of DentistryFaculty of Health SciencesUniversity of CopenhagenCopenhagenDenmark

Jüri Kurol Department of OrthodonticsThe Sahlgrenska AcademyUniversity of GothenburgGöteborgSweden

Stefan Lundeberg Department of Pediatric Anesthesia and Intensive CareAstrid Lindgren Children’s HospitalKarolinska University HospitalStockholmSweden

Tomas MagnussonDepartment of Stomatognathic PhysiologyThe Institute for Postgraduate Dental EducationJönköpingSweden

andSchool of Health SciencesJönköping University JönköpingSweden

Katharina M. MainDepartment of Growth and Reproduction Copenhagen University Hospital (Rigshospitalet)CopenhagenDenmark

Luc MartensDepartment of Paediatric Dentistry and Special CareUniversity of GhentGhentBelgium

Lars Matsson Faculty of OdontologyMalmö UniversityMalmöSweden

Ingegerd Mejàre Department of Paediatric DentistryFaculty of OdontologyMalmö UniversityMalmöSweden

Bengt MohlinDepartment of OrthodonticsThe Sahlgrenska AcademyUniversity of GothenburgGöteborgSweden

June NunnPublic and Child Dental HealthSchool of Dental ScienceTrinity College DublinDublinIreland

Sven PoulsenDepartment of Pediatric DentistrySchool of DentistryFaculty of Health Sciences, University of AarhusAarhusDenmark

Contributors xv

xvi Pediatric Dentistry

Magne RaadalDepartment of Clinical DentistryFaculty of Medicine and DentistryUniversity of BergenBergenNorway

Ulla Schröder Department of Paediatric DentistryFaculty of OdontologyMalmö UniversityMalmöSweden

Bengt Sjödin Department of PeriodontologyPostgraduate Dental Education CentreÖrebroSweden

Marit Slåttelid SkeieDepartment of Clinical DentistryFaculty of Medicine and DentistryUniversity of BergenBergenNorway

Irma ThesleffDevelopmental Biology Research Program Institute of BiotechnologyUniversity of HelsinkiHelsinkiFinland

Svante TwetmanDepartment of Cariology and EndodonticsSchool of DentistryFaculty of Health SciencesUniversity of CopenhagenCopenhagenDenmark

Lill-Kari Wendt Centre for Oral HealthSchool of Health SciencesJönköping UniversityJönköpingSweden

1

1Pediatric oral health care: the perspectives

Sven Poulsen and Göran Koch

How it began: the historical perspective

The history of pediatric dentistry as we know it today is usually considered to have started in the latter part of the nineteenth century. However, in 1743, Robert Bunon published his book Essay sur les Maladies des Dentes, where he for the fi rst time discussed at length dental problems during childhood. Bunon emphasized the connection between the diet and health of the pregnant mother and the mineralization of her child’s teeth. He also studied the infl uence of infectious diseases on den-tal development and described the principles of serial extraction. The importance of good dietary habits for prevention of dental disease was repeatedly stressed in his book. Robert Bunon rightly deserves the title “the father of children’s dentistry”. One of the fi rst dentists who dedicated himself to providing regular dental care for children was John Greenwood, who practiced in New York in the 1780s. He advertised a reduced fee for children who signed up for regular dental treatment. It is also known that around 1800, C.F. Delabarre undertook dental treat-ment in overfi lled Parisian orphanages in wartime France. The fi rst known proposal for a regular dental care program for children was put forward in 1851 by A.-F. Talma, dentist to King Leopold I of Belgium, and was based on regular examination of all children between the ages of 5 and 12 years. Similar programs were proposed in many other countries. In this early era, enthusiastic pioneers – often on their own initiative – organized dental care for children (Fig. 1-1).

Community responsibility: the population perspective

The growing interest in dental care for children at the end of the nineteenth century was partly caused by large epidemiological studies on caries in children published

in 1893–1895. These studies showed that more than 80% of the children had carious teeth and that only a few per thousand had received any dental treatment. These results were thoroughly discussed at world dental congresses and led dentists in many countries to urge their societies to organize public dental health services for children. The fi rst municipal dental clinic for children was opened in Strasbourg in 1902 under the direction of the Danish-born Ernst Jessen. This very fi rst school dental clinic became a model for the development of children’s dental clinics in a number of countries. It is interesting to note that the arguments for better dental services for children were based on epidemiologi-cal data. Using epidemiological information to docu-ment a health problem is to adopt a population approach rather than an individual clinical approach. This indi-cates that in the Nordic countries, organized child dental care has for more than a century been considered a collective responsibility rather than the problem of the individual. Formal legislation and regulations concern-ing child dental care were passed by the parliaments of all Nordic countries several decades ago and dental services, including outreach preventive services, have been developed to serve the whole child population. The epidemiological starting point of child dental care in Nordic countries may also explain why the child dental services in these countries have collected valuable epidemiological information to monitor continually the level of disease in their target groups.

From birth to adolescence: the oral health perspective

As already mentioned, child dental services originally focused on school-age children, often being limited to extraction of diseased teeth and restorative care of the permanent teeth. This focus had no rational foundation,

2 Pediatric Dentistry

but was merely due to the fact that children could easily be reached in schools. This philosophy is still prevalent in many countries in spite of the pain untreated dental disease and emergency care may infl ict on the pre-school child with subsequent dental fear and anxiety. In this book we adopt the United Nations (UN) Convention defi nition of a child (every human being below the age of 18 years unless, under the law applicable to the child, majority is attained earlier). Thus, we see pediatric oral care as a continuous effort to secure good oral health as defi ned in Box 1-1 from birth to 18 years of age. The World Health Organization (WHO) defi nition of health emphasizes that health cannot be isolated from the subjective experience of the individual (Box 1-1). In other words, a satisfactory defi nition of health needs to include somatic as well as nonsomatic dimensions. As oral health should be considered an integrated part of general health, a defi nition of oral health should also include not only sound teeth and oral structures, but also absence of dental fear and anxiety. This is consistent with recent research on patients’ assessment of how their dental and oral conditions infl uence the quality of their daily life. Methods to measure oral health-related quality of life in children are now available, and it has been shown that dental conditions such as early child-

hood caries reduce children’s oral health-related quality of life. It has also been shown that the oral health-related quality of life of children with a severe caries treatment need is improved after rehabilitation under general anesthesia (see Chapter 6).

UN Convention on the Rights of the Child: the ethical perspective

Today, concern for the child’s specifi c needs and rights is attracting increasing interest as refl ected in the UN Convention on the Rights of the Child (2). This docu-ment is important to all professionals who relate to children – including pediatric dentists.

Figure 1-1 In Nordic countries, dental care for children was initiated by the end of the nineteenth century, often by oral health care pioneers. This 1898 photograph shows a private dental practitioner, Dr Marinus Kjær, performing one of his weekly screenings in a public school in Svendborg, a small provincial town in the southern part of Denmark.

Box 1-1 WHO defi nition of general health and an analogous defi nition of oral health

General healthA state of complete physical, mental and social well-being and not only the absence of disease or infi rmity (1).

Oral healthA state of sound and well-functioning dental and oral structures as well as absence of dental fear and anxiety.

Pediatric Oral Health Care: The Perspectives 3

One of the key items in this document is that children have rights as human beings and also need special care and protection, as often expressed by the saying that “children are not small adults” (Fig. 1-2). In order to secure children and adolescents high-quality oral health

care, emphasis is now being placed on the concept of child competency (Box 1-2). The UN Convention on the Rights of the Child was adopted by the UN General Assembly on November 20, 1989, and has had a marked impact on the lives of chil-dren in a number of countries. The overriding point in the Convention is that children have rights. They have a right to be protected against bad or unfair treatment and they also have a right to be respected as individuals. Another principle is the “best interest of the child”. Whenever we take a decision affecting children, their best interest should be a primary consideration. Further, the views of the child should be respected. The child should be free to express opinions and these should be given due weight “in accordance with the age and maturity of the child”. In other words, children should have a say in matters of concern to them. A number of the articles in the convention have obvious implications for pediatric dentists and the way we organize and deliver oral health care to children (Box 1-3).

Pediatric dentistry: the clinical perspective

Pediatric dentistry encompasses all aspects of oral health care for children and adolescents. It is based on basic knowledge from various odontological, medical and behavioral sciences that are applied to the unique situation of the developing child and young person. Starting prevention in early childhood makes it possible

Figure 1-2 Until the eighteenth century children were considered to be small adults (sort of “miniature grown-ups”).

Box 1-2 Professionals should recognize that children are not “small adults”, and that special competency (child competency) is needed, when meeting children

Children are different from adults in a number of ways:• children are individuals in growth and development – physical – psychological – social• oral health, including attitudes and behavior relating to

oral health, is formed during childhood and adolescence• children’s situation is different from the situation of

adults: – they are in the care of and dependent on adults – they are not able to foresee consequences of their own

decisions and behavior.

Child competence is characterized by:• a specifi c insight into the dental and oral health for the

child and adolescent • an ability to communicate effectively with children,

adolescents, and their parents• a positive professional attitude towards children,

adolescents, and their parents.

4 Pediatric Dentistry

to preserve sound erupting teeth and keep oral structures healthy. Pediatric dentistry also implies early diagnosis and treatment of the multitude of oral diseases and conditions found in the child’s and the adolescent’s mouth, including caries, periodontal diseases, minerali-zation disturbances, disturbances in tooth development and tooth eruption, and traumatic injuries in otherwise healthy as well as sick and handicapped children (Fig. 1-3).

The quest for evidence-based interventions – preven-tive, diagnostic or rehabilitative – is urgent in pediatric dentistry as well as in all other fi elds of dentistry.

References1. World Health Organization. Basic documents, 39th edn. Geneva:

WHO, 1992.2. UN Convention on the Rights of the Child. http://www.unicef.

org/crc/ (accessed August 2008).

Box 1-3 The UN Convention on the Rights of the Child (2)

The UN Convention on the Rights of the Child was adopted and opened for signature, ratifi cation and accession by General Assembly resolution 44/25 of November 20, 1989. It entered into force on September 2, 1990, and contains important statements relevant to child oral health care, some of which are quoted below:

Article 3In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration. States Parties undertake to ensure the child such protection and care as is necessary for his or her well-being, taking into account the rights and duties of his or her parents, legal guardians, or other individuals legally responsible for him or her, and, to this end, shall take all appropriate legislative and administrative measures. States Parties shall ensure that the institutions, services and facilities responsible for the care or protection of children shall conform with the standards established by competent authorities, particularly in the areas of safety, health, in the number and suitability of their staff, as well as competent supervision.

Article 24States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.

Figure 1-3 Today, comprehensive oral health care is delivered in a modern, well-equipped dental clinic by a dedicated team.

5

2Growth and pubertal development

Anders Juul, Sven Kreiborg and Katharina M. Main

The evaluation of growth charts and pubertal develop-ment in children and adolescents is an important tool for any clinician in the assessment of health status. Opti-mal thriving and height attainment in accordance with family potential can only be achieved in an environment providing optimal socioeconomic conditions, health care, and psychosocial support. Thus, failure to thrive or to grow may be the fi rst indication of an underlying problem that may need attention. In turn, treatment of children may need to consider the specifi c growth and developmental windows in order not to disturb this delicate balance.

Measurement of growth in different phases of life

The current concept of prenatal and postnatal growth suggests that there are distinct growth phases, which should be considered separately.

Prenatal growthPrenatal growth is divided into three trimesters (by con-vention). The fi rst trimester is characterized by organo-genesis and tissue differentiation, whereas the second and third trimesters are characterized by rapid growth and maturation of the fetus. Fetal growth can be assessed by serial ultrasonography in the second and third tri-mesters. Abdominal circumference, head circumference, and femoral length of the fetus can be determined, and from these parameters fetal weight can be estimated using different algorithms (9). The fetal weight estimate should be related to normative data. Some reference curves for fetal growth are based on children born pre-maturely (11), and hence such curves therefore tend to underestimate normal fetal weights from healthy preg-nancies. Alternatively, reference curves based on ultra-sound studies of normal healthy infants exist (9) and should preferably be used. Based on the changes in fetal

weight estimates over time, the fetus can be considered as having a normal fetal growth rate, or alternatively as experiencing intrauterine growth restriction (IUGR) (8). Children born at term (gestational age 37–42 weeks) are considered mature. Children born before 37 weeks of gestation are premature, and children born after 42 weeks of gestation are postmature. At birth, weight and length can be measured and compared to normative data correcting for gestational age at birth. Based on these comparisons, a newborn child can be classifi ed as either appropriate for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA). IUGR fetuses will often end up being SGA at birth, but not necessarily so. Thus, IUGR infants may end up lighter than their genetic potential but remain within normal ranges (i.e., AGA). Therefore, IUGR and SGA are not synonymous entities, although they are often referred to as such in the literature (Fig. 2-1). Height velocity in utero is higher than at any time later in life, leading to an average birth length of 50–52 cm and birth weight of 3.5–3.6 kg after 37–42 weeks of gestation. It is therefore not surprising that growth disturbances dur-ing this phase may have long-lasting effects on growth and health later in life. Whereas the fi rst trimester is dominated by tissue differentiation and organ forma-tion, the second and especially third trimesters show a rapid gain fi rst in length and then in weight. Fetal and placental endocrinology is highly complex and hormones such as insulin, leptin, placental growth hormone, insulin-like growth factor (IGF)-2, and thyroid hormone are only some of the many growth factors involved in the regulation of fetal growth.

Postnatal growthPostnatally, height can be determined by measuring length in the supine position the fi rst 2–3 years of life. After 2–3 years of age standing height can be measured

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preferably using a wall-mounted stadiometer. Height is determined without shoes, shoulders towards the wall, arms hanging down, and the face straight forward (Fig. 2-2). The eyes should be horizontally aligned with the external ear opening. The means of three measure-ments are recorded. The stadiometer should be cali-brated on a daily basis. Importantly, the body proportions (such as head cir-cumference, facial appearance, sitting height, and arm span) may be helpful in the differential diagnosis of growth disorders (Fig. 2-1). This can simply be done by assessing the sitting height with subsequent calculation of the sitting height to standing height ratio. This enables quantifi cation of whether or not a growth failure is proportional or disproportional (such as in hypo-chondroplasia). Reference ranges for this ratio exist (5).

Changes in height can be separated into infant, child-hood, and pubertal growth phases according to the infancy–childhood–puberty (ICP) model described by Karlberg (7). The majority of children will follow the distinct growth patterns of these phases.

InfancyAfter a brief initial weight loss of up to 10% of the birth weight, growth during the fi rst months postnatally fol-lows to a large extent fetal growth rate during the third trimester with 30 g/day and 3.5 cm/month. After that a rapid decline in growth rate occurs, in both weight and height. However, this period still represents a major growth phase during the lifetime with a three-fold increase in weight over 6 months. Very little is known about the regulatory factors of growth during this period

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Figure 2-1 Reference ranges for fetal weight according to gestational age during pregnancy denoted by the blue lines (10th, 50th, and 90th percentiles) (8). Panel (a) shows examples of children with normal birth weights at term; a normally growing fetus ending with a birth weight which is appropriate for gestational age (AGA) and (�) a fetus with third trimester intrauterine growth restriction (IUGR) ending with a birth weight below the genetic potential but within normal limits (AGA). Panel (b) shows examples of fetuses with intrauterine growth retardation (IUGR) ending up AGA (�) or SGA (�).

Growth and Pubertal Development 7

of life, but nutrition and living conditions play a major role. Recently, the World Health Organization (WHO) published a new growth chart reference for infancy based on breastfed infants from different countries and ethnic origins living under optimal socioeconomic con-ditions. This chart did not fi nd signifi cant differences in growth patterns between these children, which indicates that genetic differences may fi rst become evident later in life (14).

ChildhoodIn this phase growth is relatively constant, with a gradual decline in growth velocity over time. From 2 to 4 years children grow approximately 7 cm and 2 kg/year. Beyond 5–6 years of age this rate has decreased to approximately 5 cm/year. This growth phase is highly dependent on growth and thyroid hormones.

PubertyDuring the pubertal growth spurt, which typically stretches over 4–5 years, total height gain is on average 20–25 cm for girls and 25–30 cm for boys with large

interindividual variations. There is some tendency that early maturers obtain a higher peak height velocity com-pared to late maturers (Fig. 2-3). Sex steroids increase the pulsatile growth hormone secretion, which in turn increases IGF-1. Weight gain is highly individual and may occur both before and after peak height velocity. In girls, the onset of the growth spurt is early and may even precede the development of secondary sexual char-acteristics in some. Typically, breast buds appear before pubic hair at 10–11 years of age, but occasionally this succession may be reversed (9). Both breast develop-ment and pubic hair attainment are graded into fi ve stages (B1–B5 and PH1–PH5) according to Tanner and Whitehouse (13). The fi rst menstruation, menarche, is a sign of adult level estradiol production and follicle maturation and occurs late during the growth spurt at approximately 13 years of age. Height attainment after menarche is small, with 4–8 cm over 1.5–2 years. In boys, the pubertal growth spurt occurs relatively late during development. Puberty commences with enlargement of testis size from 3 to 4 ml at 11–12 years of age, and this very fi rst sign of pubertal onset is usually

Figure 2-2 Standing height determined by a wall-mounted stadiometer (a). Height is recorded as the mean of three measurements. Sitting height is determined by a specifi cally designed chair (b). Head circumference is determined using a measuring tape (c). Armspan length is determined by measuring the distance from fi ngertips to fi ngertips (d).

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not noticed by the boy or even less so by the parents. Pubertal development in boys is graded into fi ve genital stages (G1–G5) according to Tanner and Whitehouse (13). Testis growth continues and within 6–12 months pubic hair can be seen. Testicular volume can be deter-mined by the use of an orchidometer to which the size of the testes is compared. Maximum height velocity often occurs at a testis size of 10–12 ml at around 14 years of age, at the time when the voice breaks and facial hair appearance occurs. Thus, boys are already relatively viri-lized at the time of the adolescent growth spurt (10). In midpuberty, many boys develop physiological gyneco-mastia, which usually disappears within 6–12 months. The onset of puberty is approximately a year earlier in girls than boys, which consequently results in earlier growth arrest in girls than boys (14–15 versus 16–17 years of age). The timing of puberty may also differ by 1–2 years according ethnicity and nationality.

Growing pains

A signifi cant number of children and adolescents experi-ences intermittently pains, localized to the shins or legs when going to bed after a physically active day. The etiology of this phenomenon is unknown, but local warmth, gentle massage, and mild pain medication, if the child is in real discomfort, can normally ameliorate the problem, which resolves spontaneously.

Evaluation of growth charts

Growth evaluation should be based on observations over time by applying longitudinal measurements of height

and weight on an age- and gender-specifi c growth chart. These charts are available for many populations and also for a variety of growth disorders and syndromes. Due to the secular trend in height, country-specifi c reference ranges should be constructed at regular intervals (6). Repetitive measures of growth will result in a trajectory of growth, which then can be evaluated against family potential (parental stature, growth of siblings). As some children show considerable seasonal variation in growth, follow-up periods of 6–12 months may be necessary. In children approaching puberty, pubertal staging (13) will additionally be necessary for adequate assessment. Growth charts are usually based on cross-sectional data from children and adolescents, covering 95% of the population (±2 standard deviations). Charts may depict centiles or standard deviation lines. Per defi nition, 2.5% of the population will be below or above the outer limits (Fig. 2-4). In contrast, height velocity curves are based on longitudinal follow-up studies of healthy children (Fig. 2-5). In the evaluation, both the position within the growth chart in relation to the parental potential and the trend of the individual growth curve are important. Deviations from the expected may represent two separate pathologi-cal conditions. In populations with a signifi cant secular trend in height attainment due to recently improved socioeconomic conditions, the growth of siblings in com-parison to the patient may be helpful as well. The simplest method to determine the family growth potential is based on calculation of midparental height (Box 2-1). During childhood, most children will follow their trajectory of growth, which ideally should follow the

Figure 2-3 (a) Three examples for height curves and (b) height velocity curves from children with early puberty (�), normally timed puberty (�) and delayed puberty (�). Note that fi nal height is almost the same (a) and that peak height velocity is higher in earlier puberty (b).

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Growth and Pubertal Development 9

family potential. There are, however, two phases in life where this trajectory may not be followed without necessarily representing pathology: (a) during the fi rst 2 years of life, children may “catch up” or “slow down” depending on their intrauterine growth and size at birth, a phenomenon also called regression towards the mean, and (b) during puberty, early maturation will lead to a growth spurt above average (vice versa for late matura-tion) and the individual child will therefore almost always deviate upwards (or downwards) compared to

the mean on the growth chart (due to the cross-sectional design of the growth charts). In general, tall children have a tendency to enter puberty early, short children to enter puberty later. Acute diseases during childhood and adolescence will often only result in a temporary weight loss with rapid catch-up after recovery. In contrast, height attainment will often get compromised in long-term or serious ill-ness. These children may show considerable catch up growth after recovery, if their bone age allows further

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Figure 2-4 Normal (Gaussian) distribution of heights illustrating the 95% reference interval by percentiles or standard deviations (SDs).

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Figure 2-5 Normal height curve (a) based on healthy children. Lines denote mean ±1 standard deviation (SD) and ±2SD. One indi-vidual patient is depicted on the curve (�) before and after operation for a pituitary tumor (craniopharyngeoma) resulting in growth hormone defi ciency. A typical deceleration is seen prior to diagnosis. Horizontal lines (red arrow) denote bone age. Following operation the child suffers from pituitary insuffi ciency and is substituted with L-thyroxine, hydrocortisone growth hormone, (GH) (arrow), and testosterone (Te) (arrow). This results in a fi nal height well within target height. T = target height range, F = father’s, and M = mother’s height expressed as SDs. (b) Normal height velocity curve based on Tanner’s longitudinal study of healthy children. The same child (�) is depicted on this curve illustrating the marked growth acceleration following GH therapy, as well as the acceleration when puberty is initiated.

Box 2-1 Calculation of family growth potential (equal to target height or genetic height potential)

Girls [Maternal height (cm) + paternal height (cm)]/2 – 6.5 cmBoys [Maternal height (cm) + paternal height (cm)]/2 + 6.5 cm

To allow for growth variation within a family, the target height range is calculated as midparental height of ± 6.5 cm for both genders.

Potential pitfalls of this approach are: (a) the parents differ considerably in height centiles and (b) one of the parents is not of normal stature.

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growth potential. Thus, growth deceleration is seen com-monly in the year(s) prior to diagnosis of severe chronic disease (e.g., brain tumors or malignancies) which is often fi rst noticed in retrospect. Detailed evaluation of growth includes bone age determination and fi nal height predictions.

Bone age determination

Linear growth continues until the fusion of the ossifi ca-tion centers. Thus, determination of bone maturation may help to assess the growth potential in an individual, as many disorders of growth are associated with either delayed or accelerated bone age. Bone age is mostly measured with a radiograph of the left hand and wrist and a comparison of the epiphyseal growth plates with age- and gender-specifi c references (Fig. 2-6). Two main systems are used clinically: (a) the Greulich–Pyle method (3) and (b) the TW method (12). Computer-based automated bone-age assessments are currently being developed and will help to reduce interobserver variation and time expense.

Final height prediction

Both methods of bone-age determinations (Greulich–Pyle and TW methods) can be employed in prediction models (Bayley–Pinneau and TW method, respectively)

for fi nal height (1,12), with a broad margin of error. Both methods are based on studies of healthy children who were followed up until fi nal height, in whom bone ages were determined at various ages. Heights at each bone age were assigned a certain percentage of the fi nal height, e.g., a 13-year-old boy with a bone age of 14 years is assumed to have reached approximately 90% of his fi nal height according to the Bayley–Pinneau tables, and his current height can then be transformed into a fi nal height estimate. Pitfalls in this approach are (a) the nor-mal biological variation of bone age in comparison to chronological age which is ±1 year and (b) the fact that prediction models are based on normally growing children and may therefore both underestimate and overestimate fi nal height in pathological conditions.

Dental age determination

Dental age or dental maturity may be assessed in differ-ent ways. The simplest method is to record the teeth erupted and compare to normative data. A more precise method is to judge the development of the teeth from radiographs. Haavikko (4) has given normative data for individual permanent teeth, while Demirjian (2) has developed a scoring system based on assessment of all lower left permanent teeth (except the third molar) from an orthopantomogram. Demirjian’s method has

Figure 2-6 Two radiographs of the left hands of two healthy children. Note that the mineralization of the small bones has not yet occurred in the younger child (left).

Growth and Pubertal Development 11

gained general recognition as the most precise. In general, the correlation between dental age and bone age is, how-ever, relatively low (Fig. 2-7).

Disorders of growth and puberty

Intrauterine growth restriction Many adverse conditions can lead to impairment of intrauterine growth and development. Infections, medi-cations, environmental chemicals, exposure to tobacco, maternal diseases, and uteroplacental insuffi ciency may cause early or late growth restriction. A fetus may follow a growth trajectory below normal throughout pregnancy and be born SGA, or growth restriction may have its onset during the third trimester and lead to IUGR. Over the past few decades research has revealed that antenatal and early postnatal growth patterns may have health consequences in adult life, which may be caused by fetal programming to accommodate adverse condi-tions. Links have been established to cardiovascular disorders, dyslipidemia, diabetes mellitus, pubertal timing, and reproductive function. The majority of children born SGA or IUGR (80–85%) will show spon-taneous catch-up growth after birth, typically within the fi rst 2–3 years of life. Thus, the remaining 10–15% of IUGR/SGA children do not show catch-up growth and remain short in childhood and end up as short

adults. These children respond well to treatment with biosynthetic growth hormone. Silver–Russell syndrome is associated with prenatal as well as postnatal growth failure, and children typically respond with signifi cant improvement of fi nal height despite the fact that they generally have no evidence of growth hormone defi ciency.

Postnatal growth failureToday, being of short stature is less well accepted by many societies than being tall. Therefore, many children are presented in the clinic (Fig. 2-8). In the majority of cases a growth curve evaluation will reveal that the child is within its family potential. A typical growth curve of a child with familial short stature is shown in Fig. 2-8(a). These children are typically growing at a normal growth rate and thus following their growth trajectory. These families need reassurance, as there is today no convinc-ing treatment schedule available that will reliably and signifi cantly increase fi nal height. If, however, the child’s position on the growth curve does not correspond to the familial potential or the growth trajectory deviates downwards due to low growth velocity, the child should be investigated further. Many chronic and systemic diseases (e.g., asthma, sleep apnea, malabsorption, and metabolic diseases) and systemic steroid treatment may lead to growth disorders. In rare cases even large doses

Figure 2-7 Illustrative examples showing low correlation between bone age and dental age. (a) A healthy girl, aged 10 years 9 months, with advanced dental maturity (nearly complete permanent dentition: DS4, M1) compared to the skeletal maturity (prepubertal hand–wrist radiograph). (b) A healthy girl, aged 11 years 6 months, with delayed dental maturity (early mixed dentition: DS2, M1) compared to the skeletal maturity (postpubertal hand–wrist radiograph).

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