The Childhood Years: InterFace and InnerFacts of Management Dentistry Pediatric dental issues relate

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The Childhood Years Inter-Face and Inner-Facts
of ManagementDentistryPediatric dental issues
related to the care of the 2-10 year old child
affected by dentoalveolar clefting.

• Mary J. Hauk, DDS, MPH
• Pediatric Dentist
• April 24th, 2007

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The role of the pediatric dentist on a
craniofacial team

• The most important of which is to function as a
  liaison between the team and the family dentist
  or private pediatric dentist who provides the
  childs routine dental care. As we are all well
  aware, communication and coordination of care is
  critical in achieving optimal results and this
  extends to health care providers outside the
  team.
• In many cases the team pediatric dentist serves
  as the primary dental provider for the children
  we see. In that capacity we serve a role similar
  to the pediatrician. We become the gatekeeper for
  dental services. Just as a pediatrician, as
  primary care provider overseas the childs
  medical care.
• Therefore, we oversee the childs dental needs
  until he or she graduates to adult dental and
  prosthodontic dental care.

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Team Pediatric Dentist

• Roles
• Liaison to Family/ Pediatric Dentist
• Primary Dental Care Provider
• Similar role as pediatrician
• Dental services
• Oversee Dental needs of patient until adult
  dentition / prosthodontic needs
• Facilitate transition to adult dental care

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Stages of TreatmentThe stages of treatment for
children with clefts can be divided into these
categories. This talk will cover the toddler
preschool and school age patient.

• Prenatal
• Newborn
• First year
• Toddler - Pre-school
• School aged
• Adolescence
• Adult

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Toddler/Preschool

• Stage can be divided into
• Pre-cooperative (Toddler)
• 1-2 year olds
• too young to follow instructions for routine
  care
• Cooperative (Preschool)
• 3-5 year oldsAs
• pre-school children who although young are able
  to participate in their appointments.

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Toddler

• Pediatric dentistry
• - preventive care
• - parental education
• Growth and development monitoring
• Documentation
• Too Early for Behavior modification just make
  it fun!

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The Toddler

• totally dependent on his parents for preventive
  care and thus our focus is on parental education
  reguarding
• diet,
• oral hygiene
• dental health.

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The American academy of Pediatric Dentistry and
the American Academy of Pediatrics recommends the
first dental evaluation at 1 year of age for
healthy children and sooner if there are
problems.
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1 year old exam

• This visit is primarily directed at
• diagnosing problems
• parental education on prevention of dental
  caries.
• This appointment becomes more important for
  children affected with clefting since several
  studies by Johnsen and Dixon as well as Dahloff
  et.al. have shown an increased incidence of
  dental caries in this population.

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Oral Rehabilitation

• Pre-cooperative
• Extent of treatment
• Conjunction with other procedures
• Order of GA
• Before oral procedures
• Before/After other head and neck
• After Sterile procedures
• Simultaneous if GU

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20 of the pediatric population without clefts
develop ECC . (Serventn 1993) Incidence is
greater in 2 year olds with dentoalveolar clefts.
(Yin and Tsai) .
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• General anesthesia is not the only way we provide
  dental care for this age group but in light of
  the multiple medical procedures children with
  clefts receive, they are often apprehensive,
  precooperative, and extent of treatment needed
  warrents GA or other procedures are scheduled
  under GA.

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If pediatric dentist joins another providers GA
case, then consider the order treatment is
provided.

• surgery to the oral nasal complex, then dental
  care should be completed first to prevent
  disruption of the more delicate surgical
  procedures.
• surgery involves the head and neck but not in the
  oral cavity, the dental procedures can be done
  before or after
• after any sterile procedures to reduce the risk
  of contamination of the surgical field
• simultaneously in some cases such as during GU
  procedures

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Pre-school

• Pediatric dentistry
• behavior modification
• caries prevention dependent on parents at
  this age
• parental education
• Prepare the child for school
• speech aids
• restoration and esthetics
• Growth and development
• Documentation of outcomes of previous treatment

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Pre-school
Caries prevention and parental education continue
throughout the childs development with more
responsibility being expected of the patient as
she becomes able to participate in her own care.

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Pre- School
Also important at this age are the steps needed
to prepare the child for school. This includes
fabrication of speech aids to assist in
communication and restoration of teeth for
esthetics and function.
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Pre-school
Additionally, records to track growth and
development and to document outcomes of previous
treatments should be obtained during this stage.
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School Age - 6 to 10 yearsConcerns

• Appearance
• Function
• Effective Speech
• Timing of surgeries
• Minimize number of surgeries
• Advocacy for services with school and insurance

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School age child
Dental concerns include adjustments to
appearance and function to facilitate
assimilation into the school environment. -
fabrication of an obturator - anterior tooth
replacement - to encourage effective speech -
discussion of the timing of surgeries - combine
surgical procedures to minimize the childs
absence from school and other activities.
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School Age Advocacy for services

• This may range from letters or phone calls to the
  childs school or insurance company
• to
• testifying to the state government to
  facilitate passage of legislation mandating
  coverage of services for these children.

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School age - Clinical care

• Pediatric Dentistry
• Prevention and Maintenance
• Documentation
• Growth and Development monitoring
• Prosthetics new addition
• Once the child has reached this developmental
  stage, they are often ready to care for and
  tolerate appliance placement for replacement of
  missing teeth, and obturation of oronasal
  fistulas.

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Maintenance

• Efforts to maintain the oral cavity in a healthy
  state to permit best outcome of treatment
• Includes
• Oral hygiene education
• Caries prevention
• Restoration of Carious lesions
• Routine dental care

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Maintenance of the oral cavity a new challenge

• child begins to take over caring for his own oral
  hygiene.
• Education is now focused on the child
• Importance of continuing parental participation
• To maintain the oral cavity in a healthy state to
  permit the best outcome of treatment.
• The younger school age child may lack
• dexterity to perform the oral hygiene tasks
• long term vision of the consequences of
  non-compliance.

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Maintenance of the oral cavity

• Increased incidence of dental caries in the child
  with dentoalveolar clefting. (Bokhout et.al. and
  Dahloff et.al.)
• Restoration of carious lesions as early as
  possible to
• prevent spread to adjacent teeth
• permit the most conservative restorations
  possible to reduce interference with orthodontic
  treatment.
• These are best accomplished through routine
  dental care by a family or pediatric dentist.

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Maintenance Assess at annual staffing

• Who provides routine dental care?
• How often?
• Is fluoride exposure at therapeutic levels?
• Oral Hygiene regime?
• Dietary issues?

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Maintenance

• Periodontal Health
• Prevent bone loss around anterior teeth
• Anterior teeth may have poor crown to root
  ratios
• Healthy tissues for primary closure of graft site
• Additional bone loss increases risk of
• Loss of dentition, alveolar bone volume and graft
  failure
• Dental Health
• Appliance anchorage
• Pulp vitality
• Teeth maintain alveolar bone in cleft site

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Maintenance

• Assessment of issues affecting the patients
  ability to perform oral hygiene
• Amniotic banding can result in impaired fine
  motor skills needed for holding a toothbrush

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Dental Caries Risk Factors

• Open mouth posture
• Oral respirations
• Increased plaque
• Xerostomia

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Dental Caries Risk Factors

• Dental caries most common childhood disease
  (Buchanan, 2007)
• Increased incidence in children with cleft
• Prolonged feeding times
• Xerostomia mouth breathing
• Oronasal fistula/appliances become a resevoir for
  carbohydrates and bacteria

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Maintenance

• Access to dentition
• Dental alignment
• Upper lip tightness
• Shallow Vestibule
• Treatment
• Lip Revision
• Abbey Flap
• Vestibuloplasty
• Something as minor a supernumerary primary
  incisor which interferes with access to the
  lingual surfaces of incisor.

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Restoration

• Dental Caries
• Healthy oral cavity
• Prevent spread to adjacent teeth
• Preserve dentition for appliance retention
• Type of Restoration may interfere with appliances
  (stainless steel crowns have smooth simple
  surfaces which make band retention difficult.
• Alveolar bone is present only if tooth is present

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School Age
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Restoration

• Periodontal Disease
• Gingivitis
• Gingival Hypertrophy
• Impaired wound healing
• Loss of bone support to dentition needed for
  orthodontic anchorage

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Documentation

• Outcomes assessment of earlier treatment protocols

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Growth and Development

• Monitor tooth eruption to determine the timing
  of ABG
• Pan-oral
• Maxillary occlusal film
• Dental age vs. chronologic age
• Determine timing of referral to Orthodontist for
  pre-surgical alignment 1 2 yrs before ABG
• Consult with Orthodontist to avoid duplication
  of records

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School age 6-10 Years

• Stages can be divided into
• Divide into pre-alveolar bone grafting
• Alveolar bone grafting
• Post alveolar bone grafting

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Timing of Alveolar Bone Graftng

• Monitor the development of the teeth in cleft
• Highest success rate before tooth erupts
• (Hall and Posnick)
• Eruption begins when ½ - 3/4 root development
  (Eldapel et al, Hillerip et.al.)

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Timing of alveolar bone grafting
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Timing of alveolar bone graft
No tooth to erupt into cleft site Defer graft
until just before implant placement Maximize
preservation of bone
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Timing of Alveolar bone graft
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Preparation for Alveolar bone graft

• Removal of primary teeth in surgical field to
  permit healing and primary closure of graft site
• Arch Expansion
• Stent fabrication
• Gingival health reduce inflammation in surgical
  site

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Dental - School aged

• Orthodontics
• pre-ABG alignment
• OMFS ABG
• Pedodontists goals
• avoid exposed tooth in graft site
• healthy gingival tissues
• primary tissue closure
• Orthodontics
• post-ABG alignment

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Outcomes AssessmentOslo Scale
Bardach
Goal is to provide maximum bone volume to permit
implant placement
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Prosthetics

• Purpose
• Normalize soft tissue drape
• Correct anatomical problems that interfere with
  speech

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Prosthetics

• Long term treatment planning begins in the mixed
  dentition.
• Transitional appliances
• Improve soft tissue drape
• Close oronasal fistula
• Restore oral function
• While waiting for bone maturity for definitive
  care

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School AgeLack of facial supportImpaired muscle
movement
Henderson
An acrylic removable partial denture can provide
soft tissue support
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Transitional Prosthetics

• Easily adjusted to accommodate growth
• Relatively inexpensive
• Stability of premaxilla in bilateral clefts
• Premaxilla is still mobile
• Movement will cause cement bond failure of fixed
  appliances

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School AgePost Alveolar Bone Graft

• Dentistry
• Prosthetic habilitation
• Tooth recontouring
• Early implants vs later implants
• Fixed vs Removable prosthetics

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Prosthodontic Habilitation

• Tooth Recontouring
• Enameloplasty
• Composite bonding
• Crowns
• Laminates
• Make canine/premolar look like lateral
  incisor/canine
• Correct crowding/spacing

enameloplasty
Crown
Henderson
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Replacement of Missing Teeth
Vig
Implants are considered the method of choice
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Implants Method Simulates Natural Tooth
Replacement

• Agenesis of tooth in cleft site
• Loss of tooth in cleft site
• Maintain alveolar bone graft

Vig
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Early vs. Late Implants

• Debate about timing of implant placement
• Use typically limited to mature jaw
• Passive eruption is completed
• Early placement
• Maintain graft
• Permit a more stable oral repair earlier
• Eliminate need for transitional prothesis
• Relative submersion from adjacent passive
  eruption

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EarlyPassive Eruption of Adjacent Dentition
Inside Dentistry 2007
This graphic demonstrates the passive eruption of
the teeth adjacent to the implant and the gradual
submersion of the implant over time. In order to
restore the implant on the right, bone must be
removed to access the collar for crown placement.
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Implants

• Lack of long term studies demonstrating the
  efficacy and safety of implants in the
  preadolescent and early adolescent period.
• Recommend implant placement only after growth
  maturity in both arches. (Brecht, Fantuzzo, Fan,
  Guckes and Roberts)

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By delaying implant placement until after
skeletal maturity has been reached you are using
the implant in a way that has been tested and the
outcome is more predictable. Secondary exposure
of implant collar is not required. By waiting
until late adolescents or adulthood to place the
implant you are prolonging the time the child has
to wear an obturator to close a fistula and
transitional prosthethic devices such as a
flipper or a Maryland bridge.
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Late Implant

• Photos

Implants are only one of several fixed prosthetic
options for tooth replacement in the cleft site.
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Fixed vs Removal Prosthetics

• Factors in deciding which treatment approach
• Patients ability to maintain
• Cost
• Long term stability of current dental status
• Presence of oronasal fistula
• Presence and Quality of Bone Graft
• Condition of adjacent teeth
• Underlying medical conditions

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Fixed

• Advantages
• Less bulky
• Stimulates alveolar bone
• Feels Natural
• Stability

• Disadvantages
• Expensive
• Labor intensive
• More complex cleaning regime
• No Obturation

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Fixed

• Photos

Vig
Henderson
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Removable

• Advantages
• Cleansibility
• Palatal Obturator
• Less expensive
• Easily? modified

• Disadvantages
• Bulky
• Alveolar atrophy
• C. albicans
• Palatal hypertrophy
• Can dislodge

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Removable Prosthodontics
Henderson
Bardach
Erythematous candidiasis if not removed
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Prosthetic Speech Aids
Oronasal Fistulas Palatal Lifts Pharyngeal
Obturators w/o Pharyngeal Flap w/
Pharyngeal Flap
Clinics
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Prosthetic Speech AidsOronasal Fistula
Bardach
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Prosthetic Speech AidsOronasal Fistula
bardach
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Prosthetic Speech Aids
Badach
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Prosthetic Speech AidsPalatal Lift
Bardach
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Prosthetic Speech AidsStages of Lift Fabrication
The palatal lift is added on in stages to permit
the patient to adapt to its presence and to
maximize effect with minimal volume.
bardach
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Prosthetic Speech AidsPalatal Lift
bardach
Retentive button
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Prosthetic Speech AidsPharyngeal Obturator
Mini bulb
Moderate bulb
Vig
Bardach
Large bulb
Bulb size is determined by the patients specific
needs
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Prosthetic Speech AidsPharyngeal Obturator
cooper
This obturator is designed to work with an
inadequate pharyngeal flap
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Summary The Role of a Pediatric Dentist in
Cleft Care

• Behavior modification
• Prevention
• Maintenance
• Restoration
• Monitoring
• Growth and Development
• Outcome measures

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Summary

• Speech Aids
• Transitional Esthetics
• Flipper
• Bonding
• Treatment Planning
• Timing of Alveolar Bone Graft
• Future Prosthodonitc Treatment
• Implants

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Summary

• Liaison to family dentist pediatric dentist
• Primary dental care provider
• Coordinator for dental services

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Thank-you

• See Core Curriculum for more information
• Any Questions
• mjhauk1_at_aol.com

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Thank-You