Pediatric dentistry in 2020 and beyond: A perspective of two young pediatric dentists

Introduction

The scientific revolution of the 21st century heralds the new dimensions in pediatric oral health care. [1] Pediatric dentistry is a discipline that has now embraced the concept of ‘oral and overall health’ to explain how right from the womb until adolescence; the growth and development of the jaws and the face, the power of maintaining healthy airways contributes to one’s quality of life. [2] Dentists and researchers have shown how growth during early life is related to chronic diseases that emerge many decades later. [3] A new era has begun, encouraging healthcare practitioners to look at dentistry with a new perspective. “In these waves of change we pediatric dentists will find our direction.”

Pediatric dentistry is an age-defined speciality that provides both primary and comprehensive preventive and therapeutic, oral health care for infants and children through adolescence, including those with special health care needs. [4] Today, Pediatric Dentistry is recognized as a speciality which is not based on a particular skill set, but encompassing all of dentistry’s technical skills against a philosophical background of understanding child development in health and disease. The focus has changed from providing restorative/surgical treatment to disease prevention and interception. 

Dental caries is the single most common chronic childhood disease - 5 times more common than asthma, [4] times more common than early childhood obesity and 20 times more common than diabetes. [5] Mouth breathing and Sleep Disordered Breathing (SDB) is also one of the most common diseases in children. [6] It is therefore time for a breakthrough in thinking and a clearly defined vision for developing strategies to disease management. In fact, the American Dental Association, the American Academy of General Dentistry, and the AAPD all recognize that the dual role of pediatric dentists is similar to that of paediatricians, gynaecologists, and internists in medicine. It is of utmost importance that children must obtain collaborative care from dental and medical teams for a complete physical, mental and social well-being. [7]

Different Areas of Revolutions In Pediatric Dentistry

 

• Oral Care 

 

Every child is different, a customized and comprehensive treatment plan along with a framework for home oral hygiene must be provided to help the child. The oral health team must emphasize on full mouth rehabilitation, it will also eliminate the increasing cost and discomfort of re-treatments. [8] The current approach is caries lesion management at tooth level, followed by caries management to control the ongoing caries process in the oral cavity such that the balance is sustained towards net mineral gain. The control of dental biofilm plays an essential role in caries development. [9] Thus, evidence supporting toothbrushing, flossing, varnish, gels, prophylaxis (rubber cup) at recall visits before the varnish application is weak and conflicting. In addition, the recent paradigm shift puts equal emphasis on modifying dietary behaviours. [10]

 

• Breastfeeding and Pediatric Dentistry

 

The role Tethered Oral Tissues (TOT’s) was underestimated and has gained a lot of momentum in recent years. Today, there is enough research showing the role of TOT’s in breastfeeding [11], speech [12], breathing [11,13], sleep [13], swallowing [11,12], oral myofascial dysfunction [14] and growth of jaws [14]. The definition and assessment of Ankyloglossia have been revisited in recent years based on a function that is tongue mobility. [15] The understanding in treating infant oral health is growing and changing and this represents an excellent opportunity for physicians and dentists to find ways to effectively join forces to create a successful outcome.

 

• Sedation 

 

Most of the pediatric patients have received treatment in the dental office with minimal discomfort and without expressed fear, using behaviour guidance techniques. A dentist who treats children should be able to accurately assess and implement basic and advanced behaviour management techniques. Minimal or moderate sedation can be used for less compliant patients. Some patients with special care needs who have extensive oral healthcare needs, acute situational anxiety, pre-co-operative age-appropriate behaviour, immature cognitive functioning, disabilities, or medical conditions require deep sedation/general anaesthesia in a safe manner. [16] In these cases, the operating dentist, the licensed anaesthesia provider and the dental assistant must be trained in pediatric advanced life support (PALS). [16] 

 

• Restorative Dentistry 

 

Dentistry is moving away from the mechanistic approach which failed to address the underlying cause of the disease, leading to a continuing process of replacement dentistry called the ‘repeat restoration cycle’.8 It is time to update your team’s approach to the non-surgical management of caries. Micro-invasive ways like the Hall Technique [17] and Silver Diamine Fluoride (SDF) are used most commonly. Moreover, in some situations, SDF may replace waitlists and sedation for many young patients until they mature before performing the treatment. [18] Newly developed materials, technologies and techniques have now given ways to preserve tooth structure more effectively. Not only are they child-friendly and cost-effective, but they also provide a painless and anxiety-free experience. 

 

• Interceptive Orthodontics 

 

The importance and the role of epigenetic factors in growth have been stressed upon right from the time Melvin Moss mentioned in the Functional Matrix Theory that there are no genes for bone development. Soft tissue dysfunction is an alteration in the muscular activity of the muscles. Ramirez et al [19] mention that dentists must be aware and evaluate each patient if dysfunction in the muscular activity is present and how this soft tissue dysfunction has affected the occlusion. We don’t need to wait and wait until all teeth erupt and eventually extract them due to lack of space and inability to modify growth at a later age. Pediatric dentists are the ones watching the child’s growth; any prefabricated or customized growth modification appliances should be considered as the first line of treatment. [20]

 

• Oral Myofunctional Therapy

 

According to the Academy of Orofacial Myofunctional Therapy (AOMT), Orofacial Myofunctional Disorders (OMD’s) are disorders of the muscles and functions of the face and mouth. An incorrect breathing pattern results in dysfunctional adaptation of the orofacial muscles. OMD’s may directly or indirectly result in dysfunctional habits like atypical swallowing and chewing, non-nutritive sucking, bruxism, speech disorders, TMJ disorders, incorrect postures, malocclusions [20,21] and sleep disorders [22] develop. OMD’s also interfere with the stability of orthodontics treatments. These disorders are important to be diagnosed by dentists, pediatric dentists, orthodontists, dental hygienists, speech-language pathologists and other professionals dealing with the orofacial complex.

Our ability to identify these disorders can help widen our scope of practice. Furthermore, it will support us in reasoning out the etiology behind the commonly observed signs and symptoms in our practices.

 

• Importance Of Anticipatory Guidance On Weaning

 

Attention has been drawn to the strong correlation between jaw shrinkage and the agricultural and industrial revolutions. What has changed in this revolution? The transition to softening diets and a reduction in the amount of chewing, resulting in an improper swallow. [2] A person swallows 500-1000 times in a day and this incorrect swallowing can affect the growth of the jaws, the position of teeth and muscle dysfunction. It is a relevant and meaningful responsibility of a pediatric dentist to give this anticipatory guidance to parents. [23]

 

• Pediatric Sleep Disordered Breathing (SDB)

 

Presently, the impetus behind understating Pediatric SDB is a revolution in itself. SDB refers to a spectrum of sleep-related breathing abnormalities that include snoring, upper airway resistance syndrome, obstructive hypopnea syndrome, and obstructive sleep apnea (OSA). [24] It has been seen that Pediatric SDB is affecting the children’s growth behaviorally, socially, academically and their overall well-being. A study conducted by Bonuck et al [25] found a high prevalence of UARS and mouth breathing compared to sleep apnea in children. The symptoms of these were dynamic, suggesting the need for early and continued vigilance in early childhood. Ultimately, concluding that a very strong association was present between SDB and orofacial muscle tone and development of nasomaxillary complex. [26] 

This is where our role as a pediatric dentist becomes important. Even the ADA and FDA in its policies state that we as pediatric dentists must undergo training to identify signs of SDB and how it can be treated with an interdisciplinary approach.

 

Evidence-Based Practice:

The classic definition of Evidence-Based Practice (EBP) is from Dr David Sackett. EBP which states that “the conscientious, explicit and judicious use of current best evidence is in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research”. [27]

So, EBP is not only about applying the best research evidence to your decision-making but also using the experience, skills and training that you have as a health professional and taking into account the patient's situation and values (e.g. social support, financial situation), as well as the practice context (e.g. limited funding) in which you are working. The process of integrating all of this information is known as clinical reasoning.  When you consider all of these four elements in a way that allows you to make decisions about the care of a patient, you are engaging in EBP. [28]

 

Conclusion:

EBP is of paramount importance as the purpose is to improve the treatment outcomes with the most proficient care available. That’s how we can grow our field. There is tons of research showing how medicine and dentistry can integrate together and it's growing rapidly. It's about time for pediatric dentists to understand their role in different positions and how we can unite and collaborate with physicians to make these children live healthier and happier lives. In conclusion, Richard Dawkins quotes “Evolution is almost universally accepted amongst those who understand it and almost universally rejected by those who don’t.”

Conflicts of Interest and Disclaimer: The authors do not have any conflicts of interest in advocacy or promotion of education in this field. 

Funding Information: No sponsorship or external funding was used to support this study.

 

References:

1. Splieth, Christian H. (Ed.) Revolutions in Pediatric Dentistry. 1st Edition 2011.
2. Sandra Kahn, Paul Ehrlich, Marcus Feldman. The Jaw Epidemic: Recognition, Origins, Cures, and Prevention. BioScience, Volume 70, Issue 9, September 2020, Pages 759–771.
3. Juliette Tamkin1.Impact of airway dysfunction on dental health. Bioinformation. Jan 2020. 
4. American Dental Association Commission on Dental Accreditation. Accreditation standards for advanced specialty education programs in pediatric dentistry. Chicago, Ill.; 2017.
5. Health and Health Care for the 21st Century: For All the People C. Everett Koop. Am J Public Health. December 2006; 96(12): 2090–2092.
6. Christian G. Sleep disordered breathing in children. The Indian Journal of Medical Research. February 2010. 131(4):311-20.
7. Integrative and collaborative care models between pediatric oral health and primary care providers: a scoping review of the literature.Tylor L Gauger, Lisa A Prosser, Margherita Fontana, Peter J Polverini. J Public Health Dent. Jun 2018.
8. Elderton RJ. Clinical studies concerning re-restoration of teeth. Adv Dent Res. Jun 1990; 4:4-9.
9. Innes N.P.T, Frencken J.E, Bjorndal L, Maltz M et al. Managing Carious Lesions: Managing Carious Lesions: Consensus Recommendations on Terminology. Advances in Dental Research 2016; 28(2):49–5.
10. White Paper on Dental Caries Prevention and Management. FDI 2016. 
11. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. 2005 May-Jun; 41(5-6):246-50.
12. Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002 Dec; 127(6):539-45. 
13. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res. 2016; 2(3):00043-2016. 
14. Yoon, A. J., Zaghi, S., Ha, S., Law, C. S., Guilleminault, C., & Liu, S. Y. (2017). Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional–morphological study. Orthodontics & craniofacial research, 20(4), 237-244.
15. Yoon A, Zaghi S, Weitzman R, Ha S, Law CS, Guilleminault C, Liu SYC. Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. Sleep Breath. 2017 Sep; 21(3):767-775.
16.  American Academy of Pediatric Dentistry. Use of Anesthesia Providers in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patient. THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY. Revised 2019.
17.  Innes NP1, Evans DJ, Stirrups DR. Sealing caries in primary molars: randomized control trial, 5-year results. J Dent Res. 2011 Dec; 90(12):1405-10.
18. Michelle L Thomas, Kelly Magher, Leda Mugayar et al. Silver Diamine Fluoride Helps Prevent Emergency Visits in Children with Early Childhood Caries. Pediatric Dentistry. May 2020. 
19. Ramirez-Yañez GO, Farrell C. Soft tissue dysfunction: A missing clue when treating malocclusions. Int J Jaw Func Orthop 2005;1: 483-494.
20. Daglio S, Schwitzer R, Wüthrich J. Orthodontic changes in oral dyskinesia and maloclusion under the influence of myofunctional therapy. Int J Ororfacial Myology. 1993; 19:15–24.
21. Daglio SD, Schwitzer R, Wüthrich J, Kallivroussis G. Treating orofacial dyskinesia with functional physiotherapy in the case of frontal open bite. Int J Ororfacial Myology. 1993;19: 11–14.
22. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med. 2013 Jun; 14(6):518-25. 
23. Lieberman DE, Krovitz GE, Yates FW, Devlin M, St Claire M. Effects of food processing on masticatory strain and craniofacial growth in a retrognathic face. J Hum Evol. 2004 Jun; 46(6):655-77. 
24. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004; 69(5):1147-1154.
25. Bonuck KA, Chervin RD, Cole TJ, et al. Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study. Sleep. 2011; 34(7):875-884.
26. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2013; 3:184. 
27. Sackett, D., Rosenberg, W., Gray, J., et al. (1996). Evidence based medicine: what it is and what it isn't: it's about integrating individual clinical expertise and the best external evidence. BMJ, 312, 71-72. 
28. Hoffman, T., Bennett, S., & Del Mar, C. (2013). Evidence-based practice: across the health professions (2nd ed.). Chatswood, NSW: Elsevier.

Authors: Dr. Rinky Thakkar MDS (1), Dr. Ankita Shah MDS (2)

1. MDS Pediatric and Preventive Dentistry, Mumbai, India; Fellowship in MFS Orthodontics,  Affiliated to University of Barcelona, Spain; Preceptor UTHealth Pediatric Dentistry, Houston, Texas, United States.  Email Id: drtrinky22@gmail.com

2. MDS Pediatric and Preventive Dentistry, Mumbai, India; Fellowship in MFS Orthodontics, Affiliated to University of Barcelona, Spain; President of India Airway CoLab Chapter. Email Id: ankita@dentician.in
   Address: Dentician: 502 Royal Apartment, Bhaudaji road, Sion West, Mumbai- 400022, MH, India

 

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