Treatment Planning: Principles

Hello. Welcome to this talk on treatment planning for children. So we’re going to run through some principles, really, when we’re thinking about treating children, just generally. And then, in the next lecture class, we’ll talk about management. So the aims of this talk I think really is to think about what are the general principles we need to think about when we’re planning treatment for children? And then, identifying key questions to ask when taking history so that it can kind of help guide us towards what we need to plan for this child. And then, and like I said, next talk I’ll go through some tips for how you undertake and examine a small child, how you choose to think about special tests.

So what makes a good treatment plan? It really is about preventing or managing pain and sepsis. So you want to think about promoting a positive attitude and treatment. Remember, if you get it right as a child, then hopefully they will carry that through to adulthood. And you want to think about trying to give them good aesthetics and functioning occlusion. Pretty much what all of us want really for our teeth. But for you to be able to get to that point you’re going to need a detailed assessment. So think about, first of all, preventing or managing pain and sepsis. So what you don’t want to do is leave uncontrolled infection.

Now, children are pretty good actually of just kind of getting on with having chronic pain and infection. They don’t know any difference, I think that’s how it is. So many studies have shown after children have had rehabilitation, whether it’s in the chair or on the general anaesthetic, quality of life improves afterwards. You know, they’re eating better, sleeping better, they’re better at school. So even if they may not necessarily be complaining about problems, it’s probably having an effect on the quality of life. So you don’t want to leave and control the infection like I thinking it’s baby tooth is going to come out in a couple weeks.

Really, for all of us we’re all aware of the issues with antibiotic resistance, so on, so prescribing antibiotics should be the last resort. Any dental patient, we can think about can we remove the source of the infection. I think particularly with children, we to try and anticipate problems, don’t wait until they arrive with swelling and having to deal with it then. You really want to think, well, that cavity in six months is probably going to progress in pulp, so I should probably deal with it now rather than wait for the next review. That way, you kind of anticipate problems have a much easier solution than having to think about giving local extractions or something.

So when we think about promoting a positive attitude to dental care, so we know that this is something that’s an issue. What we all ideally is our patients should be less anxious after they’ve had treatment, not more. And we want them to be adults who can accept dental care under the local anaesthetic. We’re not doing great at the moment on that. This is a last adult dental health survey from 2019, and it showed that most anxious ones with extreme anxiety by age group of 16 to 24. So if we get them really extremely anxious at that age, that’s just being carried through into adulthood.

So it’s so important we get it right when they’re children, because really would influence how they interact with and how they set dental treatment for the rest of their lives. OK. So promoting a positive attitude to dental care. We know that if you have a negative experience in dentals, you get pain, you’re going to be more anxious next time. That’s just human nature. Someone did a study awhile back and they found that you can actually be 19 times more anxious the next time you go. So that’s quite a lot more anxious. So what’s important is, don’t have pain. Don’t experience pain that first time, and then you’re not going to be more anxious next.

So when it’s children, that’s thinking about, should I be using local? And if you’re thinking, well, I’m not going to get away of this feeling without, then don’t. Better to give local, have a pain free experience, and then they’re not going to be more anxious next time. Particularly, for a child if they have a painful experience, it’s really going to be difficult to gain their trust and carry on with the rest of treatment. So that means you need to choose your behaviour management carefully. You’ve got to think about, well, how am I going to do this. And you’ve got to think, what amount of treatment am I doing, how old is this child, can they cooperate with children.

Because for a very young child and you often repeat at 12, 15, to even require treatment. That’s a big ask for someone to sit in a chair and do. So then it may be that actually general setting is the correct first choice. Likewise, if they’ve got mineralised first permanant molars, they may need to come out. Again, that’s not easy for most children to cope with at the age of eight or nine. And that actual general anaesthetic it’s appropriate for that. But, if you’re not thinking about that, then you probably want to think, well, OK let’s think about the order. I climatized this child, introduced them dentistry, start with something easy.

First your sealant, some scan and polish, and then build my way up to do fillings, extractions, maybe I do the quadrant dentistry, if I can. And if you’re thinking about giving local for first time, then what you want to think about, well, where is the best quadrant I could give that where firstly, they can’t see the needle and then they’re not going to feel quite as much numbness of the lip, and so on. So sort of the upper posterior quadrants are a really good place to start if you’re going to give local the first time because you can find it and do it without without the child realising, particularly in the upper right quadrant if you’re right handed.

And then, actually, it is a positive experience and then they’re more likely to think next OK, yeah, I know what to expect. And then you want to think about, well, what do I how do we achieve good aesthetics and functioning occlusion. So you’ve got to think long term and you may want to be thinking about collaborating orthodontists with restorative dentists depending on what condition they have. To give a somewhat compromise first permanent molars 6’s, or if got a dental anomaly. If you’ve got any of these complications, you want to be planning ahead for that.

So just some basic principles. When we think about primary teeth and we’re thinking about what sort of treatment we do, we’re really concentrating on E’s here. If you’ve got a child who sort of carries in the D’s and E’s, start with the E’s. The primary molars. Because they are the ones that are going to hold the occlusion in place. If we extract E’s we particularly pull the first permanent molars, the 6’s corrupted, you are going to get a lot of space loss, that can be a real challenge later. So you really want to think about hanging onto those E’s if possible. D’s, the first primary molars we’re not so bothered about.

Obviously, we’ve got super cooperative child, we’re going to restore them and sort out any pain problems, but I would always start with E’s. They’re the ones I want to concentrate on. If you’re going to have to extract the primary canines, C’s always balance. So if you take out one in one, you must balance with the other side. Because you can lose your centerline. You can get a shift and that could cause a real problem later. I don’t balance off tooth that’s C’s always. Remember that when the treatment planning and thinking. And then you’ve also got to think, well, does this tooth need to be filled? Yes it has cavities, but is it actually near exfoliation?

Or would extraction be the better option? I always say, I remember when my students once was drilling a tooth and literally holding onto it with one finger and drilling it with the other because it’s quite so mobile. And you’ve got to be thinking actually, I don’t think this tooth needs a filling, I think it needs to come out. So you’ve got to be sensible. In a mixed dentition, you’re really thinking OK, how is this dentist developing? So remember, by the age of nine, you dot to be thinking maxillary canines. Can I palpate them. So you want to be sure can I check them. So I would saying age nine, think canine.

And if you can’t palpate the canines, you may need to investigate. Particularly, maxillary permanent canines are really the most likely to be ectopic and can go off course, longer path of eruption. So you’ve got to be checking where are they, are they in the right place. And again, in that mixed dentition phase, if you’re thinking you’ve got poor prognosis first permanent molars, then this is where you want to think about potentially involving orthodontists and planning ahead. If you’re thinking planned extractions, because you’ve got this really good window, where you make it an elegant solution for a child with Molar Incisor Hypomineralisation. Whereas if you wait until they’re in a permanent dentition, seconds have come through, then you’ve missed that opportunity.

And I think in a permanent dentition, it’s all about maintaining teeth and bone wherever possible. Lost teeth, whatever reason, can we maintain the bone? Can we set them up so that when they get to 18 and I move on to adult restorative care we give them the best chance to have a good dentition long term. So that’s what we talk about, those are the basic principles of what we want from a treatment plan. That’s what we’re hoping for, but to get that and to decide what we need, we need that detailed assessment. And that’s what we’re going to talk about in the next lecture class. Thank you.