Treatment Planning: Examining the Child

Extra-orally, this is really good. You can look at the general appearance. Is there anything sort of unusual, syndromic you want to think about? Behaviour, what were they like coming into the clinic? Were they screaming and crying and clinging on to their parent’s leg? Or were they quite happy, jumping into the chair, mouth wide open, perfect patient? So lots of things we can get out of that just from watching them sort of come into the clinic and lots of facial appearance and things that tell us. I always say, I’m not going to tell you how to do an intra-oral examination. You’re doing this at the time that you want to think about it in a systematic way.

So you put oral hygiene, soft tissues. Teeth, I’m thinking are they appropriate for the age? Are they symmetrical, anything you need to be concerned about? Looking at caries, looking at tooth structure and colour, looking at occlusions, all the things we would normally do. But I think sometimes some of my students really struggle to look at very small children, and they say, oh, I can’t examine them. And I think, just remember, this lap to lap examination is a really nice way of being able to look at a small child’s mouth. And I always warn the parent, they might scream and cry for two seconds, but they’ll open really wide, and I’ll have a great look around and we’ll be all done.

The ones that are really canny are the ones that just kind of clamp their lips together, and they just don’t cry or do anything because they don’t want to open their mouths. And so sometimes you have to kind of tease your finger into the sulcus a little bit and just massage it, and that helps to relax them so you can open it up and have a look. But a really small child, there’s no excuse for not being able to have a look, particularly if you’ve got the parent on board and explaining what you’re doing to help. And then thinking about special tests, you’ve got radiographs. You’ve got other things you might be thinking about.

If it’s trauma, you may be doing sensibility testing. You have the plaque score, which is quite a nice way of sort of monitoring oral hygiene status, or periodontal probing for children over seven. And I’ll just go through all of those. So you’re thinking if you’re taking radiographs, what are you taking them for? Are you trying to diagnose caries for anterior teeth or posterior teeth? Are you looking for signs of infection or pathology? Is it a trauma assessment? Are you looking for anomalies? There’s a lot of information you can get from a radiograph so you’ve got to really think about, well, what am I really looking for? And then I can decide what’s the best radiograph to take.

So we don’t really have– so the FGDP here in the UK don’t have guidelines for children. They’ve been talking about it for ages. It hasn’t happened. The last really good guidelines we had were 2003, the EAPD, and actually, they are in the process of upgrading them now. So hopefully, there’ll be new, up to date guidelines available. But it’s just to give you a rough idea that if you’ve got a child of a low risk of caries, you still want to be taking baseline around five-ish just to see there’s nothing going on. And then how often you take them, again, it’s going to depend on their caries risk.

And remember, like I said earlier, if you can’t palpate the canines by age nine, got to be thinking about do I need a radiograph to check where they’re growing? Are they growing on course? I’m a big fan of the vertical bitewing. So this is just your normal, small PA film, and you just rotate it 90 degrees. And the reason I like it is children tend to tolerate that far better than the horizontal bitewing because it’s not going so far back. And also, because you’re focusing on the D’s and E’s, it gives you lots of information. I can see the caries. I can see the furcation area. I can see if there’s permanent successors.

So it gives me more information in the horizontal bitewing. So I think if you haven’t tried them before, do look at those because they do, they really help with the radiographs. And likewise the other one I’m quite a fan of is using the upper standard occlusal view, and instead of the big occlusal film where you try to use a corner, if you’ve got a small child, that’s a very big film coming towards them, and they sometimes look a little bit hesitant, whereas if you use a large PA film horizontally, you can get all the information you want, but it’s much easier for that child to tolerate. So you can think about these sort of tips for how to take radiographs.

And just to remind you, we should be using BPE examination for our children over seven. When you’re doing it for a seven year old, it’s really simple. You’re just using zero, one, two, three code so it’s quite straightforward. In fact, zero, one, and two if they’re up to 11. So it’s straightforward. It’s just six teeth. You do it really quickly. So unless they’re not cooperative, there’s no reason why we shouldn’t be doing the exam. We’re really bad at remembering to do them, all of us, so we tend to do this as a continued audit in our department to encourage us to remember to do the BPE.

So in summary, if you’re thinking about a treatment plan for children, there are some general principles that will help you, but obviously, each one needs to be individual to that child and that family. You can’t just have a blanket treatment plan that you use. You will need to tweak it for each child. But to help you to get to that point and decide exactly what treatment plan I’m going to do, you’ve really got to have a good history. You’ve got to have an examination because that will really help guide you. And hopefully, this talk will have shown you some of the tips that we use for getting it. Thank you very much.