Ensuring optimal oral health in pediatric patients poses unique challenges for dental professionals. With dental caries and traumatic dental injuries prevalent among children worldwide, addressing their oral health needs requires specialized approaches. This article provides a comprehensive overview of key considerations in pediatric oral health management, encompassing clinical, behavioral, and communication strategies. From selecting appropriate local anesthetics to mitigating behavioral barriers, dental professionals are equipped with evidence-based techniques to enhance the dental experience for young patients.
Summary :
Pain Management – Great oral health begins in childhood, but pediatric patients are a uniquely challenging group for dental professionals. This article aims to summarise the key oral health needs in pediatric patients, discuss best-practice guidelines for treatment, and present evidence-based strategies for overcoming the most common challenges.
Dental caries remains the most common health condition afflicting children worldwide, with an estimated 514 million children suffering from caries of primary teeth.[1] Children are also especially vulnerable to dental injury, with one-third of all preschool children worldwide reported to have sustained a traumatic dental injury (TDI) to primary teeth, and a quarter of all school-aged children having sustained a TDI to permanent teeth.[2]
Preventing and treating dental caries, TDIs, and other common childhood oral health concerns presents significant challenges for the dental professional. One such challenge is the wide variation in the physiological characteristics of this age group, giving rise to important clinical considerations.
Choice of local anesthetic
When choosing a local anesthetic for pediatric patients, pharmacokinetics and duration of action are prime considerations.
A child’s smaller body mass requires a lower dose to achieve an adequate but safe level of anesthesia. Articaine is increasingly favored in children aged four and older because it is rapidly metabolized, resulting in a short elimination half-life of about 20 minutes, thereby possessing a decreased potential for systemic toxicity.
Further, articaine diffuses through hard and soft tissues more reliably than other local anesthetics. As a result, it may be possible to achieve palatal soft tissue anesthesia using maxillary buccal infiltration rather than palatal injection, a painful and potentially traumatic procedure for young patients.
A long-acting anesthetic, such as bupivacaine, can leave children vulnerable to self-inflicted soft tissue damage after treatment. It is therefore rarely indicated in the pediatric dental population.
Because the variation in body mass across this patient group is so wide, there is no one-size-fits-all approach to pediatric dosage. The maximum dosage should be calculated on a patient-to-patient basis according to the weight of the child, not to exceed 7 mg/kg for articaine. However, the clinician should always strive to use the lowest dose possible to achieve the treatment goal.
Use of epinephrine
Where possible, a local anesthetic with a lower volume of epinephrine is preferable for pediatric patients. Higher epinephrine concentrations from partial intravascular injection can have a more pronounced effect on children, so careful aspiration is of the utmost importance.
In patients with contraindications like cardiovascular disease, an anesthetic without epinephrine such as plain Mepivacaine is recommended for short procedures.
Administration method
Whenever possible, anesthesia should be administered to children by intraligamentary injection (also known as periodontal ligament injection). The insertion pain is relatively low, it requires a lower dose of local anesthetic as the anesthesia is confined to a smaller area, and it resolves more quickly after treatment, making it an ideal method for pediatric patients.
Infiltration anesthesia is suitable for many procedures in children. Up to the age of five or six, for example, it may be sufficient in the mandibular posterior region due to the less dense bone structure in younger children.
From the eruption of the permanent first molars, conduction anesthesia of the inferior alveolar nerve at the mandibular foramen may be considered for surgical procedures in the mandible. It may be possible to use an epinephrine-free anesthetic.
Palatal injection is especially painful for children. It has been demonstrated that the buccal infiltration of articaine (1/2 to 2/3 of a cartridge in children) can provide successful palatal soft tissue anesthesia without the need for a palatal injection.
Analgesics and antibiotics
The management of post-operative pain must also be taken into consideration. Paracetamol (acetaminophen) is considered the gold-standard analgesic and antipyretic for mild to moderate pain in children. Due to the association with a condition called Reye’s syndrome, medications containing aspirin should be advised against in children under 14.
Amoxicillin is typically the first-line antibiotic for post-operative infection control in children but can be substituted with clindamycin in the case of a penicillin allergy. Tetracyclines should not be prescribed before the age of eight due to the risk of enamel discoloration.
Behavioral challenges in treating the pediatric patient
In addition to clinical considerations, there may be significant behavioral barriers relating to age, communication skills, cognitive ability, and attitudes toward dentistry.
While many children are able to manage their discomfort or apprehension, dental professionals often encounter children with a lower capacity for behavioral and emotional regulation. They may exhibit behaviors that make treatment stressful and potentially unsafe for both them and the patient, such as:
These behaviors are most often seen in very young children and those with developmental or behavioral disorders. This patient group, termed “pre-cooperative” or “lacking cooperative ability”, possesses underdeveloped cognitive abilities, attention spans, and/or coping strategies necessary to navigate potentially uncomfortable situations like dental visits.
Pediatric patients of all ages can demonstrate maladaptive behaviors due to their attitudes toward dental treatment. Up to 33% of children and adolescents are believed to suffer from dental anxiety and many more experience apprehension or aversion that can cause challenging behaviours.[3]
A young patient’s attitude and behavior at the dentist can be influenced by a number of factors, including:
While the development of these factors is outside the control of the dentist, there are plenty of strategies for mitigating their impact. In the following sections, we will explore various behavioral management techniques, communication strategies, and clinical tools that dental professionals can use in order to manage the needs of pediatric patients.
Positive pre-visit imagery
Positive dental imagery can show children what to expect and combat any negative preconceptions they may have about their dental experience. Provide or direct parents towards resources, like YouTube channels, story books, or virtual tours of your practice, that they can share with their children ahead of a visit.
Desensitization
Desensitization is a well-established method for diminishing negative emotional reactions associated with dental anxiety in pediatric patients, particularly neurodivergent children.[5] It involves exposing the child to the source of their fear in a controlled and gradual way, allowing them to become comfortable before moving on to the next stage. To illustrate, a sequence of desensitization at the dental office may go as follows:
Tell-show-do
The tell-show-do technique is an evidence-based method for reducing anxiety in pediatric patients. It removes the fear of “the unknown”, helps to desensitize the child to fearful stimuli, and gives them a sense of control. It has been shown to be successful even in emergency pediatric dental treatment, where pain and anxiety are often heightened.[6] When used alongside other techniques like virtual and audio-visual distraction, its efficacy is shown to be even greater.[7][8]
The tell-show-do process, to be repeated at each step of the procedure, is as follows:
The “show” step should be interactive with a sensory component, e.g., demonstrating the sound a piece of equipment makes, showing the child the materials you will use, or letting them touch or hold an object before using it. For younger children, pretending to demonstrate actions on their doll or teddy bear first can also be helpful.
Positive reinforcement
In order to learn the appropriate way to behave in any environment, children require feedback and positive reinforcement of desired behaviors. The dental operatory is no exception. Incorporate the following actions to utilize this technique:
Distraction
Distraction is an effective method of diverting the child’s attention away from the discomfort, anxiety, or boredom of a dental visit.[7][8][9][10] It is also successfully used to manage pain; given the significant psychological component of pain perception, it is theorized that diverting attention away from the source of the pain can reduce the perception and therefore intensity.[10]
Distraction techniques can be as simple as providing toys and storybooks in the waiting area, to the use of more innovative technology like virtual reality (VR) glasses. VR has been shown to reduce anxiety and pain perception in pediatric patients, with success in clinical scenarios ranging from rubber dam placement to extractions.[10][11][12][13]
Other examples of distraction techniques include:
Modelling
Modeling uses another child as a “role model”. The patient watches a cooperative sibling or another pediatric patient who exhibits desirable behavior during dental treatment and sees the behavior being praised and rewarded. The child then learns and imitates this behavior during their own treatment.
Memory restructuring
Memory restructuring is especially helpful for reducing fear or anxiety in children who have had prior negative dental experiences.[14] Negative memories are turned into positive memories in a four-step process:
Sensory-adapted dental environments (SADEs)
For children with anxiety or sensory processing difficulties, a sensory-adapted environment can greatly support relaxation and cooperation.[15][16] Examples of sensory adaptations include:
Accompanying adults
For the safety of the young patient, it is vital that the dental professional is able to command their undivided attention. Parental interference — even well-intentioned encouragement — can be a distraction. If possible, encourage the accompanying adult to wait outside or stay quietly in the background for the duration of the treatment.
Remember that children take their behavioral cues from their parents, so any stress or anxiety shown by the caregiver can inspire the same feelings in the child. If the parent is uneasy, taking a moment to address their concerns can positively influence the child’s behavior.
Enhanced control
Dental treatment can make children feel powerless and vulnerable. Enhancing control gives the child choices, or even just the perception of choices, to help the child feel some agency over the situation.
A common method of enhancing control is to establish a system of non-verbal communication signals the child can use to control the treatment, such as a raised hand for “stop”. This not only reduces the risk of the child using disruptive and potentially unsafe behaviors to pause treatment, it is also shown to reduce intra-operative pain perception.[17] Of course, it is important to respond to the signals quickly and consistently to maintain the child’s trust and compliance.
Examination techniques
For toddlers and babies, the knee-to-knee examination technique can provide safe restraint under which to conduct an examination. Parent and clinician sit facing each other and the child is laid across both laps, with the legs on the parent’s lap and the head resting on the clinician’s lap. Parents can also sit in the dental chair and position their child in front of them, comforting and restraining the child as necessary.
Complete analgesia
Pain is one of the most commonly cited reasons for dental anxiety and phobia, which often begin in childhood, so achieving complete analgesia should be a priority in pediatric patients.[4][18] Local anesthesia is the gold standard for pain management, but the injection can be distressing in itself. The use of pre-injection topical anesthesia is a safe, simple, and effective way to give a pain-free injection, potentially averting the onset of dental anxiety in the process.
A topical anesthetic can also be used exclusively in minor procedures such as scaling, crown placement, or extraction of very loose teeth, eliminating the need for an injection altogether. However, topical anesthesia should be used selectively over small areas to maintain control of plasma levels.
Minimally invasive techniques
In some cases of dental caries, cavities can be restored using the minimally invasive Atraumatic Restorative Treatment (ART) technique. Decay in the tooth is removed using a hand instrument as opposed to an electric drill, and no local anesthetic is required, representing a much less traumatic experience for the child. Then, to preserve tooth vitality and tooth functionality, Biodentine XP can be applied from the pulp to the tooth surface in the Bio-Bulk Fill procedure, with final enamel restoration to be completed within 6 months [19].
Sedation
Inhalation sedation using nitrous oxide and oxygen is a safe and effective option for children who need extra support to manage their anxiety, contain movement, suppress the gag reflex, or tolerate long treatments. It is also helpful in patients for whom adequate local anesthesia cannot be achieved. It has a rapid onset and recovery and can be easily titrated and reversed at the end of treatment. However, care must be taken when using inhalation sedation in conjunction with other sedative medications, and in children with certain medical conditions.
Cognitive behavioral therapy (CBT)
Researchers at The University of Sheffield have developed an approach based on the principles of Cognitive Behavioral Therapy (CBT), a therapeutic intervention that has had great success in patients with anxiety and phobias. They have published a number of resources for dental providers and parents to work through with young patients, consisting of simple activities that can be done at home and in the chair. You can find more information and resources here.
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