HANDOUT

PAEDIATRIC DENTISTRY

CHILDREN’S HOSPITAL AT WESTMEAD

A/Prof Richard Widmer Head, Dental Department The Children’s Hospital at Westmead Cnr Hawkesbury Road & Hainsworth Street WESTMEAD NSW 2145

INTRODUCTION Paediatric Dentistry involves treating a complex range of dental problems in children, viz: dental caries, dento-facial trauma, periodontal conditions, orthodontic problems, and in many cases requires detailed assessment of the patient's medical and social status. Dental caries and periodontal disease are the two main dental disorders in children. Both are preventable. The use of community based water fluoridation and locally applied topical fluorides have significantly reduced the incidence of dental caries as has the wide-spread dissemination of preventive activities and information. As well gingivitis and periodontal, whilst not generally as destructive in children as adolescents and adults, has also been significantly affected by the strong preventive effort mounted both professionally and commercially. Water fluoridation, introduced to capital cities in Australia (except Brisbane) during the period 1961-1978, remains the single most important community based strategy available, to decrease the caries burden. Approximately 2/3 of Australians have access to a fluoridated water supply, while around 1 per cent have access to water supplies with naturally occurring concentrations of fluoride above 0.5ppm. Although the magnitude of the reduction in dental caries attributable to water fluoridation - in the presence of other sources of fluoride - is considerably smaller than was the case previously, it is still estimated to confer and maintain an approximately 20-40 per cent reduction in decay within western populations. Reduction in caries in permanent teeth in children is likely to be towards the lower end of this range; while for primary teeth, the reduction is likely to be towards the upper end. Fluoride toothpaste (1000ppm or 400ppm) dominates the market. The lower strength toothpaste is recommended for children age 6 months to 10 years. Only a small ’pea sized’ amount is needed on the brush. 1. DENTITION The Primary dentition is composed of 20 teeth, all of which erupt prior to those of the permanent dentition. There are 8 incisors, 4 canines and 8 molars. The Permanent dentition consists of 32 teeth, the central incisors, lateral incisors, canines and bicuspids, which replace the primary teeth, and the first, second and third permanent molars, all of which erupt posterior to the primary teeth. The formation of the primary teeth begins in utero with the dental lamina formed around the 4th to 6th week from ectomesenchyme. Development of the permanent teeth is initiated at about the 20th week of embryonic life, with the permanent tooth buds arising from the dental lamina lingual to the primary tooth germs. The number and shape of the teeth are subject to strong genetic regulation. Disturbances in induction during this early morphogenetic stage may lead to numeric or morphological aberrations of the teeth. The calcification of the primary embryonic tooth follicles commences at around 3 to 4 months in utero. The primary incisors begin to calcify first and the second primary molars complete the calcification process by 12 months of post-natal development. Disturbances of the calcification process can result in a chronological hypoplasia of the enamel forming at that time. Thus the primary teeth can be a record of foetal development and can provide valuable information on the timing and extent of any inter-uterine insults; for example, such an event at 8 months gestation may leave an obvious horizontal hypoplastic defect on the second primary molars. Special studies quantifying the levels of environmental pollution have used exfoliated primary teeth as a measure of lead exposure. 2. MORPHOLOGY The teeth of the primary dentition have a cervical constriction. The enamel and dentine layers of the primary teeth are approximately equal in thickness and are generally thinner than in the permanent dentition.

The primary teeth have varying numbers of roots, depending on their position within the dental arch; for example, if a toddler accidentally knocks out a primary anterior tooth, it is often a great surprise to parents that the tooth has a long root, as such roots are generally resorbed before exfoliation of the primary teeth, and not seen. In contrast the roots of the primary teeth are shaped like "ice tongs". They are more delicate and divergent than those of the permanent molars. Resorption of roots of primary teeth is usually physiological, whereas resorption in the permanent dentition is pathological. 3. ERUPTION OF PRIMARY TEETH At birth the gum pads are slightly indented, indicating the position of the developing teeth. The primary teeth begin to appear through the gum pads at about 6 months of age, their eruption being completed by around 2 years of age. There are no distinct differences between sexes and the normal range of eruption is relatively small. The primary central and lateral incisors erupt initially followed by the first primary molars, the canines and finally the second primary molars. There appears to be little connection between the normal eruption time of primary teeth and other developments such as skeletal maturity, body height or psychomotor maturity of the child. A genetic influence, however, has been shown in reports on familial trends towards early and late eruption. Also, severely delayed eruption or impaction has been reported as an inherited trait. The primary teeth do not erupt into the mouth in the same sequence in which they are formed in the alveolar bone. Thus at the age of 12 to 14 months when the primary incisors and the first primary molars have erupted, that is, numbers 1, 2 and 4, there is a space where number 3 has not yet erupted. This is often a worry to parents, who may need reassurance. Spacing between teeth is common in the early primary dentition and spacing between the upper incisors and canines and between the lower canines and first molars are known as primate spaces. A lack of such spaces in the primary dentition is an indicator that the permanent teeth may also be crowded. 4. ERUPTION OF PERMANENT TEETH In general, the age at eruption of permanent teeth is more variable than for primary teeth. There are sex and racial differences as well, in that girls are somewhat ahead of boys and that the teeth of Caucasians erupt at a later age than most other races. When the first permanent teeth start to appear at about 6 years of age the child moves into what is known as the mixed dentition. This lasts until all the primary teeth have exfoliated. The upper and lower incisor teeth are exfoliated first between 6 and 8 years of age. The remaining canine and bicuspid teeth are shed between the ages of 9 and 12. The initial permanent teeth to appear are the first permanent molars. These teeth erupt at the back of the mouth behind the last standing primary molars and are entirely new teeth without any primary teeth having been shed to make way for them. Parents are often surprised to know that they are there. They are the largest human tooth and are important in the establishment of the dental arch. They are never replaced and have to last a lifetime. A common finding with the next permanent teeth to arrive, the lower incisors, is for one or more to erupt lingually to the retained primary teeth. Occasionally, a dark bluish area of mucosal tissue is apparent before eruption of the tooth. This is an eruption cyst, and usually ruptures spontaneously, although a moderate level of discomfort can be reported. Parents need reassurance that this is usually only a variation on the normal eruption pattern. The permanent teeth, like the primary teeth, commence formation in utero but, unlike the primary teeth, do not begin calcification until the post-natal period and can thus provide a record of development post-partum. The initial teeth to calcify are the first permanent molars. Calcification of

the crowns of the permanent teeth continues until about age 8 (excluding the 3rd molars, that is, wisdom teeth). Dental malformations can result from systemic or environmental insult such as a difficult, prolonged labour; calcium imbalance; prolonged high fevers; chemotherapy and radiation therapy. An understanding of the chronology of dental development allows an estimate of the child's age at the time of disturbance. When all the permanent teeth have erupted the child has what is termed the permanent dentition. Dental Occlusion The final relationship of the upper and lower permanent teeth is dependent on developmental processes of the cranial base, the jaws and the patterns of tooth eruption. These skeletal processes are under the dual influence of genetic and environmental factors. The growth and development of the craniofacial skeleton are principally by bony displacement at the facial sutures and surface remodelling of bones. The early relationship of the gum pads does not bear a relationship to the future dental occlusion. Initially, when a baby attempts to appose the gum pads, contact is mainly in the posterior region and this contact is not precise. During the first year of life, the relationship of the gum pads and erupting teeth begin to settle down and by the age of 16 months the first primary molars attain occlusal contact. Once this is established the jaws are normally closed to the same position each time. Once all the primary teeth have erupted, the alveolar bone develops and there is a considerable increase in facial height. This has a secondary effect on the palate resulting in an increase in palatal height. Individual variability in growth of the cranial base and the jaws is great and the co-ordination of development with the various components is not always perfect. Environmental influences such as finger sucking or dummy sucking or other oral habits can have a marked effect on the final relationships between the maxillary and mandibular teeth. These relationships are classified both dentally and skeletally as either Class I, II and III. As far as dental classification is concerned, about 65% of the population have a Class 1 dentition with an orthognathic profile of the upper teeth overlapping the lower teeth by 2 to 4 mm. A Class II dentition, that is, a relatively retrognathic mandible with the upper teeth significantly anterior to the lower teeth by at least 4 mm, occurs in around 25% of the population. A Class III dentition (that is, prognathic mandible with the lower teeth in front of the upper teeth) occurs in around 10% of the population. Dental Soft Tissues The dental soft tissues should not be overlooked in this review, as they are an important part of the developing occlusion. They comprise the attached and free gingivae, the periodontal ligament, which attaches the tooth to the alveolar bone, and the oral mucosa. The typical firm, pink stippled healthy gingival tissues develop slowly from the age of 2 to 3 years. Around the neck of the tooth is a shallow sulcus (the gingival crevice), signifying the attachment of the gingival tissues to the tooth. The clinically "normal" gingival crevice harbours inflammatory cells and produces exudate. If not adequately cleaned the marginal gingival tissues become inflamed and bleed easily when brushed. An efficient oral hygiene regimen aimed at consistently eliminating the bacterial dental plaque will resolve the clinical symptoms. The health of the gingival tissues can be a valuable barometer to the general health of the child. If a healthy child of school age shows generalised periodontal disease and loss of bone from around the teeth, it suggests problems in the child's host defence mechanism. As well, many drugs can affect the gingival tissues, for example, dilantin and cyclosporin, causing them to be markedly enlarged and bleed easily.

Variations in Normal Development The size of the teeth is mainly determined by genetic factors. It is generally acknowledged that males tend to have larger teeth than females and racial differences are also seen. The deviations from normal may be general or localised and may involve the crown or the root, or both. Variations in Tooth Size Microdontia (smaller teeth than normal) Generalised microdontia is rare, but can occur in connection with congenital hypopituitism, ectodermal dysplasia and Downs syndrome. Local microdontia involving a single tooth is more common and often associated with a decrease in tooth number. The commonest tooth to be smaller than normal is the upper lateral incisor. The frequency of occurrence of microdontia in the upper lateral incisor is approximately 1% with an autosomal dominant inheritance. Some environment factors such as irradiation during tooth development may also cause microdontia in a localised area. Macrodontia (teeth larger than normal) This is a rare condition, but is occasionally reported in connection with generalised gigantism and congenital hemifacial hypertrophy. A bilateral enlargement of the upper central incisors has occasionally been reported. Root Anomalies The roots are considered shorter than normal if the length is less than the length of the crown. Short roots are thought to be an anomaly of genetic origin. It is three times more common among girls than boys and predominantly affects the upper central incisors. Short roots are also seen in connection with osteopetrosis, hypoparathyroidism and dentine dysplasia. Local affects such as trauma or irradiation may also cause root under-development. Variations in Tooth Shape The maxillary lateral incisors exhibit the most variety in crown form, for example, peg-shaped incisors. An important defect of the shape of the roots is called taurodontism. The anomaly is genetically determined and has been associated with certain syndromes. Other variations in the morphology of the tooth include incidents where teeth have been joined during development or where the tooth has split during development and formed extra teeth. Variations in Colour The most usual discolouration of teeth is a simple yellowing associated with poor oral hygiene. Other colours associated with poor oral hygiene can include black, green and orange. As well calculus, usually formed in close proximity to the salivary duct openings, can pick up stain usually yellow or black. Professional cleaning will usually be needed to remove such stains and definitely needed to remove the hard deposits (ie calculis). Source of stain: Extrinsic Oral bacteria Foods, medication (eg. Iron supplements) Intrinsic Blackened teeth: dental trauma which leads to internal bleeding will often result in a

darkened tooth. Green/black: congenital liver disorders. Porphyrias. In the primary dentition if a tooth begins to go dark following trauma, it is managed conservatively as such teeth can significantly lighten up in time. If a discoloured tooth develops a sign of local infection ie. gingival swelling,sinus tract , pain, or tenderness to percussion then it will require root canal therapy (endodontics) or extraction. As well, in the permanent dentition, the darkening of a tooth will require careful assessment. Initially endodontics will usually be required. Any residual tooth discolouration can be bleached out.

Variations in number Numerical variations of teeth appear to be the result of local disturbances in the induction and differentiation from the dental lamina. There is strong evidence that tooth number is genetically determined and there are large differences in the incidence of the numerical variations among ethnic groups. Anodontia (total absence) This is an extremely rare condition and usually associated with such conditions as ectodermal dysplasia. Hypodontia is the absence of up to 4 teeth, and oligodontia, the absence of four or more teeth. In the primary dentition, the lower incisors are usually affected, however, this is a rare condition. No sex differences have been found, but there is a strong correlation between the primary and permanent dentition. In the permanent dentition, which is more frequently affected, the upper lateral incisors and lower second bicuspids are the most common teeth reported to be missing. Well over 150 systemic disorders are connected with hypodontia-oligodontia in the permanent dentition, for example, ectodermal dysplasia, Down Syndrome, and Cleft lip and palate patients. Supernumerary teeth The prevalence of extra (supernumerary) teeth in the primary dentition is low. Almost all the extra teeth occur in the anterior mandible. The prevalence of supernumerary teeth in the permanent dentition is slightly greater than in the primary dentition with most supernumerary teeth occurring in the midline of the maxilla. There is a higher prevalence among boys than girls and there is often more than one extra tooth - although their occurrence is generally symmetrical. Extra teeth in the permanent dentition can cause a lot of problems in that they delay or misdirect the eruption of the permanent teeth. Indeed, this is often the presenting symptom. Consequently most supernumerary teeth in the permanent dentition should be extracted. Disturbances in the formation of the teeth The quality and quantity of all the calcified elements of the teeth can be affected, that is, enamel, dentine and cementum. When the quality of enamel is affected there are changes to the colour and translucency of the enamel (enamel hypomineralisation or enamel opacity). When the quantity of the enamel is affected enamel hypoplasia results. Most defects to the hard tissue involve both a quantity and quality defect. In the primary dentition about 3% of children can be expected to have enamel hypoplasia; in the permanent dentition this figure is between 2% and 5%. Enamel opacities are far more common in the permanent dentition with an estimated prevalence of between 25% and 80%. These opacities are associated with environmental factors that can be local (for example, trauma, infection, irradiation) or general (for example, hypocalcaemia associated with neo-natal tetany, severe rickets, intoxication and gastrointestinal conditions). Inherited conditions affecting formation include amelogenesis imperfecta and dentinogenesis imperfecta with or without an associated osteogenesis imperfecta. Disturbances in tooth eruption The total time for the eruption of the primary dentition is about 20 months, with only minor deviations from average figures and with no significant sex differences. The total time span for the eruption of the permanent dentition is about 14 years. Sex differences are significant and the deviation from average is large, especially for the last teeth to erupt, the wisdom teeth. Disturbances to eruption can involve early arrival or early loss of teeth, misplaced eruption, impaction and failure to erupt. If a child is born with teeth, or the teeth arrive soon after birth, it is most likely that these teeth are normal primary teeth rather than supernumerary teeth. The frequency of occurrence is estimated at 1 per 2000 to 3000 births and there are no sex differences. Most of the teeth have a normal shape and occur in the midline of the mandible. They can be loose as they have very little root development and can be a problem for a new mother who is establishing breast feeding. Occasionally neonatal teeth may be associated with syndromes such as chondroectodermal dysplasia.

Neonatal teeth should be extracted only if they are very loose, if there is a risk of possible inhalation, or if they are causing difficulties breastfeeding. The premature eruption of the permanent teeth is rare. The main local cause is the early loss of primary teeth through dental caries. Systemic factors such as hyperproduction of thyroid, pituitary and sex hormones have been reported as having affects on tooth maturation and eruption. Other factors which increase the metabolism has also been suggested as stimulating eruption, for example, fever and high blood pressure. Delayed eruption affecting all teeth in both the primary and permanent dentition can be associated with such systemic factors as hypopituitism, hypothyroidism, Down's syndrome, cleidocranial dysplasia, ectodermal dysplasia, achondroplasia, and amelogenesis imperfecta. As well, premature infants may show delayed eruption of their primary teeth. Local factors involved in delayed eruption usually affect only one or a few teeth, for example, inherent crowding, as a result of the early loss of teeth through caries, trauma, or other disorders. Teething One of the great myths of teething is just that, teething as a disease entity. There seems little doubt that newly erupting primary teeth can cause local discomfort, but there is no consistent correlation with any systemic illness. Local discomfort includes, such things as increased drooling, reddened cheeks. It is felt any systemic signs, such as fever and malaise are too generalised to be consistently blamed on teething. Also when getting teeth, particularly the first primary molars (ie age around one year) children are increasing their socialisation and getting exposed to a greater number of potential pathogens anyway, and so increase their likelihood of a concurrent illness. Symptoms associated with teething As far as the primary teeth are concerned it is reported that at least 60% of all infants experience local symptoms of varying severity. The gingival tissues may be red and swollen. The child will show signs of local irritation with a tendency to rub the gum with a finger or another object. There can be excessive drooling, redness in the cheek and a general malaise. Interestingly, the arrival of permanent teeth can be accompanied by similar local manifestations but the symptoms appear far less pronounced. The usual problem in the permanent dentition is a lobe of gingival tissue known as an operculum overlying the erupting tooth. Mechanical trauma from an opposing tooth can lead to considerable swelling and pain from the operculum. This classically occurs around erupting lower third molars. The question remains whether primary tooth eruption has any influence on the general condition of the child. Hippocrates maintained that tooth eruption may cause severe illness. This opinion remained deep-rooted in ancient medicine and is also reflected in death statistics. During the 18th Century in France, almost half of all deaths in infancy were ascribed to teething troubles. The general symptoms most often mentioned in the literature are irritability, fever, infections in the respiratory tract, anorexia, constipation, diarrhoea, hypersalivation and skin rashes. It appears that there is no absolute association between tooth eruption and disturbances in the general condition of the child. But local inflammation at the site of eruption may make the child irritable, occasionally even cause a rise in body temperature or mild change in peristalsis. Treatment for such problems is symptomatic, with the use of teething rings, analgesia and antipyretics. Treatment: symptomatic relief. Even though a dental assessment is not often a part of a child's regular medical check up, an understanding of the normal dental development and its variations is a valuable diagnostic tool. Dental health is part of total health.

5. TRAUMA It is estimated that at least half of all children will have had a dental injury before they reach adolescence. The most common dental injury to the primary dentition (0-6 years) is the accidental intrusion of a maxillary incisor: the tooth is pushed 'up' into the alveolar bone and it can be totally 'out of sight'; for the permanent teeth (6 years and beyond) a fracture of the enamel crown is most common. Most dental injuries in the primary dentition occur in the 1 to 4 age group, when the child is becoming increasingly mobile. Boys and girls seem to be equally affected and the injuries range from minor chips of enamel to fracture and displacement of teeth-alveolar bone with associated soft tissue damage. Many of these injuries occur in the late afternoon when children and parents are tiring and the children excitable. The peak incidence of damage to the permanent dentition is in the 8 to 11 year age group, with a male predominance. Historically, this has been thought to be due to the aggressive nature of the sport and play of boys, but this stereotype could well be changing. Causes It is not surprising that children between the ages of 1 and 4 suffer most of their oro-facial injuries in falls. Learning to walk and be co-ordinated takes a lot of practice. Other sources of injuries include motor vehicle accidents, falls from play equipment and child abuse. North American studies report at least 50% of abused children have head or neck injuries, or both, with around 10% of these cases having a dental manifestation. For school-age children (6 to 12), falls and collisions during competitive and non-competitive leisure activities are the major causes of injuries. There is abundant evidence on the extent of injuries which occur in tough physical contact sports. Participants can receive blows to the face from any direction (often from below the chin) as well as damaging themselves on goal posts and fences. It is a growing concern that a number of injuries now occur in non-competitive sports. Activities such as skate boarding, water sliding and BMX cycling are all sources of oro-facial trauma. Finally, children with protruding maxillary incisor teeth (a Class II malocclusion) are much more susceptible to dental injuries than children with the more usual less prominent (that is, Class I) alignment of their incisors. Classification of Injuries Soft tissue damage: skin, mucosa, gingivae, muscle The soft tissue damage usually involves the gingival tissues and oral mucosa. The gingival damage needs to be managed conservatively because the long term viability and aesthetics of the teeth are strongly influenced by the way these damaged tissues are handled. When examining oral mucosal wounds, it is important to check for degloving type injuries and full thickness tears, particularly in the chin region of the lower lip. Hard Tissues Teeth, Bone Traumatic displacement (luxation) of teeth within their bony sockets can occur in any direction, depending on the nature of the injury and the age of the child. Complete avulsion of the tooth is the most extreme form of luxation. The luxation injuries by definition involve tearing of the periodontal ligament. This can present as bleeding from the gingival margins (sub-luxation) and bleeding from both mucosal and gingival tissues (luxation). Damage to the crown, with or without associated root fractures, occurs less frequently than luxation injuries in both primary and secondary dentition. If the crown fracture is severe, the dental pulp will be exposed. This appears as a red or bleeding zone in the fractured area. The alveolar bone houses the teeth. Alveolar bone fracture is a further complication of dental trauma, especially in the anterior segment of either jaw. It can occur in both dentition, but is more common in

the secondary dentition. Dentoalveolar fractures are suspected when the degree of tooth displacement is severe and when the degree of mobility of segments of the dental arch is excessive. Fractures of the facial bones, especially the mandible, must be considered when reviewing a child with oro-facial trauma; for example, chin point trauma is a common injury associated with mandibular condylar fracture. The mandible is more likely to be fractured than the maxilla, with most fractures involving the condyles in the under 10 year olds and the body of the mandible in the over 15 year olds. Facial bone fractures can present with such symptoms as a painful or altered occlusion of the teeth, mandibular deviation on opening and pain over the temporomandibular joint. An OPG radiograph as well as an antero-posterior and Towne's view may need to be taken. Management The management of dental trauma follows the broad tenets of all trauma management; that is, check the patency of the airway, and check breathing and circulation, and control bleeding. Primary Dentition The simplest injury is a sub-luxation of the primary tooth. This presents with bleeding from the gingival tissues. If the tooth is still able to adequately closed together against the opposing teeth and not loose enough to be dislodged and aspirated, it may be left alone. If the tooth is displaced (that is, lateral luxation) and is interfering with the occlusion and cannot be returned to its proper position with stability, it should be extracted. However, if the tooth is intrusively luxated the tooth is pushed up into the bone and is partially or totally out of sight) and the occlusion is not a consideration it can be left in situ to re-erupt. Such intrusive type injuries of the maxillary anterior teeth are the most common sustained by the primary dentition. The injury occurs when an unstable toddler falls, striking the maxillary anterior teeth, and forcing them into the alveolus. Most of these types of injuries will resolve on their own in 2 to 6 weeks with several intruded teeth re-erupting back into occlusion by around 6 months. Initially, antibiotics (Penicillin) and analgesics should be prescribed. Long term follow-up is required. Another common injury involves a fracture of the crown of a primary tooth. This can be minimal, that is, in enamel only, or more severe involving the dentine and dental pulp. If the dental pulp is not exposed, the tooth may simply be smoothed over, otherwise the pulp or the tooth, or both, may need removal. If avulsion has occurred, the primary tooth is not routinely reimplanted. This is because of the potential for damage to the developing permanent tooth and the difficulties in firmly splinting teeth in an often unco-operative toddler. Such loss of the maxillary anterior primary tooth is not damaging to occlusal development and it is unlikely that space loss will occur. If the avulsion occurs before the child is 4, it is likely that eruption of the permanent tooth will be delayed. Many parents are aware of the potential for re-implantation of teeth and may resist the recommendation that the primary tooth be left out. It is, however, the preferred treatment in most situations. Any tooth, primary or permanent, which has been avulsed must be located. Usually the child or parent will find the tooth and bring it with them. If it is not possible to locate the tooth or fragments, radiographs should be obtained to determine if it was ingested, inhaled or displaced into the lip or other oral soft tissues.

TRAUMA TO THE PERMANENT DENTITION Trauma to the permanent teeth most commonly occurs in the 8 to 10 year old child. Crown fracture is the most common type of injury followed by subluxation and avulsion. The simplest crown injury to permanent incisors is an enamel chip. This can be left or smoothed over if sharp. If, however, the crown damage is greater and the second layer of the tooth (the yellow dentine) is exposed, or if the dental pulp itself is exposed, such a tooth needs restoration. This prevents contamination of the dental pulp (with resultant pulpal death) and, secondly, allows for the restoration of aesthetics. Additionally, it is always prudent to examine the lip and oral mucosa for any dislodged tooth fragments. Often if the fractured piece of tooth is available the dentist may "glue" it in place. Long term treatments are complicated (endodontics, gingival surgery, prosthodontics) but often the tooth can be saved. Sometimes permanent teeth may suffer a broken root only. The outcome of specific treatments depends on the location of the fracture and on taking an initial conservative approach to management. Splinting is essential. Such root fractured teeth will often appear clinically extruded and be abnormally mobile. The loss of a permanent tooth is a serious complication. It usually occurs to a young person and affects the dentition for the remainder of the child's life thus proper management is important. When a permanent tooth has been avulsed, the time it remains out of the socket is the critical factor in determining the success of a reimplant. If reimplantation is delayed, resorption of the root surfaces will invariably occur, resulting in later loss of the tooth. Only 10% of teeth reimplanted within 30 minutes develop root resorption, but 95% of those reimplanted after 2 hours show root resorption. As there is no effective treatment for resorption, it is essential that the avulsed permanent tooth be reimplanted as soon as possible. This may be done by parents, doctors, teachers, school nurses or others. The important thing is that it be done as soon as possible. To manage a child who has avulsed a tooth, the following steps should be taken: (1) Find the tooth. Be sure it comes to the emergency room or clinic with the patient. (2) Determine if it is a primary or permanent tooth. In general, if it is a front tooth and the child is 6 years old or less it is primary. If the child is 7 years old or more, it is permanent. (3) Gently rinse the tooth in saline or milk if contaminated, but do not scrub or touch the root. (4) Insert the tooth into the socket in its normal position using a neighbouring tooth to check it has

not been placed in the wrong way round (it happens!). Do not be concerned if it seems slightly longer than the other teeth. Local anaesthesia is rarely needed for initial reimplantation.

(5) Prescribe antibiotics. (6) Send the child to the dentist immediately for fixation of the teeth and repair of soft tissues. If reimplantation is not possible the tooth must not be allowed to dry. It is best stored (wrapped in cling wrap) in saline or milk, or, as a last resort, the patient's saliva. Any child who had an avulsed tooth reimplanted should be given a tetanus booster if needed. Prognosis It needs to be stressed that not only is the immediate management of dentofacial injuries important, but also the long term management. For example, luxated teeth may lose vitality and develop abscesses over a period of several years. As well, avulsed teeth have a tendency to be resorbed, especially if the extraoral period was greater than half an hour. Regular review is necessary to prevent this.

Summary Dentoalveolar trauma is unfortunately a daily event. The prompt management of such injuries is vital in re-establishing a healthy dentition. As well, the promotion of preventive action is paramount: from seat belts and bike helmets to mouth guards. The purchase of over the counter one-size-fits-all mouthguards is not only a waste of money but dangerous. Well made mouthguards fitted by a dentist are a sensible investment to reduce the frequency and severity of costly dental injury and to preserve the attractive aesthetics of natural teeth. They must be worn in competition and at practice.

6. HAEMORRHAGE/SWELLING Spontaneous oral haemorrhage is rare and is usually associated with haemangioma or AV malformations. If the oral bleeding has been chronic one may suspect a small haemangatenous malformation around an erupting tooth. Oral bleeding following dental procedures is usually associated with tooth extractions although routine operative procedures such as restorations, biopsy, may also lead to an acute episode. First line of defence in coping with an acute oral bleed some hours after a tooth extraction would be to apply 15 minutes of firm pressure via a gauze pack or, if unavailable, a tampon could be used. If this fails to adequately control the haemorrhage, local anaesthesia with adrenalin could be injected and, as well, resuturing of the extraction site and packing of the extraction site with a resorbable gel will be adequate in most cases. As well smaller pieces of the adhesive skin wound dressing material can be used intra-orally and moulded over the site to both protect the extraction site and apply pressure. Children with obvious significant facial swelling of dental origin will usually require referral and admittance to Hospital. Intravenous antibiotics and management of the teeth under LA or GA will be needed. In most cases the facial swelling will be due to a carious tooth. Other dental causes include previous trauma to teeth and developmental malformation of teeth. Non-dental causes of facial swelling can include bacterial (e.g., Actinomycetes) or viral (e.g., Herpes) infections. A history of never having had dental work done or never having had a dental visit, does not exclude a dental cause for the infection. 7. DENTAL CARIES AND PERIODONTAL DISEASE Traditionally, dental caries has been regarded as a static phenomenon, eventuating in loss of tooth structure while the basis for treatment and management of this ubiquitous disease has essentially been mechanical. It is now realised that the development of dental caries is a common yet complex series of dynamic events under the influence of numerous inter-related biological, social, behavioural and psychological factors. Thus the chronic, infectious and multi-factorial nature of dental caries is now well recognised, although the intricate interplay between individual causative factors is still poorly defined. For children throughout the industrialised western world, although caries incidence and its severity has clearly decreased, dramatic evidence is accumulating to show that almost 60 - 70 per cent of the caries burden falls on approximately 20-25 per cent of schoolchildren. That is certain ‘high risk’ caries-susceptible individuals persist within our communities for whom preventive measures and restorative care alone are not enough to control the disease. The identification of these high risk individuals remains the single most important factor in further significant reduction in caries incidence. Important clinical indicators include previous caries experience and visible plaque accumulation. Dental caries is still the most costly diet-related disease in Australia ahead of coronary heart disease, hypertension and diabetes. Caries associated with prolonged bottle feeding babies is very common.

There will usually be a rampant decay present in the primary dentition which can be attributed to having a bottle of sweetened liquid taken to bed at night and/or used extensively during the day. Most Vitamin C supplement drinks, juices and sweetened drinks, can lead to rampant decay. As well, dummies dipped in honey are similarly involved with extensive dental caries. The pooling of sweetened liquids in the mouth of a sleeping child makes a perfect medium for bacterial multiplication and acid production. Treatment 1. Remove sweet liquid from bottle, honey from the dummy. 2. Briefly use an artificial sweetener as a possible means of weaning away from sucrose drinks. 3. Restore the teeth, or extract, under local or general anaesthesia.. This problem is of real concern to all health professionals, and it stems from a lack of knowledge and correct dental/medical advice. Clinical Description - Dental Caries (Early Childhood Caries) 1. Typical features i. Brown yellowish cavitation of teeth, anteriors and posteriors can appear dark black at a

later stage when decay is arresting. ii. In the primary dentition, a specific form of severe dental caries is known by many

names but primarily as prolonged feeding caries. Studies have reported a range of approximately 3-18 per cent in Australia.

Clinically the maxillary anterior teeth are affected initially, whilst the lower incisors are not involved. Later lesions appear on both maxillary and mandibular posterior teeth.

iii. Often associated with a prolonged bottle habit. The bottle often contains liquids with

fermentable carbohydrate, including milk. Prolonged, ‘at will’ breast feeding also has been implicated in this pattern of tooth decay.

2. History: The role of carbohydrates, particularly sugar is still recognised as the major contributing factor in caries initiation and progression across the whole population. A history of prolonged nursing with a nocturnal bottle and/or excessive frequency of sugar intake will be indicative of a decay prone child. 3. Physical examination Check: Palatal surface extensively decayed in prolonged feeding caries Interproximinal surface Facial surface Occlusal surface cavities in grooves Lower anteriors usually not involved (if ever carious, suspect salivary gland absence) 4. Investigation Dietary history especially in relation to prolonged feeding caries. Can be related to general neglect.

5. Management Dental Health must be seen as an integral part of total health. Thus:

Χ Early dietary advice must include advice on avoiding establishment of feeding habits/patterns (which can be detrimental for dental health) such as nocturnal bottles with cordial, milk with or without flavour, carbonated drinks, vitamin C liquid supplements etc.

Χ Prolonged nocturnal at will breast feeding. (Children who have significantly prolonged their breast feeding and feed at will nocturnally, cana be at an increased risk of dental caries.

Χ Teeth should be cleaned as soon as practicable after they appear in the mouth. Initially a face cloth is adequate to wipe the teeth, later on, at around a year of age parents should introduce a fluoride toothpaste with a soft brush.

As well if obvious caries is present topical fluorides other than toothpaste may be prescribed following dental consultation. The Australian Academy of Paediatric Dentistry recommends that ideally the first dental consultation be at one year of age, but certainly by age three. As a guide to targeting the most likely children to have early decay, a parent’s (expectant mother’s) educational level is critical. Other factors include language, cultural issues and access to dental care. The prime sites of tooth decay are in the grooves and fissures on the biting (occlusal) surfaces of molar teeth, in between teeth (interproximal) especially the molars, and on the facial surfaces of the maxillary incisors. The placement of “sealants” to occlude the fissures on permanent molars (and sometimes on primary molars) is strongly recommended.

• Often facial swelling, involving the upper lip, cheek, or canine fossa goes unrecognised as being

of dental origin. A history of previous dental contact is relevant in deciding a dental cause for such swelling, ie. previous fillings etc. but is NOT exclusive for determining a dental cause.

• Often an initial investigation of dental pain and facial swelling will sometimes include a nuclear medicine scan. The results can suggest a diagnosis of osteomyelitis. If there is a dental abscess resulting from decayed or traumatised teeth this needs treating with drainage and removal of the tooth/teeth or root canal therapy. The antibiotic of choice is penicillin. The suspected osteomyelitis will resolve with this treatment, if the dental origin of the swelling is accurate. For significant facial swellings metromidazole may also be considered.

• Periorbital cellulitis. A maxillary dental infection spreading into the canine fossa can be mis-

interpreted as a periorbital cellulitis. The importance in making this distinction centres on the selection of antibiotics to be used and the dental intervention. Again penicillin will be the drug of choice, often with the addition of metromidazole. As well, initiation of root canal therapy (often the upper l lateral incisor) is required. A useful guide to checking on a dental cause will be to gently percuss the upper anterior teeth. A non vital tooth will be quite painful when percussed.

For significant dental/facial swellings consideration should be given to referring the child for admittance to hospital. Periodontal Diseases The dental soft tissues should not be overlooked in this review, as they are an important part of the developing occlusion. They comprise the attached and free gingivae, the periodontal ligament, which attaches the tooth to the alveolar bone and the oral mucosa. The typical firm, pink stippled healthy gingival tissues develop slowly from the age of 2 to 3 years. Around the neck of the tooth is a shallow sulcus (the gingival crevice), signifying the attachment of the gingival tissues to the tooth. The clinically “normal” gingival crevice harbours inflammatory cells and produces exudate. If not adequately cleaned the marginal gingival tissues become inflamed and bleed easily when brushed. An efficient oral hygiene regime aimed at consistently eliminating the bacterial dental plaque will

resolve the clinical symptoms. Whilst gingival inflammation is relatively common amongst children it becomes almost universal amongst adolescents. The importance of stressing inculation of oral hygiene behaviours, to improve gingival health in children and adolescents is an attempt to limit the natural progression of gingival disease to periodontal disease, and eventual tooth loss in later years. The health of the gingival tissues can be a valuable barometer to the general health of the child. If a healthy child of school age shows generalised periodontal disease and loss of bone from around the teeth, it suggests problems in the child’s host defence mechanism. Problems such as genetic disorders, papillon Le Fevre syndrome, hypophosphatasia or immune deficiencies such as a leukocyte adhesion defect, or cyclic neutropenia. 8. TONGUE TIE There is no doubt that careful joint assessment of infants/children presenting with possible tongue tie, is required. Alongside speech/feeding assessments dental implications need to be considered. For infants and young children usually the speech and feeding issues dominate but, by around age three dental considerations are also significant. Eg. A significant tongue tie can restrict a child’s ability to adequately clean their mouth, ie remove food debris from the buccal sulcus or roof of the mouth, or wet their lips. As well there can be damage to the long term gingival health of the lower incisors if the frenal attachment is near the gingival margin and not just in mucosa. Speech may or may not be affected. A tongue-tie release may be suggested for both, or either, dental or speech reasons. Other fraena. A diastema between the upper central incisors, ineither or both dentitions, can be due to a large labial frenum. Resection of such tissue is advised only after careful assessment and may be delayed till the teen years, after all permanent teeth have erupted, and natural closure may have occurred. These fraena can be traumatised quite easily and tend to bleed profusely, but stop with local pressure. Note: Other causes of a central diastema include supernumerary teeth, developmental cysts, familial tendencies and absent teeth (oligodontia). 9. UPDATE ON RESTORATIVE MATERIALS The past twenty years have seen major changes in the types of restorative materials available, for example, the use of tooth coloured , composite resins , for repair of the dentition now enables: (a) Minimal cutting and shaping of teeth required for satisfactory repair. (b) Very good aesthetic results. (c) The ability to seal teeth against decay. (d) Silver amalgam still has its uses, however, with the advent of new procedures, its use has

decreased. But it is often the material of choice for restorations of posterior teeth. 10. IMPORTANCE OF THE DENTITION The formation of a healthy permanent dentition via a healthy primary dentition is very important in the development of satisfactory mastication, speech and, as well, in the formation of adequate facial form, for example, facial height and profile.

11. ORAL HABITS Pacifiers: All infants use their mouth to explore their world. Some more than others continue this and enjoy non nutrative sucking, on a pacifier or digit. Digit sucking is a normal finding in infants and children. It often causes an anterior open bite and posterior cross-bite. Side effects: Dental: Open bite anteriorly. Teeth are unable to occlude except posteriorly. Management: To discourage by around age five ie a year before the permanent

teeth begin to erupt. Usually the permanent incisors will then align without any problems with overbite and overjet.

Digits Infants who end up sucking fingers or thumbs will do more than just move teeth (orthodontic effect) they will also procline the anterior maxilla (orthopaedic effect). This combined orthopaedic/orthodontic effect can be quite difficult to correct especially when the habit persists through childhood into the teens. Introduction of an anatomically shaped pacifier is a preferred alternative to digit sucking since termination of the pacifier habit is easier than eliminating a digit habit. Children are encouraged to give up the pacifier habit around age three years. Digit habits usually decrease in intensity when children begin school and peer pressure modifies their sucking behaviour. Rewards, positive reinforcement, and reminder devices are techniques that discourage digit sucking. Intervention should take place only when the permanent dentition begins to erupt. Success is likely if the child is interested in stopping the habit. 11. ORAL PATHOLOGY Natal and neonatal teeth. Teeth in the mouth at birth are natal teeth. Teeth that erupt within the first 30 days after birth are neonatal teeth. 85% are normal members of the primary dentition and should be retained. If aspiration is a concern, then removal of the tooth should be considered. Dental laminar cysts - broad based, one centimetre, fluid filled, bluish tinted cysts that present on the alveolar crest in newborns. Palpation gives the impression of a fluid filled vesicle. Dental laminar cysts develop from the epithelial remnants of the embryologic precursor of teeth. Treatment is usually not necessary as the cysts spontaneously rupture within the first few weeks after birth. Congenital epulis of the newborn - the lesion is most often located in the anterior maxillary region, is present at birth, and is seen in female newborns three times more frequently than males. It is usually pedunculated, firm and variable in size, ranging from a few millimetres to several centimetres. Excision is indicated. Tetracycline staining - intrinsic staining of teeth as a result of antibiotic therapy with tetracycline. The stain may vary from yellow to brown to dark gray. Tetracycline should be avoided when possible during pregnancy and postnatally until the child reaches eight years of age. Mucocele - occurs most frequently on the lower lip but may also be found on the palate, cheek, tongue, and floor of the mouth. It is a well-circumscribed, soft swelling of variable size. When superficial, it is translucent and bluish. If located deeper, the colour will be similar to the surrounding mucosa. Treatment is surgical excision.

Oral Ulceration Oral ulceration is not common in infants and children. It can be A. Acute or chronic and of…. B Infectious origin - HSV, HIV, hand, foot and mouth. Non-infectious origin - aphthous, neoplastic, inflammatory. The most common acute infective oral ulceration is associated with a primary oral herpes simplex infection. The usual presentation involves an infant or child presenting with general malaise, fever and oral symptoms (ulcers on the lip, palate and red swollen bleeding gingival tissues). Predisposing factors include erupting teeth and immunosuppression. Aphthous ulceration Aphthous ulcers usually occur in children, not infants. They are sited around the mouth in such places as depth of the buccal sulsus, at the reflection of the mucosa or on the palate. They can be described as minor or major depending on presentation. Most common are the minor aphthae. Treatment is symptomatic with, topical anaesthetics and coverage of ulcerated areas with adhesive skin bandages (stomadhesive wafers). Precipitating factors can include local trauma, general malaise etc. Some authorities suggest assessment of vitamin B and blood iron levels to be helpful, diagnostically. Facial Swelling Odontogenic infections are frequently misdiagnosed or overlooked when infants and children present to non-dental practitioners. As noted earlier most odontogenic infections are associated with non vital teeth (caries or trauma) but can also involve the gingival/periodontal tissues (eg around erupting teeth). Facial infection of odontogenic origin can present in the sub orbital region, mimicking a periorbital cellitis or in the buccal region and submental region mimicking maxillary salivary gland or lymph node involvement. Lumps and Bumps - Intra Oral/Extra Oral An infant or child presenting with a chronic or acute swelling needs careful evaluation. Intra Oral Acute/Chronic: Dental caries Decayed tooth Gingival swelling Tooth impaction Erupting tooth/Operculum/Trauma Eruption cyst Lateral dental cyst Giant cell lesion Immune Disorder Langerhans cell histiocytosis Papillon Le Fevre Syndrome Cyclic Neutropenia Leucocyte Adhesion Defect Occasionally an eruption cyst will be apparent as a bluish swelling overlying an erupting molar. In some instances it may help to relieve symptoms of discomfort by deflating the cyst with a sterile needle.

Extra Oral Facial Atypical mycobacterium Buccal Rare tumour/Burkitts lymphoma Parotid salivary glands Lingual/Palatal Sub-mandibular salivary gland stone Descending ranula in the neck. Note: A history of recent dental work is not essential for a diagnosis of ‘dental abscess’ to be made.

As well tooth coloured fillings can mask previous dental work and mask identification of restored teeth. Restored teeth can often be the cause of a dental abscess.

Halitosis Bad breath for children is uncommon. It can be associated with respiratory tract infection, gastrointestinal problems, or uncommonly an in-born errors of metabolism. However, the most likely cause is poor oral hygiene leading to plaque build up both buccal/lingually, interproximally and on the tongue. It is these latter two areas where anaerobes can predominate and generate unpleasant mouth odours. Persistent mouth odour in the face of good oral hygiene will require further consultation to eliminate ENT (eg. chronic infection in the tonsillar crypt) , gastro-intestinal problem (eg. asymptomatic GOR) or diet-related causes. Grinding Hard and soft tissues Tooth grinding is quite a common cause for concern with parents and care givers and usually they are very concerned with the noise associated with the habit. Such habits as grinding, gnashing or sliding can be either physiological or pathological. Physiological tooth grinding usually involves the primary teeth, both in the primary dentition (0-6 years) and the mixed dentition 6-12 years. It is thought that such grinding in some way is associated with promoting the normal exfoliation of the primary teeth. The extent of wear can be extensive, even exposing the dental pulp, necessitating extraction of the tooth. In most cases if the tooth grinding persists through to the mixed dentition, damage to the permanent dentition (usually the first permanent molars is not significant. Physiological tooth grinding can occur in children who have no special needs, in children with special needs, e.g. Down Syndrome or neurological disorders. Pathological tooth grinding is when the level of tooth wear continues into the permanent dentition. It can be very extensive. This usually occurs with children who have special needs as mentioned previously. In certain cases the tongue or cheek/lips can be extensively damaged as well. Treatment is always difficult, with each child presenting unique problems. Treatment alternatives include: - parental reassurance - relaxation techniques - mouth guards - fixed metal/acrylic tooth caps, to open the bite - tooth modification and/or extraction The level of often irritating noise associated with grinding is not necessarily indicative of the degree of damage. It is important to note that teeth which suffer extensive grinding wear are not necessarily painful especially with hot/cold foods. This is an important difference with teeth that are worn down due to acidic erosion (either extrinsic or intrinsic acids) which can be quite sensitive to temperature changes.

12. WATER FILTERS The use of water filters is now becoming quite common in many communities. There is a wide range in cost and performance of water filters and whether or not fluoride is removed and needs to be replaced is the cause of much discussion. As a general rule it is our philosophy to assume that the fluoride has been removed by the purifier in part, if not entirely, however we do not advise the use of fluoride supplements to replace the lost fluoride. It is our feeling that the widespread use of fluoride toothpastes as well as the use of soft drinks and reconstituted fruit juices (that have been reconstituted with fluoridated water) will provide adequate amounts of fluoride. 13. FLUORIDE Fluoride is an essential mineral element that also aids in prevention of tooth decay. In preventing tooth decay it acts in two main ways. Firstly, it can have a systemic effect when incorporated with water (or salt, or milk) and ingested. Secondly, it can be applied topically. Ingested fluoride has a beneficial systemic effect on the whole of the developing tooth whereas fluoride applied to the surface of erupted teeth has only a surface (or topical) effect on formed enamel, e.g., toothpaste, professional gels. Fluoridation of water supplies involves addition (or in some cases removal) of fluoride from water supplies, so that the level of fluoride ion available is at the recommended level. After absorption the major part of the fluoride is deposited in bones and teeth. When incorporated into bones and teeth, the hydroxyapatite crystal of the enamel is changed to fluorapatite crystal. The most effective, safe and economical method of obtaining systemic fluoride during the period of tooth formation is through the water supply. In extreme cases, excess fluoride may lead to fluorosis. Fluorosis in its mild state may consist of white flecks or spots on the enamel, and in its severe situation may cause mottling of enamel, ie., the enamel may be pitted, discoloured and/or stained. In areas not accessible to fluoridated water, fluoride is available through supplements such as tablets or drops.

Fluoride protects against dental decay in several ways:

(a) Increasing surface remineralisation of teeth.

(b) Affecting biochemical pathways thus preventing bacterial substrate utilisation.

(c) Decreasing plaque adherence to teeth.

(d) Increasing enamel hardness.

(e) Enhances post-eruptive maturation of enamel.

A concentrated topical application of fluoride ion by a dentist to newly erupted permanent molars (i.e. ages 6-8 yrs and 12-14 yrs) aids in decreasing caries susceptibility of teeth. Fluoride releasing adhesive gels have an anti-microbial effect on bacteria present. It is sufficient to know that these different forms of fluoride exist and that professional fluoride applications in cases of advanced caries or newly erupting teeth, as well as home use in the form of toothpaste, is helpful in arresting, or preventing, tooth decay.

FLUORIDE SUPPLEMENTS

Dose levels are set to achieve maximum caries protection for permanent teeth. 1. The following recommendations are generally adequate but it must be remembered that

prescription of fluoride tablets/drops is always on an individual basis and variation to these recommendations may be made.

Χ Fluoride supplements (tablets and drops) have limited application as a public health measure.

Χ Fluoride supplements are beneficial in reducing dental caries only among children in non-fluoridated communities, but this benefit is small.

Χ Clinical data demonstrating the caries preventive effects of prenatal fluoride supplements are limited.

Χ Overzealous use of supplements has been associated with dental fluorosis.

Research has identified that the period between twenty months and thirty six months is the time when maxillary incisor teeth are most susceptible to fluorosis. A new Schedule (Table 2-3) has been proposed for supplementation of high caries risk patients, living in areas where the water supply contains less than 0.5mg/L of fluoride. This schedule does not have an upper age limit, consistent with the view that individuals may continue to be of high caries susceptibility beyond 8 years of age.

2. Table 2-3: Daily fluoride supplement dosage schedule* for persons considered at particularly

high risk of caries

Age interval

Domestic Water Fluoride Concentration

<0.3mg/L <0.3 - 0.5mg/L

6 months < 4 years 4 years < 8 years 8 years +

0.25 0.50 1.00

0

0.25 0.50

* Proposed schedule from Discretionary Fluoride Committee NH&MRC (1992). All supplements should be formulated as lozenges. Persons whose daily dose is 1.00mg should consume two tablets of 0.25mg twice daily, that is, two in the morning and two at night.

The use of fluoride supplements has decreased significantly and is now confined to those areas where, after a thorough fluoride inventory, it is judged that the fluoride intake is below the optimum for maximum dental benefits, e.g., rural or isolated areas.

3. Toothpaste (1) Young children and infants will ingest much of the toothpaste used cleaning their teeth . (2) Thus it is recommended that all infants and children :

(a) Use only a small ( pea sized ) amount of an adult toothpaste ; ( for children under 2 years of age, use only a smear )

(b) Be supervised at all times up to an age six when brushing .

(c) And encouraged to spit out the initial froth and bubble of brushing, but for the final rinse,………

(d) Take a small drink of water ,swish around the mouth and swallow. As noted above the

main action of fluoride is believed to be topical and this “ swish and swallow “ after brushing will allow the swallowed fluoride to be “ re-cycled” back through the saliva to further protect the teeth.

14. MOUTH WASHES 1. Topical Fluorides:

The home usage of fluoride mouth rinses (gels/rinses) to aid in caries reduction is very useful but prescription of such medication is based on an individual assessment of each child caries risk and is not routinely prescribed.

The use of fluoride toothpastes (child/adult) in most situations is the most common and effective form of topical fluoride therapy.

All fluoride preparations must be safely stored so that accidental child access is prevented.

2. Antibacterial:

Daily mouthwashes to aid in plaque reduction are often required. Products can contain agents such as antibacterials, enzymes etc. When prescribed for specific periods and purposes these products are very effective in promoting gingival health, aiding healing post surgery and reducing the discomfort of oral ulceration. Other agents promoted as pre brushing rinses or anti bacterial can be effective but routine use should be based upon individual assessment. There is no substitute for a through and regular brushing technique with fluoride.. Alcohol free mouth washes are strongly recommended.

Plaque disclosing agents which are relatively commonly available are strongly recommended for regular use. The visible staining of developing plaque either bright reddish blue is really useful at encouraging improved oral hygiene.

3. Other topical agents

Other products available for the treatment of oral ulceration include topical anaesthetics with or without antibacterial and steroid activity and bland gels.

DENTAL SERVICES: Emergency Dentist On-call IN HOURS:

The CHW Dental Department : Hours 0800 -1700 Monday-Friday Phone: 9845 2582 Paediatric Dental Registrar - Page via Switchboard. CHW Phone: 9845 0000 The Sydney Dental Hospital is open for “in hours” emergencies, weekdays from 0830 - 1500 hrs (02) 9293 3200. There is no “after hours” emergency service. AFTER HOURS: Children with oro-facial problems will initially be seen by Triage and then the paediatric dental Registrars will be called as deemed appropriate . However if needed the Paediatric Dental Registrar can be contacted through the switchboard at Children’s Hospital at Westmead, telephone (02) 9845 0000 . Other After Hours Dental Services: The Australian Dental Association provides information on after hours services by private dentists on (02) 9369 7050. Other Regional Hospitals may have after hours dental services. Parents may ring the Accident and Emergency Departments of Regional Hospitals for further information. CONSULTATION/REFERRAL - A/Prof Richard Widmer Head, Dental Department The Children’s Hospital at Westmead Cnr Hawkesbury Road & Hainsworth Street WESTMEAD NSW 2145 Email: Richard.Widmer@health.nsw.gov.au