第一章 概论 - 上海交通大学医学院精品课程
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Transcript 第一章 概论 - 上海交通大学医学院精品课程
Pediatric Dentistry
Chapter 1
Introduction
1 Definition
What
is Pediatric Dentistry
Definition
An age-defined specialty that provides
both primary and comprehensive
preventive and therapeutic oral
health care for infants and children
through adolescence, including those
with special health care needs
Who ?
infants
and children through
adolescence
including those with special
health care needs
What?
provides both primary and
comprehensive preventive oral
health care
provides both primary and
comprehensive therapeutic oral
health care
2 key elements
“age-defined”
“primary and
comprehensive...care”
"infants and children through
adolescence"
"special health care needs"
age-defined
Most
specialties: procedure
defined
PD: no limitation to
treatment they provide
Pediatric
dentists are
primary providers.
There is no need for a
referral of patients
Pediatric
dentists see
patients at any age
from birth up to their
late teens
Pediatric
dentists have
the training and
experience to evaluate
and treat patients being
medically compromised.
key elements
“age-defined”
“primary
and
comprehensive...care”
"infants and children
through adolescence"
"special health care needs"
3 Structure of
the dental consultation
Greeting
Preliminary
chat
Examination
Preliminary explanation
Business
Health education
Dismissal
3.1 Greeting
3.1.1 in a friendly way
3.1.2 by name
Don’t proceed too quickly
3.2 Preliminary chat
Begin with non-dental topics
Ask an open qustion
Listen to the answer
3.3 Examination
Should
be pain-free
Should be adequate
Should not be totally
tooth-centered
3.4 Preliminary explanation
The aim: to explain what
the clinical or preventive
objectives are
In
terms parents and
children will understand.
This is a vital part of any
visit
3.5 Business
3.5.1 Remain in verbal
contact
3.5.2 Check the patient
not in pain
a) Discuss what you are doing
b) Use the patient’s name to
show a personal interest
c) Clarify misunderstandings
3.5.3
Summarize what has
been done at the end
3.5.4 Offer aftercare advice
3.6 Health education
Give advice on maintaining
a healthy mouth
The final part is goal setting
Goal setting must be used
sensibly.
3.7 Dismissal
The final part of a visit
Should be clearly signposted
Should be ensured the
patient and parents leave
with a sense of goodwill.
Structure of
the dental consultation
Greeting
Preliminary chat
Examination
Preliminary explanation
Business
Health education
Dismissal
4 Anxious and
uncooperative children
4.1
Dental anxiety is a
common problem all over
the world, especially in
pediatric dentistry
It not only prevents
patients from seeking
care but also cause
stress to the dentists
Dental
anxiety is a
problem that we as a
profession must take
seriously
4.2 How does the
dental anxiety develop?
4.2.1
Be afraid of pain or
imaginary pain
4.2.2
Uncertainty
about what is to
happen is certainly
a factor
4.2.3
A poor past
experience with a
dentist could upset
a patient
4.2.4
Learn anxiety
response from parents,
relations, friends, or
books,TV show
4.3 The extent of
dental anxiety
it is no easy task to
measure dental anxiety
and pinpoint aetiological
agents
5 Helping anxious
patients to copy with
dental care
Establish
an effective
preventive programme
Establish good dentistpatient relationship
Ensure
any treatment is
pain-free
Manage time effectively
Behavior Management
Behavior Management
Traditional
Techniques
Tell-show-do
Distraction
Modeling
Positive
Reinforcement
Voice control
Adversive
Techniques
Physical restraint
Hand over mouth
Pharmacologic
Techniques
Sedation
General
Anesthesia
Behavior Management
Pharmacological
agents
Pharmacologicalalternatives
Behavior Management
Traditional
Techniques
Tell-show-do
Distraction
Modeling
Positive
Reinforcement
Voice control
Adversive
Techniques
Physical restraint
Hand over mouth
Pharmacologic
Techniques
Sedation
General
Anesthesia
TSD Technique
T:
Tell
S: Show
D: Do
A:
Tell: Explanation of
procedures at the right
age/educational level
For Most Children:
CHOOSE WORDS CAREFULLY
AVOID
Shot
Needle
Hurt
Pull
Etc.
B:
Show: demonstrate the
procedure
C:
Do: following on to
undertake the task.
Positive reinforcement
Find something to
praise
Anything
Stress
accomplishments
Prizes at end of visit
Adaptive method
Modeling
Modeling
could be used
to alleviate anxiety due
to ‘fear of the unknown’
Live modeling
Next patient watches
It’s
not necessary to use
a live model, videos of
co-operative patients
are of value.
Cognitive approaches
Asking patients to
identify their negative
thoughts
helping
patients to
recognize their negative
thoughts and suggesting
more positive alternatives
‘reality based’;
Distraction:
Shift
attention from the
dental setting towards some
other kind of situation.
Distraction
Conversation
Mirror
Book
Electronics
Whatever…
Voice control
Tone or inflection
Volume
Soft and even
Loud and abrupt
Use to hold child’s attention
Do not telegraph frustration
Parental presence?
Supportive for very young
patients
Instructive for parents
Parent is silent partner
Never interpreter of same
language
Don’t threaten departure
Parental interactions
Parents should be told where they
should stand (sit), what they can say,
and how they should react; without
threats or condescension.
Uncooperative Patient
Explanation
maintain confidence
Direct attention to child
Speak directly
Parental presence
•Silent assurance
Positive reinforcement
Persist
Time Out
Pause for reflection
May assist the dentist
Test of stamina
Economically difficult
Restraints
Mouth Prop
Parental security
Wraps or
Papoose Board
Hand over
mouth
Mouth prop
Support oral access
Treatment aid
Apply with care
Not to impinge on
lips
Not to subluxate
mandible
May be interpreted
as restraint
•Assure ratchet works
•Open slowly
•Don’t impinge on lips
•Do not use as a crow-bar
Physical restraint
Parent may be more supportive than
wrap
Wraps/Boards
Pediwrap®, Papoose Board®
• Supports physically challenged patients
• Necessity during sedation
• Downside
• Sense of helplessness, loss of control
Avoid injury
Assure parental informed consent
Meet community standards
When to consider
pharmacologic management...
Nitrous Oxide Analgesia
Adjunct to nonpharmacological
management
Assumes a minimal level of
cooperation
Child must be capable of
following instruction
Capable of sitting alone in
chair
Capable of breathing through
the nose
Nasal inhaler hood must fit
properly
Sedation
Definition of Conscious
Sedation
Minimally depressed
level of consciousness
that retains the
patient’s ability to
maintain a patent
airway independently
and continuously and to
respond appropriately
to physical stimulation
and/or verbal command
Sedation
Strict guidelines
requiring
Monitoring &
recording
Recovery area
Additional
personnel
Functional Levels of
Sedation
Conscious
Sedation
Deep
Sedation
General
Anesthesia
I
II
III
Anxiolysis
Interactive
Non-interactive, arousable
with mild/moderate
stimuli
IV
Non-interative, nonarousable
except with
intensive stimulus
V
General Anesthesia
Conscious sedation (I,II,III)
Functional Level
of Sedation
Mild Sedation
(Anxiolysis)
Interactive
Noninteractive/Arousable
With Mild/Moderate
Stimulus
Goal
(Level 1)
Decrease anxiety;
facilitate coping
skills
(Level 2)
Decrease or
eliminate anxiety;
facilitate coping
skills
(Level 3)
Decrease or eliminate
anxiety, faciliitate
coping skills, promote
non-interaction
Responsiveness
Uninterrupted
interactive ability;
totally awake
Minimally depressed
level of
consciousness; eyes
open or temporarily
closed;resp
Moderately depressed
level of
consciousness;mimics
physiologic sleep; eyes
mostly closed, may or
may not respond to
verbal commands
alone; responds to
mild/moderate stimuli
General Anesthesia
Last resort
Indications
Immaturity
Extensive caries
Physical or mental challenge
Definition
Induced state of unconsciousness accompanied by loss of
protective reflexes, including the ability to maintain an
airway independently and respond appropriately to
physical stimulation and/or verbal command
Management entree´
selection
Most patients require simple
management techniques
A small cohort require the more
aggressive management
techniques
Advance preparation further
minimizes necessity for aversive
Number of children who
actually present as
management problem???
Estimated that 22% actually
present moderate - severe
management challenges
Management Technique Utilization
•Curve moves left with increasing age
•General anesthesia more likely to be utilized
below the age of 2.5 yrs
Successful Patient
Management
Goal: Safe, effective and quality
dental care
Significant resources are required
Successful Patient
Good
communication
Management
with patients and
parents to establish
expectations and
mitigate
misunderstanding
Patient’s recognition of
their own accomplishment,
without dreading the next
visit
Parent’s recognition of
the dentist’s
accomplishment and an
understanding of what
will be necessary to
complete future visits
6 First dental visit
There
seems to be a lot
of confusion about the
correct timing for the
first dental visit.
6.1 The correct time
The
AAPD recommends :
within 6 months of the
eruption of the first
primary tooth and no later
than 12 months of age
A
child should have his
or her first dental visit
at the first birthday!
6.2 Medical and dental
record
The
dentist should record
a thorough medical and
dental history.
6.3 oral examination
Usually
be accomplished
with the parent present in
the office.
The child patient may be
sitting in knee-to-knee
position
6.4 Assess
6.4.1
Assess the risk of oral
and dental disease
6.4.2 Evaluate the child's
oral and dental development
6.4.3
Evaluate the need
for fluoride supplementation.
6.4.4
It may be important to
discuss non-nutritive habits,
injury prevention, oral
hygiene, and effects of diet
on the dentition.
6.5 Treatment
If
treatment is indicated the
dentist should be prepared
to provide therapy or he
needs to refer the patient.
第二章
生长发育
生长发育的概念:指机体组织形态机能中所
显示的生物肉体、 心理、 生理、 情绪等变
化过程的综合,可受遗传、 性别、 营养、
疾病、 锻炼等内外因素影响而存在个体差异。
它是一个连续不断的发展过程,时间即年龄
在儿童生长发育中是一个十分重要的因素。
它包括两方面:
生长:指机体增殖的过程,是量的增加
发育:指机能和成熟的程度,是质的变化
第一节
生长发育分期及各期特点
一 按年龄阶段分期
二 按牙列分期
三 咬合发育阶段分期
一 按年龄阶段分期
生长期 年龄阶段
特
点
危险因素
胚芽期
0~8周
1 胚胎第4周,牙板出现 基因突变
2 胚胎第8周,
环境有害
1)初步形成人的面型, 因素
2)腭的发育才开始;
3)乳牙胚已经发生
生长期
阶段
特
点
危险因素
1 组织器官迅速生长
和功能渐趋出现
2 胎龄14周
8周~出生
胎儿期
1)通过胎盘与母体 母体营养不良
(40周)
进行物质交换
母体疾病
2)腭盖形成
3)乳牙开始钙化
生长期 阶段
新生儿 出生
期
~4周
特
点
1 胎儿在母体内寄
生的结束
2 乳牙冠部出现新
生线
3 唾液腺不发达,
唾液分泌量少
危险因素
唾液腺不
发达,唾
液分泌少
生长期
阶段
特
点
危险因素
1 生长快,代谢率高
2 消化功能未发育完善
婴儿期
4周~出
生后1年
3 被动免疫消失,获得
性免疫尚未完全建立
4 乳牙开始萌出,恒牙
的钙化期
营养紊乱
和疾病
生长期 阶段
特
点
1 神经系统发育
幼儿期 1~6岁
危险因素
进食次数多,
仍然很快,
糖类食品多
2 3岁时乳牙全部
乳牙外伤多
出齐,钙化低
感染后的变
3 活动多
态反应性疾
病开始出现
生长期
阶段
特
点
危险因素
扁桃腺肥大或咽
部腺样体增生常
淋巴系统的发育处
常影响儿童呼吸
道的通畅,患儿
于高峰期,颈部和
6岁到
张口呼吸,久之
学龄期
12~13岁
腹股沟处的淋巴结 容易形成开唇露
齿的颌面畸形。
可以触及。
恒磨牙萌出,窝
沟复杂
生长期
年龄阶段
特点
女孩11~12岁
危险因素
恒磨牙龋
身体骨骼出现
青春发
到17~18岁
病发病率
第2次快速生长
育期
男孩13~14岁
到18~20岁
高,病损
严重
二 牙列的临床分期
(一)牙列分期
1 无牙期:
2 乳牙列形成期:
3 乳牙列期:
4 混合牙列期:
5 恒牙列期:
二
儿童时期的3个牙列阶段
1 乳牙列阶段
2 混合牙列阶段
3 年轻恒牙列阶段
3个牙列阶段的特点
牙列阶段
1乳牙列阶段
2 混合牙列
特点
1 口腔内全部为乳牙
2 乳牙龋患开始和逐年增
多
1儿童颌骨和牙弓主要生长
发育期,也是恒牙合建立
的关键时期
2 恒牙龋患开始
3 年轻恒牙列 口腔内全部都是恒牙
恒牙龋病患病率高,病损
严重
主要任务
维护乳牙的健康完好
1 加强口腔卫生宣教
2 早发现,早治疗
1 预防错合畸形
2 防治恒牙龋病
第一,二恒磨牙的保
存
三咬合发育阶段的分期
乳牙萌出前
A
Ⅰ
乳牙咬合完成前
无牙期
乳牙萌出期
C
A
Ⅱ
乳牙咬合完成期
第一恒磨牙及恒前牙萌出开始期
(前牙替换期)
混合牙列期
C
A
Ⅲ
B
第一恒磨牙萌出完成期
(恒前牙部分或全部萌出完成)
侧方牙群替换期
第二恒磨牙萌出开始期
恒牙列期
C
第二恒磨牙萌出完成期
A
乳牙列期
第二节
颅面骨骼和牙列的生长
一 颅面骨骼的生长
(一)概论
1 出生前
1)起源:原始胚胎的支持性结缔组织
2) 化骨方式:膜内化骨
软骨内化骨
2 出生时
颅面骨骼:面骨=8:1
原因:咀嚼器官的发育落后
于脑和感觉器官发育
3 出生后
颅部生长:
1~2岁,增长最快
5岁后,增长减少
6岁,已达成人90%
10岁后,变化甚少
面部生长
高度
宽度
深度
高度>深度>宽度
3 生长曲线:
1) 颅骨:与神经系统的生长曲
线相一致
2 )面骨:一般躯体骨骼系统的
生长曲线
(二)颅骨的生长
颅骨体积的增长:
1)骨的表面增生
2)骨缝间质增生
3)软骨的间质及表面增生
(三)面骨的生长
1 上颌骨
1)体积增长依赖于:
骨的表面增生
骨缝间质增生
上颌窦的发育
2)途径:长度:
A :骨缝间质增生(额颌 颧颌 颧颞 翼腭)
B:上颌骨唇侧骨增生,舌侧骨吸收
C:上颌结节区增长
D:腭骨后缘的增长
长度增加最明显的为上颌磨牙区
宽度:
A:腭突及腭中缝的生长
B:颧骨的宽度增加
C:上颌骨前部
上颌骨宽度增长较慢
高度
A:牙齿的萌出和牙槽骨的表面增生
B:骨缝间质增生
C:上颌窦的发育
2 下颌骨
1)下颌骨的发育:由下颌突深部组织发
育而来。
2)发育方式:
骨的表面增生
无骨缝间质增生
下颌髁突软骨生长
长度:
A:骨板外新骨沉积,内侧陈骨吸收
B:下颌支前缘陈骨吸收,后缘新骨
增生
高度:
A:下颌髁突新骨增生
B:牙槽突的增高及下颌骨下缘少量新
骨增生
宽度
A:外侧骨增生,内侧骨吸收
B:髁突向侧方生长
二 牙齿的发育
(一)牙齿发育的时间
1 牙齿发育的三个阶段:生长期,钙化期
和萌出期
2 观察牙齿发育的方法:X-线片观察牙齿
钙化的不同阶段
3 恒牙发育时间表
4 恒牙钙化的10个阶段
(二) 牙齿萌出
1 牙齿萌出的概念:一般指牙齿突破口
腔粘膜的现象
2 组织学:包括一系列的变化
3 牙齿萌出规律 :1)一定的时间
2)一定的顺序
3)左右对称
4 牙齿萌出的变异
生理性流涎:乳牙萌出时,对三叉神
经产生刺激,引起唾液分泌量的增加,
但由于小儿还没有吞咽大量唾液的习
惯,口腔又浅,唾液往往流到口外来,
形成“生理性流涎”
三 咬合发育阶段的分期
乳牙列的生理间隙
1 灵长间隙:存在于上颌乳侧切
牙和乳尖牙之间,下颌乳尖牙与
第一乳磨牙之间的间隙
2 发育间隙:灵长间隙以外的生
理间隙
恒前牙萌出期
正中分开
丑小鸭阶段
下切牙拥挤现象
侧方牙群替换期
1 侧方牙群
2 剩余间隙
第三节
生长发育的评价
常用评价方法
1
实际年龄
2
生理年龄
3
骨龄
4
牙龄