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