4.1 Paediatric Dentistry

Behaviour Management and Consent in Children

Paediatric behaviour management underpins every aspect of care. Tell-Show-Do is the cornerstone non-pharmacological technique: explain in age-appropriate language, demonstrate on a finger or model, then carry out the procedure. Acclimatisation spreads simple visits (mirror and probe, polishing) before restorative work, building trust progressively. Other techniques include positive reinforcement, distraction, and voice control. When behaviour cannot be managed conventionally, conscious sedation (nitrous oxide inhalation) or general anaesthesia (GA) may be indicated — GA is reserved for extensive need or very young/uncooperative children and carries a higher medicolegal and clinical risk.

Consent: Gillick Competence and Fraser Guidelines

In UK law, a child under 16 who has sufficient understanding and intelligence to fully comprehend the treatment — its purpose, nature, likely effects, risks, and alternatives — is termed Gillick competent and may consent independently. The Fraser guidelines are narrower and apply specifically to contraceptive and sexual health advice/treatment; the two terms are frequently but incorrectly used interchangeably. Key principles:

Competence is decision-specific: a child may consent to a fissure sealant but not to a GA. Written consent is required for sedation and GA, and it is good practice to involve both parents.

Caries Management in the Primary Dentition

Early Childhood Caries (ECC) is defined by the AAPD as the presence of one or more decayed, missing, or filled tooth surfaces in any primary tooth in a child under 6. Risk factors include free-sugars intake, especially in a bottle or beaker, and nocturnal feeding.

Preformed Metal Crowns and the Hall Technique

For restoration of carious primary molars, preformed metal crowns (PMCs) outperform conventional restorations, particularly in multi-surface lesions. The Hall Technique — a biological, non-invasive approach developed in Scotland — seals caries under a PMC with no caries removal, tooth preparation, or local anaesthetic. SDCEP guidance confirms it is suitable when unaffected dentine remains between the lesion and the pulp. Systematic reviews report 12- and 24-month survival above 85%, comparable to conventional PMCs, with shorter operating time, lower cost, and high parental acceptability.

Silver Diamine Fluoride (SDF)

SDF (typically 38%) is a caries-arresting agent applied topically to active lesions. It arrests lesions by inhibiting collagen degradation and remineralising affected dentine. BSPD supports its use as a minimally invasive option, particularly for high-caries-risk children, those unable to accept conventional care, and as an interim measure. The main aesthetic drawback is a permanent black stain of the arrested lesion.

Vital Pulp Therapy in Primary Teeth

When caries exposures the vital primary pulp, vital pulpotomy removes the coronal pulp and places a medicament over the radicular stumps. Agents include:

If the radicular pulp is irreversibly inflamed or necrotic, pulpectomy with a resorbable paste (e.g. zinc oxide eugenol, iodoform-based) is indicated. Lesion sterility and canal morphology (ribbon-shaped, accessory canals) preclude conventional obturation in primary teeth.

Immature Permanent Teeth: Apexification and Regenerative Endodontics

For necrotic immature permanent teeth with thin dentinal walls and open apices, two approaches are recognised:

• Apexification with an MTA apical plug — creates an apical barrier in one or two visits; high survival (>90%) but no continued root development.
• Regenerative endodontic technique (RET / revascularisation) — uses NaOCl (1.5-3%) irrigation, EDTA final rinse, intracanal medicament (calcium hydroxide or low-dose triple antibiotic paste), and a blood clot scaffold to allow continued root thickening and lengthening. AAE 2021 clinical considerations guide case selection.

RET is preferred for the most immature teeth with very thin walls; MTA apexification suits near-complete roots. Both achieve comparable survival (~90-96%), but only RET delivers genuine root maturation.

Molar-Incisor Hypomineralisation and Enamel Defects

Molar-Incisor Hypomineralisation (MIH) is a qualitative defect of systemic origin affecting one to four first permanent molars and frequently associated incisors, presenting at eruption as demarcated opacities (white-cream to yellow-brown). Affected molars are prone to post-eruptive breakdown and often require adhesive restorations, PMCs, or, in severe cases, extraction with orthodontic space management.

Tooth Notation and Eruption Chronology

Three systems are used worldwide:

1. FDI two-digit (ISO 3950) — international standard. Permanent quadrants 1-4, primary quadrants 5-8; tooth 1 (central) to 8 (third molar) from midline. Pronounced separately: 16 = "one-six" (upper right first molar).
2. Palmer / Zsigmondy — quadrant symbol (┘└┐┌) with number 1-8; widely used in UK.
3. Universal / Tooth letter-number — primary A-T, permanent 1-32; US convention.

Typical eruption dates (mandibular precede maxillary):

Children with Special Needs and Safeguarding

Children with medical, physical, or intellectual disabilities may require tailored preventive programmes, GA for treatment, and shared-care pathways. Safeguarding children is a statutory duty: dental teams must recognise signs of abuse (orofacial bruising, torn frenum, patterned injury, dental neglect) and follow local safeguarding procedures — escalating to children's social care when a child is at risk of significant harm. The dental practitioner is often the first healthcare professional to identify non-accidental injury in the head and neck region.