Pediatric Dental Health

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You Pierced What?
Tongue piercing is on the rise, but body ornamentation is really nothing new. For centuries, body piercing has been an important part of many cultures. Some Native Americans tribes used body piercing during ceremonies. The Mayans pierced their tongues for spiritual reasons.

The first report of oral piercing appeared in the medical literature in 1992. The first report of a life-threatening complication appeared just a few years later in the British Dental Journal.

What Tongue Jewelry Is Made Of:

It is usually a barbell-shaped device. It may be straight or curved.
The barbell has an internally threaded bar, and two spherical ends.
The tongue jewelry must be made of either surgical stainless steel, solid 14-K gold, niobium, or titanium in order to decrease complications.

How Tongue Piercing Is Done:
No anesthesia is used.
The protruding tongue is clamped. The tongue is then pierced by a wide bore hollow needle, often 12 gauge in size, which is as wide as the barbell's stem. The tongue is usually pierced in the middle, at the anterior one third of the tongue.
A 12 gauge barbell stem is first used to keep the hole open. A few days later, after the tongue swelling goes down, the first barbell is replaced by a smaller one.
In the absence of complications, healing takes place in four to six weeks.
Failure to constantly wear the barbell will close the perforation.

Precautions:
The piercer must be well-trained in technique, infection control, and health and safety measures.
Gloves must be worn by the piercer during the procedure.
Autoclaves must be used to sterilize instruments and equipment, before and after the procedure.
Only tongue jewelry made of surgical grade stainless steel, solid 14-K gold, niobium, or titanium may be used. Using these materials will decrease the possibility of an allergic reaction or infection.

Instructions After Tongue Piercing:
Suck on ice cubes the rest of the day to control swelling of the tongue.
Use hot salt water rinses every 4 hours, especially after eating, to reduce the risk of infection.
Avoid smoking, drinking alcohol, or eating spicy foods until the tongue is healed.
Go to the nearest hospital emergency room if the tongue swells, if the bleeding does not stop, or if the barbell has accidentally been swallowed or aspirated.

Potential Non Life-threatening Complications:
Fractures of the teeth.
Problems with eating.
Loss of taste.
Problems with speaking.
Increased salivation.
Injury to the gingival tissue.
Scar tissue formation in the tongue.
Barbells may obscure other dental problems during dental x-rays.

Potential Life-threatening Complications:
Infection. Hepatitis B is the most serious threat. It can be transmitted in as little as 0.00004 ml of blood.
Disease transmission. Organisms include HBV, HCV, HDV, HGV, EBV, HSV, HIV, tetanus, and candida.
Airway obstruction can be due to swelling of the tongue, or swelling as a result of a severe cellulitis - such as Ludwig's Angina.
Prolonged bleeding, especially if a large artery has been punctured.
Aspiration of the barbell into the larynx or lungs, causing an airway obstruction.
An allergic reaction to the metal.

A recent article in the British Dental Journal reported a case of a patient who collapsed after continuous bleeding following tongue piercing.
Hardee PSGF, Mallya LR, Hutchinson IL: Tongue piercing resulting in hypotensive collapse. Br Dent J. June 24 2000; 188(12):657-658.

What You Should Know About Spaces Between Children's Front Teeth
Spaces between children's front teeth are a concern for many parents. This dental spacing can affect facial balance, aesthetics, speech, social behavior, and proper function. There are many causes of dental spacing (diastemas). The key to correcting a diastema lies in understanding these contributing factors.

The midline diastema is a space between the upper middle incisors. This space is a common finding in children, and is part of normal dental development. As many as 97 percent of all 5-year-olds have diastemas. Diastemas occur in about 50 percent of children between the ages of 6 and 8. Diastemas occur less frequently as children get older, because most of the spaces close naturally.

Possible Causes Of Diastemas (Spaces) In Children:
It's normal!
Diastemas are a normal part of dental growth and development in children. The reason is that around the age of 8, the unerupted lateral incisors begin to push against the roots of the already-erupted central incisors - which then causes a space to appear between the central incisors. It is only later, around the age of 12, that the upper eye teeth erupt into the mouth, and help the diastemas between the incisors close naturally.
Small lateral incisor teeth.
Small lateral incisors will allow the middle (central) incisors to drift away from each other - causing a gap between the front teeth.
A deep bite.
This is a situation in which the front teeth experience an excessive vertical overlap. Such a deep bite forces the upper teeth to tip out, causing the formation of spaces between them. Deep bite problems can be further sub-categorized as being due to: over-erupted upper incisors, over-erupted lower incisors, and/or insufficient vertical growth of the face.
Poor angulation of the teeth.
One example is called excessive side-to-side angulation of the teeth (excessive distal crown angulation). In this situation, the result is a small space above the point where the central incisors contact - giving the illusion of a gap.
Harmful oral habits.
Lower lip biting can protrude the upper teeth.
Flaccid lips (poor muscle tone) can cause protrusion of teeth.
Poor tongue posture - such as holding the tongue forward between the front teeth - can affect the position of the incisors.
Muscular imbalance.
The tongue is capable of pushing the incisor teeth forward in the case of a congenitally large tongue (macroglossia).
Hormone imbalance.
An endocrine gland imbalance, such as acromegaly, causes abnormally large jaws - but the teeth remain normal in size - causing spacing.
Physical impediments.
Extra (supernumerary) teeth, such as a mesiodens, can prevent the upper central incisors from touching normally.
In other cases, cysts can form between the upper teeth, preventing normal contact.
Occasionally, extra tissue between the incisors (the maxillary frenum) can prevent the central incisors from contacting each other.
Abnormal bone structure.
Sometimes the bone between the incisors (the interproximal bone) will have a W-shaped defect - which can be seen on an x-ray. Such a defect (actually, an open midpalatal suture) will prevent the upper incisors from touching each other.

Orthodontic Techniques In Closing The Midline Diastema:
Tipping the incisors towards each other (a mesial tipping movement).
Moving the incisors bodily towards each other (mesial bodily approximation).
Correcting the protrusion of the front teeth (decreasing the overjet).
Adding tooth-colored material to the lateral incisors to make them bigger (restorative solution).
Comprehensive orthodontic treatment.

A recent article in the British Medical Journal reviews some basic orthodontic problems.
Cunningham S, Horrocks E, Hunt N, Jones S, Moseley H, Noar J, Scully C: Improving occlusion and orofacial aesthetics: orthodontics. BMJ. 2000;321:288-290 (29 July).

Should Children Be Restrained During Dental Treatment?
Dental treatment requires considerable cooperation from the patient, especially if the patient is a young child. Treatment of an anxious, very fearful, uncooperative, or noncompliant child can be very challenging for the dentist, staff, and parents - as well as for the child.

Physical restraint of a child is sometimes necessary in order to protect the patient, dentist, and/or staff from injury while treatment is being provided. Restraints are any physical or pharmacological means used to restrict a patient's movement, activity, or access to their own body.

ETHICAL ISSUES SURROUNDING THE USE OF PHYSICAL RESTRAINT:
Infringement on a patient's autonomy and freedom of movement.
Risk of physical and/or psychological injury as a result of being restrained.
The risk vs. benefit ratio: Does the benefit of using restraint outweigh the risk of harm? Will future health-seeking behavior be jeopardized?
Determining the urgency and necessity of providing treatment: Can treatment be delayed or avoided with no ill effects?
Assent by the child: Is the child capable of participating in decision-making? Children should participate in decision-making to the extent that they are capable.
Parents' permission: Parental informed consent is necessary. The restraint procedure, alternative forms of behavior management, and the risks associated with refusal to allow the use of physical restraint must be explained to the parents.

BEHAVIOR MANAGEMENT TECHNIQUES FOR DENTAL TREATMENT OF CHILDREN:
Tell-show-do: The child is told about the procedure, portions of the procedure are demonstrated, and the procedure is then performed.
Positive reinforcement: Desirable behavior is praised and rewarded.
Modeling: Another child can be a role model for "good behavior" during dental treatment.
Physical restraint: The dentist or assistant may need to hold a child's hands during dental treatment to prevent injury to the child, dentist, and/or staff. A Papoose Board® may also need to be used. A Papoose Board® is a physical restraint device which prevents the movement of a child's hand, arms, and legs during dental or medical procedures.
Sedation: Conscious or deep sedation.
General anesthesia.

REQUIREMENTS FOR PHYSICAL RESTRAINT OF A CHILD:
Clear indications for its use: To prevent patients from injuring themselves or the staff during treatment. To facilitate emergency treatment. To protect sedated or disorientated patients from falls or injury.
Restraints are to be used only after consideration of alternative methods of behavior management.
An explanation is given to the child: The reasons for using physical restraint should be explained to the child.
An assessment of the patient's physical and emotional condition should be performed.
A dentist's or physician's verbal or written orders are required.
Use of the least restrictive method of restraint is important.
Safe application of physical restraint, or the restraining device.
Reassessment guidelines: Skin integrity and neurovascular status should be periodically reassessed.
Informed consent: Assent by the parent or surrogate decision maker is necessary before physically restraining a child, and must be documented in the dental or medical record. An immediate and documented explanation to the parents or family members as to why the physical restraint is necessary must be provided. The clinical justification for using restraint, and the duration of its use must also be documented in the dental or medical record.

Physical restraint of a child may not be used as a punishment or disciplinary measure, or as a convenience for the dentist, physician, or staff.

A recent article in the Archives of Pediatric and Adolescent Medicine reviews the use of restraint in children, in situations not involving diagnostic or treatment procedures.
Brown RL, Genel M, Riggs JA: Use of seclusion and restraint in children and adolescents. Archives of Pediatric and Adolescent Medicine. July 2000 154(7).

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