Infants at the dentist
Baby bottle, fear of the drill, worried parents – the institute of the German dentists (IDZ) examined in a nationwide study "experiences, problems and assessments of resident dentists in the treatment of younger children". Result: The know-how in the practices is there, but the supply policy framework is missing.
Many small children already have tooth decay. Preventive strategies are more successful – and less painful for everyone involved – than invasive treatment. Photo: Techniker Krankenkasse
Over 85 percent of dentists document initial caries and eating habits in children under the age of six, and almost 70 percent also ask about their parents’ caries experience. However, there is still room for improvement: just over half of the dentists record the dmf-t index as an indicator of caries development. The visible plaque index, which can provide information on the child’s oral hygiene, is regularly determined by 40 percent. The fluoride medical history is also only collected by half.
Basically, it is positive that not only pediatric dentists use a wide range of diagnostic options for children under the age of six, but that many parameters are also recorded in general dentists’ surgeries that go beyond the actual caries diagnosis.
The first visit to the dentist
The successful prevention of oral diseases should begin in infancy.
When making recommendations at the best time for the first visit to the dentist, a quarter of the dentists favor the 6th, 12th or 24th month. Ten percent recommend 30 months of age. Younger dentists in particular are significantly more likely to give advice on putting the child into practice as early as possible, which corresponds to the increased attention given to early childhood tooth decay.
One of the main risk factors for early childhood tooth decay is high-frequency carbohydrate intake. Another preventative task is to educate parents about healthy teeth for their child. 98.9 percent of the dentists surveyed provide advice – albeit to varying degrees – although “parents often find it difficult to implement nutrition tips”. Around a third of them talk to them in more detail about nutrition, and more than half are limited to information on eating habits. In children’s surgeries, advice is not given more often, but usually more intensively than in general dentist surgeries.
The parents advise
Children with an increased risk in particular need close and intensive dental care. Over 95 percent of the dentists surveyed communicate the problem to the parents, while around two thirds themselves actively take preventive measures by fluoridating their teeth. In contrast, just over half watch the children regularly. The measures carried out by dentists in children’s practices are more extensive than those in general practices. Over 90 percent of dentists advise parents to look for signs of tooth decay at home. Only about a third of them provide more information, and here too, dentists in children’s practices use methods that go beyond the tips. Almost 40 percent of dentists agree that parents have difficulty implementing nutritional counseling at home. A quarter regularly observes that dental care is started too late, the child’s teeth are not cleaned or the baby is not weaned from the baby’s bottle. Almost 50 percent of these parents perceive these problems; another quarter make these experiences less common. Defects in the control and implementation of the child’s oral hygiene by the parents are frequently reported, in part due to a lack of awareness of their own oral hygiene. The harmful eating habits in some families, which are passed on from parents to children, are also perceived as problematic.
Over two thirds of dentists regularly find that the social background in particular affects the child’s oral health. More than half report difficulties in motivating parents with a migrant background regarding their children’s dental health.
The focus of the actual work on the patient is on the diagnostic and preventive services. Invasive measures are carried out much less frequently. This applies to both age groups. The proportion of invasive interventions increases among the four- to six-year-olds, but diagnostic and advisory work is also more important for them. One reason is probably the associated problems: It is reported that children "often come too late, only with tooth decay", and that there are "large lesions" that "complicate filling therapy".
All in all, 95 percent of dentists are committed to preventing dental diseases in younger children. Overall, very detailed diagnostics are carried out in dental surgeries, even for children under the age of six. Preventive measures are carried out in almost all practices and are more important than therapeutic measures in young children. Pediatric dentists naturally invest more time and effort in diagnostics, prevention and therapy, but general dentists also seem to be well positioned in all areas.
The horror of the drill
However, treating children is not always easy. First of all, there are problems that arise from the toddler himself.
Barriers are seen primarily in the low level of compliance and fears of the children, which makes treatment difficult or even impossible – especially for children under three years of age. For example, many dentists note an unwillingness to go beyond the lack of compliance to have to sit alone in the dental chair and an aversion to the noise of the drill. Especially dentists who have not had any further training in the field of pediatric dentistry in the past few years had negative experiences significantly more often when it comes to the children’s attitude towards experiencing the "environment of the dental practice" and treatment.
In very small children, problems such as motor restlessness that slow down the course of treatment, psychological factors such as defiance or impatience are perceived as annoying with increasing age.
However, more than half of the dentists rarely experience that parents consider fillings in the milk dentition to be unnecessary or prefer extraction to filling therapy. Less than ten percent report such an attitude. On the other hand, a basic attitude towards child treatment, which is caused by false knowledge, partly by disinterest, is criticized. Which in turn leads to a late presentation of the child – often the children are only brought into practice with pain. In over half of the practices, it is regularly observed that parents encourage their children to receive treatment. Unfortunately, there is also often a report about a well-intentioned, but negative “preparation” of the children for the visit to the dentist, which makes it difficult for the practitioner to win the children’s trust: This is how the “parents used the dental practice as a negative ‘educational tool’ "And often the children are" previously (sometimes unintentionally) scared of grandparents, siblings, parents: ‘You don’t need to be afraid!’, ‘Nothing bad happens’. " One of the biggest barriers comes from the nervousness of the parents. Over 90 percent of dentists often experience that the restlessness of the parents is transferred to the child.
Not only from the child and from the parents, but also from the dentist, problems with the care of the child can arise. His attitude towards child treatment is based not least on his knowledge of this area. When asked about the risk factors for the development of early childhood tooth decay, 90 percent of dentists gave answers that largely correspond to the current state of research. It does not matter whether they were increasingly active in pediatric dentistry or trained – the knowledge appears equally well developed to everyone.
In general, the stress caused by children is much higher than in adult patients. If the parents are present during the treatment, the burden increases for almost a third of the dentists, and for only eleven percent their presence leads to a reduction in stress. Younger dentists, in particular, are upset by their parents. Only the findings were assessed as below average. On the other hand, all other occasions are perceived as more strenuous than adult treatment, especially pain treatment, pulpotomy and extraction.
A last point that is perceived as problematic is the additional time that is required for the treatment of toddlers, but is not rewarded accordingly. There was no explicit question about this, but this aspect was addressed several times in the free text responses: The treatment of children required "a lot of time and personnel without the appropriate remuneration option" and there was "no corresponding adjustment of the cash fee".
Despite or perhaps because of the problems presented, pediatric dentistry is in great demand: Over 80 percent of the dentists surveyed stated that they had undergone further training in this area in the past five years, of which almost 50 percent attended an event. 17.7 percent had completed more intensive further training in the form of a curriculum or a specialization in "dentist with additional qualifications in pediatric and adolescent dentistry from the DGK and DGZ". About half of all trained dentists stated that they had subsequently done more in the field of pediatric dentistry, with almost two thirds of them having already dealt intensively with child care for some time. There are special requests for further training in the field of child psychology and milk tooth endodontics.
The range of advice provided by trained dentists is much broader, they advise significantly more frequently and extensively. Diagnostics are more focused on problems such as early childhood caries, and more sophisticated forms of therapy are performed more often than by colleagues who have not trained.
The personal stress perception of dentists in under three year olds tends to correlate and in the case of four to six year olds significantly with the frequency of transfers. The lower the load, the less often the dentist will refer you. Those who transfer less frequently also perceive children’s compliance less frequently than restricted.
One of the two most common reasons for referral to a colleague is children’s non-compliance. For many dentists, the need for treatment under sedation or anesthesia is another key reason – both require special expertise, special equipment and good cooperation with anesthetists. In contrast, specific treatments or illnesses play a subordinate role in referral behavior.
Cooperate with colleagues
The question of cooperation with members of other professional groups with regard to child treatment was answered by 598 dentists, that is almost 70 percent, and 30 percent did not provide any information. As can be seen from the table on page 61, over half of the dentists keep in touch with pediatricians and teachers, and almost a third also with educators. Most interfaces arise with pediatricians and educators. Pediatric dentists in particular, as well as dentists who have undergone training in the field of pediatric dentistry in recent years, have significantly more frequent contact with pediatricians. Dentists in the "children’s practice" also tend to cooperate with pediatricians, but this connection is not significant. Mainly dentists in children’s dental practices as well as trained and dentists from the old federal states work with educators. Almost a third of the dentists have no contacts with other professional groups in the treatment of children. Dentists in particular, who in practice have been less concerned with pediatric dentistry, look for contact significantly less frequently here. Despite the higher density of different specialties, over 41 percent of dentists in large cities do not cooperate with other professional groups, almost twice as many as in very rural areas. The experience that dentists have in working together is usually very positive. Overall, over 76 percent find the cooperation very good or good, only 0.8 percent have had bad or very bad experiences. The good impression with this cooperation appears very homogeneous – neither is only a certain type of dentist satisfied, nor do the positive experiences with a certain professional group prevail.
Studies clearly show that the subjective quality of life in young children with untreated carious defects declines: the more carious the infection, the more serious the negative effects on the life of both the child and the parents [Martins-Júnior et al., 2013]. Due to the severity of the infestation and the lack of cooperation between the children, renovations often have to be carried out under anesthetic. Caries can be prevented preventively with simple means.
In Germany, however, it is problematic that no caries preventive measures are provided in the till system until the 30th month. Group prophylactic activities in day care centers are only just beginning to develop. Due to the high response, the current survey shows that dental treatment of small children and the prevention of early childhood tooth decay are relevant for dentists.
From the answers it can be seen that the majority of young children take far more extensive and well-founded approaches to caries prevention and control than the performance positions of the examination (01) and early examination (FU) provide. The focus here is on educating parents about the causes of caries, nutritional control, fluoridamnesis and training oral hygiene in small children with fluoride-containing children’s toothpaste [Twetman, 2008]. It would make sense from a perspective perspective to implement these measures more comprehensively and in a more structured manner, for example through an “early examination” from the first tooth. But outreach approaches after childbirth or in the crèche can also be effective [Kowash, 2006; White, 2006].
The study shows that the structural elements that are scientifically necessary as evidence of effective prevention in young children can already be demonstrated by dentists. The preventive approach to caries control would also be considerably health-promoting, child-friendly and cheaper than the restorative – and easier to ensure than a restoration of carious teeth in toddlers.
The outlook therefore shows the need to anchor practical skills for prevention and communication with the (small) child and their parents in dental training at universities. It can be assumed that the recognizable work specialization, including the more frequent referrals to the dentist with a focus on pediatric dentistry, is progressing. This will in future be able to meet the special needs of a small group of children with extensive or special treatment needs. The primary goal is to transfer the success of caries prevention in permanent dentition to the milk dentition of small children. First of all, this is due to accompanying health services research with a focus on removing existing barriers in the dental treatment of small children, through the consistent implementation of oral prophylactic approaches in the system, through an optimization of training at universities in the field of pediatric dentistry and through an intensification of the To secure further training offers.
Dr. med. dent. Nele Kettler, IDZ Cologne, and
Prof. Dr. med. dent. Christian Splieth,
University of Greifswald
A gap in supply policy
Childcare in the practice of dentistry traditionally has a high priority in terms of prevention of caries in terms of prevention of caries and has been continuously expanded for 20 years. However, toddlers (0 to 3 years) still suffer from a gap in health care provision – a situation that is discussed in epidemiological research under the term “early childhood caries” (ECC) – even though it is in this age range that the basics of the tooth are important – health can be put.
The authors wanted to gain a systematic overview of experiences and problems in the dental examination and treatment of small children from the perspective of dentists in Germany. To this end, they developed a questionnaire that captures the views and perceptions of the practitioner and discusses which diagnostic and therapeutic behavior results from this. 21 closed and three open questions were asked on the subject of child treatment, and the participants’ socio-demographics were also asked. A total of 874 dentists answered (response rate: 43.3 percent. An acceptable response compared to similar surveys among dentists.
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