Quality & Affordable Dentistry in Malaysia

Pediatric Dentistry in Selangor, Malaysia

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Many pedodontists today have taken additional training in orthodontics so that they can intervene early if such treatment would hasten a healthy, normal occlusal development, or might prevent more treatment as the child matures.
Many pedodontists today have taken additional training in orthodontics so that they can intervene early if such treatment would hasten a healthy, normal occlusal development, or might prevent more treatment as the child matures.

Dentists who have been specially trained for and exclusively treat children are known today as Pediatrics dentists. Just a few years ago, we referred to them as “pedodontists.” But as the word “pediatrics” has crept into all of our vocabularies, the term “Pediatrics dentist” has become a more descriptive term and one that is immediately understood. The post- dental school training for this Malaysian Dental Council recognised specialty is usually two years. The training usually takes place in either a dental college or a teaching hospital.

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The curriculum is quite demanding and includes such various subjects as psychology, behaviour management, pharmacology, conscious sedation, restorative dentistry, and orthodontics along with growth and development and many other disciplines.

On the surface, it may seem that there is not much difference between treating a child and an adult. But think about it! A young child has a very small mouth, and thus a small entrance way into the oral cavity. The deciduous teeth (baby teeth) are much smaller in themselves compared to adult teeth. And consider the fact that, at about six years of age, the adult first molars (also called the six-year molars) are erupting into the mouth at about the same time the deciduous teeth begin to shed. For the next five or six years from ages 6-12 (give or take a year or two on either end), the child experiences some adult teeth and some deciduous teeth. It is wonderful to know that parents and the rest of us dentists have a specialty dentist to monitor and treat our young patients. Some general dentists really like treating children, so they attend regular post-graduate Pediatrics dentistry training seminars and workshops and join specific study clubs for this. Not only are teeth in a state of transition, but here is a tremendous amount of growth and development taking place as well. Of particular interest here is the developing jaws, both the maxilla (upper jaw) and the mandible (lower jaw). It is important to monitor both and to see if they are growing in harmony or if one is in a faster growth spurt than the other.

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This all affects the developing occlusion the bite or the way the teeth of one jaw relates to its antagonist, the opposite jaw). Many pedodontists today have taken additional training in orthodontics so that they can intervene early if such treatment would hasten a healthy, normal occlusal development, or might prevent more treatment as the child matures. When pedodontists feel it’s appropriate, especially if their training and interests are not orthodontically oriented, they refer the orthodontic-problem patients to an orthodontist.

The restorative challenge is different with deciduous teeth too. Because these “baby” teeth are smaller, they are also thinner after having decay removed and are more susceptible to fracture when filled in the conventional way. Therefore, it is common practice and generally recommended that teeth with extensive decay damage have a stainless steel crown placed on them. This is done by first removing all the decay and possibly placing an insulating cement base in the cavity preparation, and then, ever so slightly removing some of the enamel of the tooth to make room for the stainless steel crown. These little crowns are stocked in various sizes and shapes for each of the 20 specific deciduous teeth. In other words, an upper left second molar would not fit a lower left second molar very well at all. So, there are several sizes for each of the 20 teeth. The dentist finds the one that fits best according to size and then contours the gingival (gum) surface to be in harmony with the slightly prepared tooth and gum line. She does this with a special miniature, specially contoured scissors, and with metal dental burs and diamonds. She polishes these with rubber wheels that are attached to the hand-piece. Once satisfied that the contour is correct, she will then crimp the entire circumference of the crown with a specially designed instrument to make the stainless steel crown fit tightly. Then it is secured in place with a permanent type of dental cement. Now, the tooth is nearly impervious to decay and usually remains in place until its normal shedding time. Had this tooth or any other deciduous tooth been lost prematurely, a space would exist in the dental arch. This space, in turn, usually starts closing as the teeth on each side of it will begin drifting towards the space. Now, you can readily see what the danger is here. There will not be adequate room for the adult tooth to erupt into its normal position when its natural time to come in occurs.

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Today, with the continuing development of the composite restorations and even with the older acrylics, children’s dentists are modifying their stainless-steel-crown techniques to adapt to this newer technology. So thanks, dentistry, especially when our little guys and gals have to have crowns on their deciduous front teeth. The stigma and loss of self-esteem and self-confidence have to have harmed many, before we were able to use the more naturally coloured and natural-looking acrylics and composites.

Oftentimes, a deciduous tooth is so damaged by decay that the nerve or pulpal portion of the tooth is exposed. This requires a pulpotomy or the removal of the affected portion of the tooth. If bleeding occurs, and it will if the tooth is still vital (alive), the usually small amount of haemorrhage must be brought under control. Various medications are used for this purpose. Then, a special medicated cement is placed into the pulp very gently, just covering the exposed area. The final step is to place the appropriate restoration for that tooth. This treatment varies for a devital (dead) tooth and quite often the tooth has to be extracted.

When a deciduous tooth must be extracted before its natural exfoliation (shedding) date, a space maintainer has to be constructed and placed to preserve this space for the succeeding adult tooth to erupt into.

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There are two other commonly administered procedures associated with deep decay of deciduous teeth. Both are called “pulp caps.” The less threatening one is called an “indirect” pulp cap because the nerve is not exposed. Although the decay is deep, a medicated substance is placed in this area. The expected results from the medicament is a stimulation of dentin growth. This is sometimes called secondary dentin and increases the insulation depth from the deep decayed area towards the pulp as growth occurs going inward.

The other procedure is more risky as to the success rate. This is the “direct” pulp cap where a small exposure into the pulp chamber has occurred. But since decay has already reached this area, some infection is almost a certainty and various results occur when the pulp is capped here. In both cases, the same result is hoped for and the appropriate restoration is placed on top of the pulp cap.

Other nuances occur when treating young patients, especially the smaller ones who are younger than eight years old. Because they have small mouths and the distance between the upper and lower dental arches do not provide nearly as much space to get our hands and instruments into to provide our services, we often use special devices and instruments. Often it is necessary to use what we call a “bite block.” These are made of a substance resembling semi-hard rubber. They are angled like a wedge so that the lesser thickness occurs at the molar area and the wider area is in the front teeth proximity. There are ridges on each side that look like serrations that aid in keeping the teeth from sliding off of it. These bite blocks come in various sizes and are often helpful for adults alike, as the patient does not need to worry about or exert the necessary effort to keep his mouth open. This is actually quite comfortable for patients and most prefer and appreciate it.

Another most important instrument that has been sized downward to fit more comfortably in young mouths is the hand-piece. We call this a “pedodontic handpiece” and it has a smaller head on it to hold the bur (cutting drill). The burs themselves can also be purchased by the dentist in miniature sizes, further aiding access into the child’s mouth and teeth. 

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Yet another consideration that is different for children is Pediatrics pathology in general. Also birth defects and genetic pre-dispositions are sometimes present and need special handling and treatment. One example of a deviation from normal from adulthood is adolescent gingivitis that often shows up in teenagers. This is a swelling of the gums that can be brought on by hormonal changes as the child goes through puberty. This is often aggravated by this one age group’s stubbornness and surge for independence, leading to a laxation of their oral hygiene regiment. In some cases, they totally ignore all oral health habits. If only they realised that this is the time of their lives that they, more than ever, should want a clean and nice smelling breath and mouth. After all, their initiation into the dating world is about to begin and nothing could be more embarrassing to a teenager (or anyone else, for that matter) than to get a reputation for having awful breath.

Lastly, what do you think might be the biggest difference for dentists treating children? Well, it’s the one thing not yet mentioned: behavioural management. Essentially, I am referring to the child’s behaviour; but sometimes it is the parent’s or guardian’s behaviour that needs the most adjustment. Let’s deal with the child’s first. Fear is the underlying cause of most problems when children come to the dentist. Sometimes, it is because of how the child has been conditioned by the parents before his first visit. Other times, it is because of what the child has heard from others, or seen and heard on television. It could also be from previously experienced dental examinations and treatment from other kinds of doctors and facilities. And sometimes the child is working out of a vacuum and has nothing to compare his initial experience with. In this case, it may just look, sound, and feel scary. After all, the dental clinic environment doesn’t often look like school, the family room, or a park. It can be very intimidating to any little one.

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The proper orientation of the child before her first visit is the most important initiation a child can have in regards to dentistry. This should be started at home actually. It should begin long before it’s ever time to think about the child going to the dentist. When a child is 12 to 18 months old, she is absorbing everything that is going on in her household. Both parents should be getting regular preventative care, probably about every six months; and in some cases, they may even be undergoing treatment to various degrees. Now, I know that these parents talk to each other about their dental experiences, at least on the evening of having received one. And I bet you can guess how these conversations went. I doubt if it were all roses and honey. And guess whose innocent little ears were listening? Mom and Dad didn’t think to protect their little one from hearing any negative talk about their dental experiences. And little Janie did not show any emotion or body language to indicate she heard or understood it. And she surely didn’t say anything as she couldn’t even talk yet. But guess what. She internalised the whole episode in her memory bank, only to have it come out a couple or three years later when she first goes to the dentist. So, step one is to guard your dental conversations around any and all babies and toddlers.

The next plan of attack is to do just the opposite of the above. Purposely embellish your dental conversations around young children to reflect fun, pleasing, and productive experiences. This will plant the proper seeds to ensure the growth of healthy dental attitudes. Just think about what this same methodology would do for all our children if we used it in all areas of their attitude, mind, and emotional formations. Then, as the time approaches nearer for their first dental visit ever, begin to read to them children’s books on the subject. Finally, on the day of the first visit, try not to make a big deal out of it, but rather just calmly go about your normal business and mannerisms and refer casually to the stories you read them. Once you arrive at the dental clinic, the rest is up to the dental staff. You will first complete your paperwork including the child’s health history, speak briefly with some of the staff, and in all likelihood be asked to remain in the reception area. Do not make a big deal out of this either, but instead just say: “Ok, Siti. I’ll be right here waiting for you. Have a good time!” Now, if the child fusses and becomes afraid and cries for Mommy, it will depend on what that dentist’s policy is for this set of circumstances. Many will still not allow the parent into the treatment area while others feel the parent’s presence and comforting hand will help both the little patient and the doctor. Dentists and especially Pediatrics dentists are somewhat divided on this issue. If you have strong feelings that you do not want to leave your child during examination and treatment times, it would definitely be best for you to ask the dentist’s policy on this while on the phone making the first appointment. If you don’t like what you hear, you won’t have wasted time and caused any embarrassment later. Then, you can continue your search for a dentist who practices the way you will be more comfortable with. Personally, I would not condemn either approach as I believe they both have merit.

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Now, the child is in the hands of the staff and, in all cases I have ever seen, a dental assistant knocks herself out to entertain and please the new child patient. She shows her the instruments, the air syringe, even plays with it and blows air on herself, then on the patient. She may even blow air into a rubber glove and make it into a fancy balloon. There will be a lot of very pleasant activity, whatever it is, and the child will have been won over before she ever meets the dentist. Now, it’s the doctor’s turn. The assistant introduces him in a casual and non-threatening manner. The dentist then continues this charade, right through the examination and diagnosis and, at a later date, into the treatment phase. The patient never will have been threatened or “hurt” and will never know of the dental experience as being anything other than fun. At least, not until she hears or reads about it later in life.

But what if this new patient’s pre-first appointment was not a storybook one as described above? In fact, what if all the pleasantries discussed had actually been opposites; in other words, just one big negative? This is the situation that will call upon the Pediatrics dentist and her staff to reclaim all their previous training and experiences. This is truly one of the most demanding challenges in dentistry and one of the main reasons I am not a paediatric dentist. Well, what to do? There are several approaches that can be made and they are: general anaesthesia, conscious sedation, nitrous oxide, restraining devices, and staff reasoning. And, we are sure we may be missing others, but these are the core ones and we will briefly discuss each.

Dental General anaesthesia in Selangor, Malaysia

General anaesthesia is the least desired and reserved for only those seemingly impossible cases. It usually needs to be accomplished in a hospital setting. The cost obviously must escalate significantly; there is much more time involved; and pre-operative and post-operative stringent practices must be followed. But, most important of all, we do not want to see our young ones rendered unconscious. There is always a risk of any general anaesthetic patient not waking up, no matter how low the risk.

Dental Conscious sedation in Selangor, Malaysia

Conscious sedation offers a safe alternative and can be administered in the dental clinic. The patient will respond to commands, being much more co operative in this “twilight” sleep or tranquillisation. This is most often administered orally, poses little threat, and requires minimal preparative attention other than to have the parent stay with the child and observe him until the next morning.

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Nitrous oxide in Selangor Dental Clinic

Nitrous oxide is quite useful and relatively easy to administer by trained dentists. The patient is calmed down significantly and relaxes through her treatment. Near the end of the procedure, the dentist will adjust the nitrous oxide supply to stop the nitrous oxide completely and increase the oxygen supply. After about five minutes of this formulation, the patient is nearly totally cleared of the nitrous effects and returns to normal. All three of these previous modalities work by depressing the central nervous system.

Restrainment

The next method, restraining the patient, at first glance, may not be very pleasant or humane but, when we think about it, maybe the most humane one of all, other than our last method of reasoning. If a patient’s hands, arms, feet, and legs are tied or held down, his head held rigid, his mouth propped open, and compliance mandated, he probably is in a much less precarious position than with any of the first three means discussed.

We still will not do any treatment to him that we would not do to him anyway and he is jump-and-twitch proof. All four of these methods, as well as the fifth one are still going to require local anaesthesia. (In some cases of general anaesthesia, this may not be necessary; in others, as with an extraction, it probably will be.) The restrained patient is still going to have a topical anaesthetic applied to the gum area to be injected. And when the anaesthetic is injected into the soft tissue, the patient will not be able to jump and possibly cause injury to himself. And, when completely numbed, he will not feel anything during treatment. Since he has been totally conscious with no drugs affecting his central nervous system, he will realise that no harm was done to him and that his treatment has been successful. He probably will not resist a second time and will behave quite admirably since no one wants to be put into this claustrophobic situation (that is, if his parents can ever get him back to the clinic). I do not necessarily endorse this treatment method; but in thinking it through in this manner, it does make fairly good sense.

The best method for treating the uninitiated, fearful, and troublesome patient is to appeal to his reason. The only problem with this is that it usually does not work, but it is worth exploring and spending at least a little bit of time trying it. It works occasionally and is certainly better than resorting to any of the other four methods.

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Now, do you see why Pediatrics dentists go to school for an additional two years of education and training? The behavioural aspects alone more than justify the expenses, energy, and time the doctor must invest. My hat goes off to all children’s dentists everywhere. They are doing a fantastic job!

Bite blocks.
Bite blocks.
Adult and child handpieces.
Adult and child handpieces.
open bite in front.
open bite in front.
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