How to Manage Children in Dental Pain – Paediatric Emergencies – PDP159

Jaz’s Introduction:
And this might be different to those in the US or all around the world. Ultimately, you guys, Protruserati are an international community. So remember that a lot of the advice here is very UK centric, and there are some differences culturally and internationally in terms of guidelines. So just bear that in mind as we discuss Best Management for Children.

Hello, Protruserati. I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. We’re covering a pediatric dentistry theme, which is something that we haven’t covered in a long time. And I want to cover something that is really REAL WORLD, something that affects general dentists day in, day out, and children in pain.

Like, I hate to see it as a dentist, as a father. I hate to see children patient who are in pain. It’s also one of the most stressful things that a dentist can face because it’s very difficult to get a good history. It’s very difficult to do an exam. Like some children will just not let you examine their mouth properly.

So how can you get the best diagnosis? In terms of managing them, there’s so many different variables and considerations, which you’ll hear about today. We talk about deep caries, reversible pulpitis, irreversible pulpitis, abscesses, and how best to manage those in your patients. But these can vary so much depending on the overall status of the child’s oral health, the attitude of the child and the parent, and also how many teeth are actually involved.

So remember that this episode is offering guidelines and I’ll give you some good information about what to do at the emergency visit, but also how to do a comprehensive exam afterwards.

Protrusive Dental Pearl
The Protrusive Dental Pearl I have you is related to pediatric dentistry. It’s the use of something called Fuji Triage by GC as an alternative to fissure sealants for actually sealing fissures.

So let me give you more information about this. Recently I saw my son Ishaan, in the dental chair because he’s got these super deep fissures. And I discussed this with Emma in the episode actually. He’s got these super deep fissures and every time he eats something and he opens his mouth and I see whatever he’s eating will be Oreos to bananas, to raisins or rice.

I’ll always find it just packed in his molars, right? They’re always stuffed with food. So I wanted to do some sort of sealant or some sort of coverage of these deep fissures. Now, on the right side, I was able to get enough compliance to do the standard fissure sealant, so the whole edge, and use something called Helioseal to seal those fissures.

So now, when food gets stuck, I know it’s not going to be causing caries in the Es and Ds. Now, the left side, by the time I got to the left side, his compliance was dwindling, and he wasn’t the easiest patient in the world to treat. So, in that scenario, I remembered from my training at dental school that there’s something called Fuji Triage that we can use as an alternative to fissure sealant when you’re struggling with cooperation.

So it’s like a bright orange colored restoration and you just get the teeth dry and just squirt some in. You can use your finger just to rub this Fuji Triage material in and it’s self setting. So now I look at his mouth I can see on the right side of his mouth he’s got the fissure sealants and on the left side he’s got this Fuji Triage material covering his fissures and it does the trick.

It can work. So if next time you’re struggling to get the ideal optimum level of moisture control, the compliance is great, and you don’t think you can get the light cure in, just stick some Fuji Triage in there, rub it in with your fingers into the fissures, and it will help you get out of a tricky situation. Let’s now join Dr. Emma Ray-Chaudhuri, and I’ll catch you in the outro.

Main Episode:
Dr. Emma Ray-Chaudhuri, specialist pediatric dentist. Welcome to the podcast. How are you?

[Emma]
Hi, good. Thanks. How are you?

[Jaz]
Absolutely brilliant. You are of course married to AJ who we had in the podcast talking about internal bleaching and I really thanked him for that connection because paediatric dentistry is such an important topic for the general dentist because it is a source of joy, it’s a source of variety for us, but it’s also a big pain area in the sense that when you have a nervous patient, when you have a patient, a child patient who’s crying, when you have that scenario where your child patient is in pain, it is devastating for the parents, devastating for the dentist.

And that can be a real source of stress for the dentist. So I thank you in advance for your time to discuss a really important topic. But just before we dive into the different diagnoses, we can make within our child patient and what’s causing their pain and how to best practice for management and advice.

So I think it’s going to be a really, really good episode in the kind of themes we’re talking about. Just tell us a little about yourself. How did you get into paediatric dentistry? How did you figure out that that was your calling, your niche within dentistry?

[Emma]
So I graduated in 2009 from Newcastle, moved to London, did VT as it was called in those days, really busy practice. And I just knew that kind of general practice wasn’t for me. I wanted to specialize, and I thought that was orthodontics. I think DF2 posts were kind of a bit more available in those days. I don’t know how available they are. But I managed to get this one at St. George’s which was orthodontics and paediatric dentistry and then six months oral surgery.

And while I was there I just, I really liked ortho, it was interesting, really enjoyed it, but I loved paeds and I just thought this is what I love doing. And yeah, it kind of went from there. I also met my husband, so pretty good job. Yeah, he was a registrar there.

[Jaz]
Two in one, yeah, a specialist degree and a husband. That’s really cool. And he’s just a great guy, honestly. I really loved talking to him on the episodes and you’ve got three children, so a busy, busy family and you’re practice owners. How do you fit it all in?

[Emma]
I don’t know. It’s a bit, it’s getting a bit easier because our youngest is 18 months, so she’s not at the crazy baby kind of stage, but it is a lot to fit in. I find, I know you’ve got kids, I find the sickness when they’re ill, trying to juggle work and illness is the hardest.

[Jaz]
This has been exactly our scenario in the last few days. So last night I got six and a half hours sleep, which for me is good. But the last two nights combined was six hours because my four-month-old, my four year old and my wife all sick with like a coughing, sneezing, sore throats, everything.

So yes, I can definitely echo that because all the emotions are very raw in me right now. So yeah, in moments of sickness, that’s when it’s really challenging. How many days a week are you clinical at the moment? It’s nice to know about work life balance for people in different stages of their life and career, right?

[Emma]
Yeah. So, I do four days at work, but not all of those are clinical. So I also do, because it’s our own practice, it was a squat practice. It used to be a bathroom shop and we converted it into a dental practice.

[Jaz]
I’m trying to think of something witty or funny to say linking bathrooms and dentists. I can’t quite do it yet, but I’ll come to it later.

[Emma]
So we turned it into a dental practice. So it’s really been kind of a big job. So kind of a work in progress to convert it into that, and kind of we’re gradually taking more and more specialists as associates. So I do a lot of managing of that, so about one or two days a week I do practice managing, and then two to three days a week I do clinical at the minute.

[Jaz]
And I find that specialist paediatrics in private practice, maybe it’s growing now but very difficult to find.

[Emma]
Yeah.

[Jaz]
And when I used to work in Oxford we used to refer all the way to Richmond, West London actually.

[Emma]
Yeah, yeah.

[Jaz]
At that point and so for a lot of parents they have to drive around a long way. Do you find that your child patients come from all over?

[Emma]
Yeah, I mean, as far as I know, I think we’re the only practice offering specialist private paeds within Sussex and Kent. There’s a lovely practice in Surrey. So I get patients from all over coming down. London’s a bit more, got a few more options now, but yeah, some areas of the country will have absolutely no access to paeds, even in hospital and things. So it is difficult.

[Jaz]
In hospitals, they got like this big waiting list in the community. They’ve got these huge waiting lists. So I think the more we can do in primary care setting would be good. And I just find that when you have children with multiple carious lesions, they can be really difficult for general dentists to manage at that stage. Because then a lot of these patients be looking at GA’s. And when you’re looking at GA’s, then you’re looking at these waiting lists and then managing these patients in and in pain and antibiotics.

So it’s a really nasty cycle. Is that something that you, do you see that actually, do you see children coming in and they just, you look at them, their mouths and you think, okay, this child needs a GA?

[Emma]
Yeah, definitely. Yeah. I mean, I offer, in the clinic, I do local anesthetic. I do lots of minimally invasive treatments. So treatment that you don’t need LA for like hall crowns or SDF, so trying to get round that cooperation. I do inhalation sedation, but that’s kind of suitable for your 4, 5 plus. So lots of people think they can do it on 2 and 3 year olds, but they just don’t have the cooperation to understand it. So yeah, there is that kind of group in the middle.

So maybe you’ve got your 3-year-olds with loads of caries. Or even your really anxious 7, 8, 9-year-olds who’ve got loads of caries. That inhalation, sedation’s just not going to touch them. So, yeah, so sometimes I have to say I’m really sorry, but you do need a general anesthetic.

[Jaz]
And have you got any established private pathways? Obviously, the hospital exists, the waiting list along. Do you work with like a private maxillofacial unit and then do you actually go over yourself to offer that care or just keen to learn more about that?

[Emma]
So, no, I don’t offer a GA list. We have a max fax surgeon who works with us, who’s brilliant, and he does anything. Maxillofacial under GA, so we can refer to him, but obviously that wouldn’t involve your fillings, your crowns, anything like that. If any of my children who I see in practice need a private, want a private GA, it would be referring up to one of the central London clinics, and they do offer private GAs.

[Jaz]
Okay. So pathways do exist, but what we want to discuss today is hopefully preventing our patients to get to that point, but that’s a whole public health matter, obviously. But what I really want to home in on is to help the general dentist who’s facing the child in pain. So let’s kick off in and discuss about this fairly big topic.

Now, I specifically said in our email exchanges that we shouldn’t cover trauma because a couple of reasons trauma is just so vast in itself. And B, trauma is one of those things which is really important. I saw the other day, a complex enamel dentine fracture, almost exposing the pulp. But I get like once every six months, I see a trauma and I look at the guidelines to do it.

But this is something that we see on a much more regular basis. And I think this is going to be more applicable to daily care, the child in pain. So we’re not going to talk about trauma. We will touch on MIH, which you rightly mentioned before we hit the record button. So we’ll talk about that as well.

But let’s talk about the different common presentations of children in pain. It’s worth mentioning, by the way, because you mentioned to me earlier that as a specialist referral clinic, you often are seeing them once the initial pain management has been done by the GDP, and they’ve been identified as, okay, they need specialist care, then they come and see you.

So what you see may be different to what they see in primary care, just because the nature of you being in specialist care. Bear that in mind. But, what we want to do is offer some helpful guidelines for the dentist. So, what are the different presentations of children in pain, the most common ones?

[Emma]
Yeah, so, you’re quite right. I’m often very lucky and the general dentists who’ve seen them are doing all the hard work, getting them out of pain, looking after them, looking after the infection. And then I get them for the, kind of, doing a thorough assessment. I’ve got lots of time. So, I really do appreciate it. It’s really hard. Seeing a child-

[Jaz]
Emma, it’s a bit like Endodontists, right? So we general dentists are doing the extirpations. And managing the hot pulps. The endodontists sees a nice empty canal. Low bleeding. They do the, we set them up, they knock them down kind of thing. So I always think about endodontists and you guys in a similar way that, and I appreciate that you said that way, that okay, you have a bit more time. And the patient, the child is not usually active pain.

[Emma]
Yeah.

[Jaz]
Yeah, exactly. I’m sure that happens though. But yeah, it’s good to have that insight.

[Emma]
So yeah, so I think paeds is a really broad spectrum, so I’m going to kind of divide it up, so you can have your babies, toddlers, you can have your pre-, and the way that you examine them and the way that you get the history will be different for everyone, so you’ve got your really young kids, your babies, your toddlers, who are going to be pre communative, you’re going to be able to get a history from the parents only really, and that’s going to be asking about kind of changes in behaviour, changes in eating, are they holding their mouth, are they avoiding letting you brush, are they chewing on objects, all those kind of things.

And we’ve both got young children, we know how hard it can be, even for parents to tell if their child’s in pain, or if they’re just doing something weird with their mouth. So, sometimes it’s not really easy to get history, particularly on the young children. But if you’re hearing that they’re suddenly not sleeping, they’re really holding their mouth.

And this can also apply to children with special needs because they often exhibit these kinds of behaviors because they can’t vocalize or kind of understand enough to vocalize what’s going on. So that kind of history would be for your younger child, if you’re getting into your kind of your school age or preschool, but they’re able to chat to you.

Again, you’re going to be getting most of the history from the parents, but you’re going to get a bit more from the child. And I’m going to be asking things like, do your teeth hurt? Before, I’ve used different words and I’ve realised some children just can’t understand them. So I’ve said, is your tooth tender?

And they’ve looked at me like, what’s tender? So you have to be careful, use like quite words they’re going to get. Does your tooth hurt? Is it ouchy? Can you tell which tooth is hurting? And then ask the parents, are they waking up at night? Are they avoiding eating? Are they avoiding drinking?

Have they had episodes of infection? Have they had facial swellings? Because sometimes you won’t be the first person they’ve seen. Or they might have gone to the doctor before or, you know. So, getting that kind of thorough history. Are they needing Calpol that, are they needing painkillers before bed?

Are school letting you know that they’re in pain? So those things that you perhaps wouldn’t ask to an adult patient. And then you’ve got your, kind of, your final group of kid patients, who aren’t really kids anymore, they’re your teenagers, kind of, your 14, your 15 year olds, and they’re pretty much adults in the way that you treat them, what you’re going to do, but you’ve probably just got a parent sitting there attached to them, and they might be a bit more nervous.

But for those children, I do a really, if they’re in pain, and I appreciate this takes time, so I know you may have that short, however long, 10-minute, 20 minute pain slot. But I think getting to a diagnosis can really kind of funnel you down to what you need to be doing that appointment and which tooth you need to be treating and which you can be leaving.

So I use the kind of acronym Socrates to try and get a structured pain history. In the older kids, I don’t use it in the younger ones, but I kind of get around it by asking all those questions. So I work out where the site of the pain is, when it started, the onset, the character of the pain, whether it’s kind of a dull, throbbing pain.

A sharpshooting pain, whether it radiates anywhere or whether it’s quite well localized to a tooth. Any associations, so does it come on when they wake up, when they go to sleep, anything like that. Timing, how long the pain will last for, how often they get the pain. Is it weekly? Is it daily? Is it once every few months?

Exacerbation or alleviation, so does it only happen when they’re having cold foods, hot drinks, biting? And does anything alleviate it, like painkillers? Have they needed antibiotics? And then, finally, the severity, out of ten, is this a ten out of ten? I would do anything to kind of get rid of this pain. Or is it just, you’re two, three out of ten, and it’s quite mild?

And kind of taking that history. Along with what dental history they’ve had before, what they may have done, kind of judging their cooperation as well from the parents and also just from how they are in the room. That’s how I kind of start my history with them. And what I tend to do with the younger ones, to try and warm them up a bit, and I appreciate this takes time again, but I get them to sit on the regular chairs rather than on the dental chair to start with, and I say, sit on mum’s lap, we’re just going to have a nice chat, you can get used to us.

And sometimes I find that they come in the room and they’re clinging to their parents. But by the time you’ve sat there, and you’ve asked them silly questions about what their favourite thing to watch on TV is and I really do quite a lot of warming them up, they’re quite happy to jump on the chair quite often.

[Jaz]
I find that, Emma, my colleagues that say I don’t enjoy seeing children, my colleagues that openly say that they are, their personas and personalities are not very childlike themselves. I’m very childish. I like to talk about Toy Story, and I like to talk about the latest films and my son’s a huge, me and my son are both huge Spider Man fans.

So I find it very easy to connect with children and come to their level and be all goofy and funny and stuff. Whereas I find that adults who struggle to just pretend that a child don’t have as much success and rapport building.

[Emma]
Yeah.

[Jaz]
So I think a big tip there is to make sure you get down to a child’s level. Be a little bit childish, be a little bit goofy, be a little funny, show the stickers and stuff. I think that greatly helps to get the child on your side and get them to comply with the instructions that are coming. Would you agree with that?

[Emma]
Definitely. And I always, I try and do something when they walk in the room. So I’ll look and I’ll say, oh, they’ve got pink shoes or a glittery top or a spiderman. I’ll go, I love your pink shoes. I mean, I wouldn’t do this to a 15 year old, but I’m talking about one of the ones I’d love your pink shoes. And it tends to build some rapport because then they’re like looking at their shoes.

I’m like, are they new? And just you really do have to put a bit of effort in and it takes time. So that’s why I really do feel for people in primary care. You’ve got a short appointment. I’m saying all these things that I do and I appreciate it’s really hard.

[Jaz]
The most common child emergency that I see. So once you’ve done the history, kind of, if they’re saying it hurts only when they’re eating on that side, they’re avoiding eating on that side. And the most common one I’ll see, it’s a shame is if I was to give you an example, avatar child, it would be an eight-year-old or seven year old with a carious lower D, and an abscess.

That’s like the standard, I find, of emergency, like the median emergency, if you like, of all the child emergencies. And that point, it’s okay. Antibiotics. Literally, I cannot even touch the tooth. We can’t do anything. There’s a clear abscess there. It’s antibiotics because the child will not let you extract that tooth that day, and then let it settle down, come back in, let’s check things again, and then go for the whole radiographs and assess, okay, what’s the damage elsewhere?

If we go with that example, and if you give me any sort of specialist inputs that you have in terms of best management for these children abscesses, and then we’ll talk about the ones that perhaps a little bit earlier and a little bit after.

For example, before then would be just a child with caries and pulpitis versus the child who’s now got chronic sinuses and multiple sinuses. So we’ll go either side of that. Let’s talk about the child with the abscess first.

[Emma]
So, I think I kind of missed off a little bit with my assessment of the kid, but yeah, I would be at that visit when they’ve come in pain, I would ideally want to be trying to get some x rays if I can.

I know again, that’s hard, but I just find without x-rays, I don’t know what’s going on. I don’t know how big that cavity is. I don’t know whether it’s into the pulp. I mean, if you’ve got an abscess, you’ve got how big that cavity is really, but you don’t know what’s going on in the rest of the mouth.

So I spend quite a bit of time trying to get some bite wings or vertical bite wings if I can. And I know that’s probably apart from giving local anesthetic, that’s probably the second least favorite thing for people to do with kids, I’d imagine. Some things I have, which I find helpful for that, I get the tabs.

I don’t know if you’ve seen them, they’re like, I used to get stickers that you stuck onto the x rays. And instead of having an x ray holder, this is all in the SDCEP guidance, by the way. They’ve got pictures of how to do x rays on kids, so it’s quite useful if you wanna kind of a visual.

[Jaz]
Brilliant, we’ll put that in.

[Emma]
I use, yeah, so I use a size zero film, which you may or may not have access to in your practice.

[Jaz]
Mm hmm, we do.

[Emma]
And then I use either a tab or a foam tab. And what you do, if you’ve not seen it, is you stick it onto the x ray, like, where you would want the midpoint of the x ray, and they bite on that, rather than having the whole holder and absolutely everything.

And then you aim the tube to the x ray. And I find lots of kids who can’t tolerate it with a holder because it’s too big and clunky and plastic. You can get x rays on. And I’ve managed it on really small little kids, like three-year-olds, that sort of age.

[Jaz]
I mean, that’s a top tip right there. And if anyone’s multitasking, listen to that bit again. We’ll just re-emphasize that the right tools for the right job. And if you’re struggling to get bitings on kids, it’s probably because you’re using a size 2 film and you’re using the adult stuff, which is not going to work. It’s just we ordered in specifically when I joined the practice, paediatric bite wing holders and size zeros.

But I appreciate that what you’re suggesting is better, which I’ve seen those sticky pads. We don’t have them, but I will get Zoe to order some because I think they are better.

[Emma]
I think they’re pretty cheap as well. I don’t think they’re, yeah, they don’t cost a fortune and you can also rotate them so you don’t have to use them as a horizontal bite wing. You can use them as a vertical bite wing. And I find that really useful if you’re wanting to look at the inter radicular areas on primary teeth. For any sign of infection, how close the successor is, how long this tooth’s got left in the mouth. That sort of thing and some kids who are quite gaggy they may prefer it that way around because although it’s a bit longer It’s not going so far back in the mouth. So I saw it-

[Jaz]
So with this how do you manage the child and if you don’t mind just your topic of radiographs, children who have the infantile swallow and they sort of stick their tongue out and just before they bite together, so before they bring their teeth together and stick their tongue out, those are the trickiest.

So what I’ve usually tried to do is get them to have a swallow first and then tell them, I’ll just be pushing on your tongue a little bit and I’ll just get slowly close together and that’s and usually that that works out. Anything you want you can help us out with these issues?

[Emma]
Yeah, that’s a constant. That’s probably the most common thing with x rays. I think I tried them on my own daughter, and I think she did that as well and managed them. So I act a bit silly and I say, like, you’re a cheeky Mr. Tongue and I’m going to be pushing Cheeky Mr. Tongue out the way with my x ray. And I show them, I get them to have a feel of the x ray, I get them to have a feel around it, and I’ll say, look, it’s not, there’s nothing rough on it, there’s nothing sharp, it’s a piece of cardboard, but in your mouth it’s really sensitive, so everything feels different, and Cheeky Mr. Tongue’s going to want to get involved.

And again, this isn’t for a 15-year-old, because they would just roll their eyes at you. This is your kind of younger kid. And I’m putting it next to the tongue, and they’ll probably look like they’re going to close, and then their tongue flips it over the teeth, and you think, back again.

And I might have, I don’t know, five, six goes at that, and eventually I go, yes, you’ve done it! And they managed to get their teeth together, and then I run to the machine, press the button, and we’re done. So it is a lot of, but I just find them invaluable.

[Jaz]
It’s not just me then struggling with that.

[Emma]
Oh, no, no. Yeah. It’s cheeky Mr. Tongue.

[Jaz]
That’s right. I love that. Cheeky Mr. Tongue. Okay, now we’re going to add that to our vocabulary, vocab list of child friendly terms. And so, but my worry is, I’m just, just to make this appeal to the GDP in practice, talking about that abscess again, very often I find that getting any pressure on that tooth, any radiographs on that day, when it’s a clear cut abscess, do you think it will be okay for the GDP to has that 10 minute emergency, their child is clearly febrile, fever and stuff and having the cowpole and they just need some amoxicillin suspension, just skip on the radiographs on that occasion?

[Emma]
Yeah, of course. Of course, you’ve got to do what you can do. I think for comprehensive treatment planning, you need radiographs. But you’ve got to do what you can do on that day. So there’s some kids I can’t take radiographs for because they’re not going to let me. And if on that day, they’re in pain, you think they’re unwell, they’re systemically unwell, you can justify antibiotics.

Yeah, that’s obviously the right course of action. But I think it’s important to say to the parents, and to also record in your notes from a medical legal kind of perspective that you’ve advised them that this is an emergency visit, you’ve focused it on that corner of the mouth, they need to come back because it’s likely they’ve got problems elsewhere for a full exam and that you haven’t done a full exam on that day.

And then check the abscess that’s gone down, get one of your team, if you’re able to give them a call, check it’s gone down, and get them back, properly do an exam, and let the parents know.

[Jaz]
Emma, I find that a lot of GDPs are, like, once they do bring the child back, I find that a lot of GDPs are, I don’t know, shy, or not proactive in taking radiographs as often as we would like.

[Emma]
Yep.

[Jaz]
And this is just an admission, I like to take them. A lot of colleagues do not like to take them. I just find from what I was trained by Helen Rodd at Sheffield, and her words always stuck with me, that when you take bite wings, you’re able to diagnose six to eight times more caries than you are just this clinically, right?

And so you’re missing a lot of data. And sometimes I take these bite wings and I think, whoa, clinically the situation looked amazing, but these D’s are absolutely shot.

[Emma]
Yeah. Sometimes I see, I mean, the reason you can’t see holes often in kids like you can in adult teeth is they’ve got really broad, wide contact points on primary teeth. So you probably, yeah, so it’s hidden underneath the contact point. And until it’s got quite big and it’s really broken through, you can’t see a cavity. And on most kids I use my loops, so I’m looking at them, I’m drying their teeth, I’m having a really good look. And sometimes I can’t even see that kind of shadowing of the marginal ridge.

But you take the bite wing and you’re like, whoa, that one’s nearly pulpal. Yeah, I think I would miss a lot if I didn’t take bite wings. But I appreciate, I mean, I think there was a post recently on Facebook, people talking about when to take x rays in kids that I saw, and I saw there’s a really big variation.

And lots of people weren’t saying they’re not taking them because they don’t want to, they can’t be bothered. They just felt that it was over irradiation. So I think there’s lots of reasons that people don’t take them. It’s not all just because they don’t have time or things like that. There are just different schools of thought on it. But for me, they’re an absolute must. I can’t diagnose without them.

[Jaz]
What’s the youngest age? Like, imagine we’re not talking about pain anymore. Just for a brief second, we’re talking about a routine child examination. At what age for your routine child they’ve been seeing, they’ve got, they appear to be low caries risk, let’s say.

What age should you first attempt bite wings? So just give you a baseline and also make sure they’re not in that scenario where they have got all this caries, which wasn’t obvious clinically. And then based on that and all the other information about their carries risk, you can then set intervals, right?

[Emma]
So yeah, so I don’t do many routine patients anymore because we’re like a specialist referral center, but I did used to in a private practice. So the SDCEP guidance recommends that you could think about start taking them from four. And that’s for your regular patients without evidence of caries. As I said, I will take them younger than that if I’m able to, if I’ve got pathology.

So if I’ve got a reason to take them. If I’ve got a kid though, they’re four or five and I know they’ve got really low likely carries incidents. I probably wouldn’t start at four if I can have a really good look. I might start at five, that sort of age, but it’s pretty young that I’d be looking at starting. I did my own daughter at five, if that’s any.

[Jaz]
Treating your own children is like, it’s traumatic in a way for the dentist. I treated my son the other day actually. He’s got some really deep fissures on his D’s. It’s extremely deep. Every time he eats something, like his D is just, whatever he’s eaten is inside the lower D’s and E’s actually. So it’s got really deep fissures. And so it kept bugging me. So I saw him, I did fissure sealants on the right. And at this point I made a video of this and this point, his compliance was really not great. And I wasn’t going to get to the left side. So then I had to use Fuji Triage rolls in. And Fuji Triage, fissure sealants. Is that naughty? Am I naughty? If in that dying moment, I had to just switch to Fuji Triage. That’s the only thing I can get in.

[Emma]
That’s a technique. Yeah, that’s a technique for pre-cooperative kids. Yeah, it’s a finger stamp technique. Sometimes they even recommend sixes. So yeah, you’ve got to do what you can do to in the situation.

[Jaz]
It’s the two-month review suggests everything is going well, and they’re both the officiants on the right and the Fuji Triage on the left is still going. So I’ll keep the Protruserati updated year by year on how those hold up. But I just feel so much better now. And you know what is really, okay, this is this is really interesting talk about Emma.

It was so good to see under my five times loops my own child’s mouth, right? Because me and my wife are really, no, we’re dentists. So we are really thorough about brushing my son’s teeth. Mostly me because I’ve just taken charge of that. And I said, I will do that because she does so much. Let me at least brush the kid’s teeth. Okay. So, I’m very, very thorough with that yet. I was embarrassingly really upset and shocked about how much plaque I saw on the buccals and linguals areas.

[Emma]
Yeah.

[Jaz]
And I realized the mistake I was making was that I was just focusing so much on the occlusals that I just wasn’t even going on the buccals and the linguals palatal. And just so good to see that. And then now I’ve been changing the way I brush and changing the position. So before, he’d be the same level as me. Now he’s way below me so I can get better access and stuff. So sometimes I would encourage everyone to just yeah, bring the children and look on the loops and see all these issues.

But if we’re dentists and I see this in my own child, you’ve got to think about the public. And sometimes, he’s too sleepy. We’re out somewhere. We’re driving home. He’s asleep. And we miss a night, it happens. So you think about the public. And then parents say to me, oh yeah, well, morning’s a real struggle.

You only really brush it at night, and we had a good day. And so the actual state of affairs in the real world is not very pretty. Is that what you found as well? History taken about brushing habits.

[Emma]
Yeah. I mean, I had exactly the same scenario. I examined my older daughter, Aria’s 6s, and I could see plaque on the buccal margin of the upper sixes and I brushed them for her and AJ brushes them for her and she does them herself.

And I thought, if we can’t get rid of all that plaque. Like, it’s the same. Yeah, I do find it’s really variable. I think, in practice now, I’ve got probably quite well motivated patients because they’re coming specifically, they’re choosing to come and see a paeds specialist. So I’m getting more of your twice daily brushes.

I have some anti fluoride parents, but we are getting these more twice daily brushes. But yeah, I’ve worked in all sorts of places and hospitals and some people, they’re not brushing even every day. They’re brushing like, a few times a week. They’ve got a split family situation, so they might be going to their dads at the weekends or aunties or all different arrangements.

And they might say oh yeah I brush their teeth all the time but when they go to dad’s he lets them drink coke and they don’t have a toothbrush or you know so there’s all.

[Jaz]
I hear that all the time. Yeah.

[Emma]
All different arrangements and I mean I think you can only give the advice based on what you know and see how they can fit it into their family situation. And I think there’s probably a lot of, oh yeah, we definitely brush twice a day, when you think they probably don’t brush twice a day, because they’re sitting in front of a dentist and they’re telling you what you want to hear. So yeah.

[Jaz]
And we just got to be very mindful of that. And, it was very refreshing for me to see that in my own child. So we’ve changed habits. And when I see it on another child now, I just tell the, I share the same story now with my parents, the story I share with parents, I look, even me, when I look at my own son’s child, I was missing areas. So, keep helping your child and I will help you to help your child.

I will coach you to see how you can get better outcomes with your child. Just going back on the topic now in terms of abscess. Antibiotic suspension at that point is too late. Obviously, a comprehensive examination, the importance of radiographs, we’ve stressed on that. What about, here’s a tricky one now, and I think the rest of the episode we’ll be talking about this scenario is, let’s talk about instead of generalised caries.

The localized caries on that, four or five year old on a D heavily caries and now symptomatic. So it is difficult to make a distinction on a child of, is this reversible pulpitis or is this irreversible pulpitis? And whether you need to extract that tooth or which child nowadays is even suitable for pulpectomies.

It’s not something that’s commonly done in practice. And I’d love to hear your views and guidelines, SDCEP, etc.

[Emma]
Sure. So I think the kids with the abscess, you’d be wanting to get them back, do your full exam. And yeah, that sounds like a tooth that needs to come out for the tooth fairy, as I would say to them.

And it’s whether you think they can cope with that in primary care, whether you think they need to be referred to like a community or private specialist or wherever for sedation or general anaesthetic. And it’s likely if they’ve got that one tooth with the abscess, they’ve probably got something else going on elsewhere.

And then obviously putting in a thorough preventative regime. So we’ve kind of dealt with that one. And then if you’re looking at your other children, so say you catch them a little bit earlier, you’ve got your four, five year old, they might have a caries D, it’s really from your history, whether you think it, and your x rays if you can get them, whether you think it’s reversible or irreversible.

And that can be difficult for a kid because they may not give you the same quality of history as an adult would. But you’re looking for those kind of things like the lingering pain after they’ve stopped eating, wake at night time, needing painkillers, all those kind of things that are pushing you to your irreversible pulpitis.

The reversible pulpitis would be the kind of, they have a cold drink and it hurts for a few seconds, it hurts on brushing, they’re not woken up at night time, they’re probably not needing painkillers. That’s kind of your reversible.

[Jaz]
Or maybe Emma, the parent, would say that he’s just refusing to let me brush in that area.

[Emma]
Yeah.

[Jaz]
And it’s very resistant. Otherwise, okay, but he just won’t let me brush it because it says it hurts. Can you please take a look? And then that’s when you find a cavitated distal margin of a D or an E, for example. And then at that point, yes, hopefully if your child hasn’t got abscess and you have a bit of time, take the radiograph and make the assessment.

But let’s say you’re this is where I’m throwing tricky scenarios at you, so I do apologise in advance. These are real world issues. You go deep caries, but the diagnosis is still reversal pulpitis. You don’t think they’re getting up at night. It’s not quite necrotic. It’s not quite an abscess yet. These are really tricky ones to manage.

Yes, we can talk about whole crowns and stuff and we can talk about fillings. I actually recently read on a Facebook post as well recently, a filled D is a dead D. So we’ll talk about as well, basically, because a lot of times you do direct restoration in a D and then that tooth will abscess in about six months to two years. So let’s talk about these very tricky decision making scenarios. Please offer some guidelines on that.

[Emma]
So if you’re seeing, so you’ve got that cage, you’ve probably got reversible pulpitis. If you’ve got any radiograph, you can’t see any radiographic changes. And on a primary tooth, it’s going to be in that inter radicular area rather than at the apex of the tooth.

[Jaz]
Hence the vertical bite wings.

[Emma]
Yeah. That’s why they’re so useful. So on those, I would want to be, probably, at that first visit, trying to put some sort of temporary filling in that area. So trying to clean it out the best I can. Say I’ve got my 10 minute slot, 20 minute slot. I’m putting some kind of temporary filling to see if that tooth then settles down. And then-

[Jaz]
LA or no LA? Again, tough questions. No right or wrong. I’d love to know what you do as a specialist, what you advise, and we can take that on board.

[Emma]
If you’ve only got a short appointment, you don’t think you’re going to get LA. Then scooping it, we’re literally doing a temporary kind of filling, scooping it and getting a temporary filling in there to try and just see if the symptoms settle. That’s really just to get them out of pain and to get your diagnosis, then you get them back.

[Jaz]
But if it’s not cavitated, then I guess you’re going to purposely cavitate then get access?

[Emma]
Then you probably are going to, well, what I do is I use hall crowns. So I don’t really, if I’ve got an MO or DO filling. It’s so much easier for the kid just to put a whole crown over it, you don’t have to do, I’m really into minimally invasive dentistry, you don’t have to do any prep, you don’t have to do any caries removal, we know they work, they last, but not everyone has the materials, not everyone has the equipment, not everyone knows how to do them, so. I’ll talk about other things, but what I would do is, is I would get them in.

[Jaz]
We will touch on hall crowns; I think it’s really important. I also do hall crowns. I actually got a video on YouTube. I checked the other day. I got a video on YouTube for patients of me putting a hall crown on a child, and I just saw the other day it’s got 18, 000 views and like parents are watching it and just learning about that.

Yeah. So, yeah, that’s going well. But yeah, I’m a huge fan of it. But unfortunately, most colleagues I speak to, especially in busy practices, don’t have the appetite to do it and don’t have the resources to do it. My principal won’t buy me this 350-pound kit from 3M or whatever. So let’s, let’s touch on that very difficult scenario for the dentist whereby they’ve got deep caries and they don’t, whole crown is just brilliant for that. Then if we haven’t got much time, it’s cavitated and you scoop out the mush. And what kind of temporary filling would you be suggesting in that stage?

[Emma]
So IRM or Resin Modified Fuji, something like that. Just to get it in, get them back when you’ve got time a week later, do a full exam, and book them in to have a proper filling done on that tooth, which if you’re going to really get it cleaned out, you want to make the tooth numb, you want to get good isolation, which to me is just so much harder than placing a whole crown, much harder for me, and harder for the kid, which is why I love them so much. And we know from the research, they don’t last as well. But you’ve got to work with what you’ve got. So, yeah.

[Jaz]
I think let’s talk about that. Let’s make some clear recommendations. Like, guys, if you’re going to book a child in, you’ve dealt with the emergency, you’ve got your 1.2 UDAs, for example, those in the UK, and you’ve dressed the tooth and dealt with the acute scenario of deep caries, and you’re going to bring them back in and you find out, ok , actually the contralateral second deciduous molar also has caries.

Surprise, surprise. You take the bite wings and there we are. And now, for three UDAs or whatever, we’re talking about NHS here, but it can apply to anything. You’re going to do all that, or even if you’re private, you’re going to charge the patient for all that length of time to do the one side and the other side under LA, which is going to be traumatic for the child, traumatic for you.

Let’s just go ahead and say, guys, maybe now’s the time. Maybe this podcast will be the one that remind you that we should perhaps be considering hall crowns because they are the best. And is that what the SDCEP recommends as well?

[Emma]
Yeah, they are kind of the recommended technique for multi surface cavities in the primary dentition and they’re just, we’ve got loads of data on them now and they’re shown just to last so well.

Sometimes they come off. But it’s not the same as a failure of a filling where you might have secondary caries around it. You might have lost more of the tooth. It’s kind of, the crown’s popped off and you’re like, so what? If the tooth’s OK, I’ll put it back on. They’re just so easy.

[Jaz]
I’ve never had one, Emma, that’s come away. Only because I don’t do the numbers that a specialist would do. When it comes away, do you find that it’s just, like, leaves cement behind? And it’s like a nice GIC crown that’s left inside?

[Emma]
Yeah, sometimes. Or sometimes it’s come off in the crown. I find that happens most if you’ve got, so they come in set sizes for anyone who doesn’t know, they’re like two to seven, and I always say it’s a bit like fitting a pair of shoes when you go shoe shopping, so you try on the different sizes, but they don’t come in half sizes, so some kids are a half size, so you’ve got to then, so you can feel it and it’s kind of going on and off, it’s not got that nice click, they’re the ones that tend to come off for me, because I can crimp them, so I haven’t bought expensive crown crimpers, I use upper D forceps, And I just use it to tighten the margins a bit, but they can still come off sometimes.

[Jaz]
And when I’ve been in that scenario, I know this isn’t specifically about hall crowns technique, but let’s talk about it. The hall crown doesn’t come in half sizes. I love that analogy of the shoes. That’s brilliant. So, sometimes if you’re going for a smaller one, because of the bigger one, it’s just going to get in the way of the contacts of the adjacent piece.

So you’re picking a smaller one. So now you have to make your tooth that you’re treating a little bit smaller and break the contacts. Is that something, how you’d manage that, right?

[Emma]
Yeah, so I always put sep-, well, nearly always, unless there’s space. I always put separators in a few days before, so the orthodontic rings, I put them on floss, put separators in to get some space.

However, if the tooth itself needs a bit of reduction, I will either use so ortho interproximal strips that you might do for IPR.

[Jaz]
IPR for all? Yeah. Yeah, sure.

[Emma]
Yeah. But being really careful because obviously they’ve got little lips in the way, so you need to hot. And I’m always a bit nervous when I’m doing that.

[Jaz]
Or the little saw ones can be quite handy in that scenario.

[Emma]
Okay, yeah, I’ll try those. Or I’m going to do something like using like, I think a really fine bur, but very carefully just a zip between the contacts. Or sometimes you need to do that to take off the bulbosity on a D if it won’t sleep down over that or yeah, but no-

[Jaz]
Sometimes the issue is, I mean, this is a real niche, tricky scenario is because they have got cavitated caries, the adjacent teeth have tilted into the cavitations.

And that is the trickiest scenario because in the base of the tooth at the CEJ is wider than what you have more coronally. And that’s just the worst scenario, isn’t it?

[Emma]
Yeah. And then sometimes. If they’ve got to that, you need to think about, are they a restorable tooth? Is it better to lose this tooth? Sometimes I’m using the crown slightly rotated, or using a different arch crown, or, yeah, I’ve tried all sorts of things in the past.

[Jaz]
Okay, we definitely need to make an episode, Emma, on hall crowns, just everything, the defensive guide to hall crowns. It’s going to happen, but let’s get, it’s me digressing, not you, by the way, Emma, it’s me leading it to different tangents.

But pain, so deep caries, on that emergency appointment, which is the main focus of today. Let’s address it. Ideally use LA, but you said that sometimes in a rush and if you can just use a hand instrument to clean out the mush and then bring that child back for a definitive assessment.

[Emma]
Restoration.

[Jaz]
Yes, absolutely. What if it’s irreversible pupitis on that child? Is there much place for extirpations and pulpectomies in children? It’s a very tough thing to do for a child. Again, LA and all that kind of stuff. What should a dentist do in that kind of irreversible pupitis scenario?

[Emma]
So yeah, so, really good question. I rarely do them, but they do have a place. So the place would be in a kid that you’re really desperate to hang on to a tooth for some reason. They might have hypodontia, there might be a reason that you don’t want to extract it at this point, they might need to have hospital care, they might have a bleeding disorder, all those kinds of things.

Or they might be a kid who’s really well motivated, they haven’t got loads of other cavities, they’ve just got this kind of one or two cavities, and you think yeah, I could save that tooth. It hasn’t got root resorption. So those are the ones you’re going to focus your pulpotomies on or if you didn’t want to do an extraction at that visit, so you felt that it was a bit much for the child Although I find an extraction is easier than getting them to sit through a pulpotomy I would find on the first visit.

I would rather take the tooth out. So I think if you can get the tooth numb You can usually get the tooth out, it’s the numbing that’s the thing, and you need that for either procedure anyway. So yeah, so I think they have their place, I think people are using them less and less, particularly because we have the options of selective caries removal, we don’t need to go actively into the pulp, like, we used to get the cavities scratchy clean and we’d probably inadvertently unroof the pulp and then have to do a pulpotomy. And we’re using-

[Jaz]
But for irreversible pulpitis, that wouldn’t really be an option, right?

[Emma]
Yeah, yeah. For irreversible pulpitis. Yeah. So if you’ve got irreversible pulpitis, your options are, you can either extract that tooth, you can unroof the pulp chamber and place something in the pulp chamber as a temporary measure like lead amidst it if you can get hold of it and temporize over.

You can do a full pulpotomy on that day if you’ve got time. So you’re fully unroofing the pulp chamber, you’re leaving the pulp stumps, so in the orifice to the root canals. And you’re either placing ferric sulphate or MTA and then you’re filling that cavity and doing like a proper pulpotomy, which is going to take time and probably isn’t going to be what you’re doing on your emergency visit.

[Jaz]
Very true.

[Emma]
And I rarely do them, to be honest. Or, if you’ve got a really, really pre cooperative kid and you know that they need a referral for general anaesthetic or inhalation sedation or something, but you’re desperate to do something to get them out of pain, but you just know you’re not going to be able to either extract the tooth or do a pulpotomy.

Kind of the least best option, but it is in the SDCEP guidance, would be to use the hand excavators, try and get as much out as you can and place a dressing like leather mix in that caries cavity with a temporary filling. But it’s variable whether that gets them out of pain or not. But that’s kind of your training.

[Jaz]
I mean, we can’t cover every single scenario. For those, Protruserati, on the app, please comment in the community section. Or if you’re watching on YouTube, please do comment there. And it’d be great to see you on the Facebook group, various places. Just, let’s continue the discussion. This is something that’s very, very real world.

In these scenarios where you’ve got a child with multiple caries, and sometimes when I’ve referred to community, for child with multiple caries. I’ve dealt with the acute situation. I refer to community because I think they’ll benefit from inhalation sedation. The letter I get back and this is a little bit controversial.

I get the letter back and it says the child when I saw them was not in pain. Therefore, as per the fiction trial, we suggest just seeing him regularly, fluoride varnish and they don’t even mention SDF in the letter I don’t think, but yeah, fluoride varnish and because the child’s not in pain, we don’t need to see them.

So this is currently what community, National Health Service community are saying to us. They’re saying that we’re following the fiction trial. Yes, there’s multiple cavities as carriers, but because the child’s not in pain, the fiction trial suggests that you can just dip them in fluoride and keep things going.

What are your personal and professional views on management of a child as per the findings from the fiction trial? And I don’t know much about the fiction trial. If you know, you can shed some light on that. It’d be great as well.

[Emma]
So I think that’s really hard. I think you would want to be making sure I’m not saying you, but whoever’s making this decision would want to be sure that the child hasn’t got there. And the SDCEP guidance is quite good for this because it shows you some ideas of which teeth are likely to progress to pain. You do want to be thinking, are these teeth likely to progress to pain before exfoliation? So your teeth that have got cavities like right close to the pulp and they’re not getting to an exfoliation age.

Teeth that just kind of close cavities. And they’re not cleansable. You can’t get in there with a toothbrush or fluoride. And they’re likely to cause pain. Those I would be a little bit worried about not doing something with. I mean, SDF I use a lot, silver diamine fluoride. And if you’ve got a nice, open, cleansable cavity, you can treat some, if the parents are willing, you can treat some of these teeth that you perhaps would have before extracted, providing there’s no pulpal symptoms with something like SDF.

But leaving teeth just because the kid’s not in pain and then they have to go back through the referral system again makes me a bit nervous, to be honest. I mean, I don’t know the individual case.

[Jaz]
I’m so glad you’re saying this because I feel the same way and I just feel, okay, maybe controversial. I feel fobbed off as a general dentist who’s taking the effort to refer to the community and I feel sometimes I feel fobbed off and I get it because these services are so busy and I get it. But I don’t think as a nation, as a, we need to maybe look at how we’re doing. It’s a bigger, bigger level, way bigger than the podcast.

So, but yeah, just thought I’d mentioned that. Now, you mentioned a really good point about cavities that are non-cleansable. So one thing that general dentists have advised and, or something they do in practice is having that cavity, but then just drilling it a little bit to make it now cleansable, what are your views on doing that and then monitoring and SDF and fluoride for that child who’s not in pain and just to keep them out of pain?

[Emma]
Yeah, I think that’s a reasonable option. And again, I’ll keep mentioning the SDCEP guidance, but that’s in there as well as an option. So yeah, you can open a cavity, make it cleansable. You’d want to make sure you had a good pulpal and periapics diagnosis, so you know you’ve got healthy pulp, or reversibly inflamed possibly.

And you haven’t got any sign of infection. Because the last thing you want to be doing is sitting on infection. Because either you don’t know because you haven’t managed x rays. Or you haven’t managed to tell. And then just whacking fluoride on it. So you want to be sure that this is a healthy tooth.

That they can keep cleansable. That they know how to keep cleansable. And either putting fluoride in there or ideally SDF. But it does make the teeth black. So, yeah.

[Jaz]
It’s not for everyone. But the whole plaque management. It has to be right for the mouth. If the child’s struggling to use the end of the toothbrush, and you’re not going to just make it cleansable because there’s no cleansing happening.

So it’s got to be the right motivated child and parent, right? So that goes without saying, I think. You mentioned earlier before we hit the record button about, a possible diagnosis that a GDP could make for a child in pain to do with MIH. Can you just briefly describe for the GDP about what is MIH, what kind of pain presentations, and just best advice on managing children with MIH in practice?

[Emma]
So, MIH, so Molar Incisor Hypomineralisation, which is a very long word, so MIH, really, really common. It affects one in six children in the UK, so you will be seeing it in practice. And what this essentially is, is the first permanent molars, doesn’t have to be all of them, can be one of them, can be all four, and sometimes the incisors have a qualitative defect of enamel.

So that means the enamel is lower quality. It’s reduced mineral content. We don’t know quite why this happens, but there’s lots of research and the current evidence seems to suggest it’s some form of illness or illness in the mother in the last trimester of pregnancy, premature birth, difficult birth, illness up to age three.

Combined with genetic predisposition and then possible other factors, but it’s not set in stone. These teeth that do form like that.

[Jaz]
One thing on the etiology Emma, one thing I always ask parents, I ask Mom usually is, I don’t know if this is the right thing or not, but interesting discussion. Every time I diagnose MIH, I look at the Mom and I say, was this child a cesarean birth? And it’s just, I just, and they say yes or no, we discuss it. I don’t know. I just felt as I read somewhere that it’s more linked with cesarean birth. Is that true?

[Emma]
Yeah. Premature birth. Loads of things. Nearly anything you could list in childhood. It’s linked.

[Jaz]
Exactly.

[Emma]
Yeah. I always do this as part of my medical history is I always ask about birth history, illnesses and first few years, pregnancy history.

Anyway, these teeth, so they’re reduced mineral content. The way that you will notice is they’ve got these really demarcated opacities, so clear areas of different kind of chalky colour of tooth, and it can be white, it can be brown, it can be yellowy, and sometimes when you see them, they will already be a bit broken and crumbled and broken down.

These teeth, they’re not as strong as a regular tooth. So they can break down on normal masticatory forces, so just eating and chewing. They can get caries more rapidly. They can be super, super sensitive. I’ve had children with this, and their teeth don’t look so bad, so they’re not broken, but you can see the opacities if you look, but they say it hurts to go out in the wind, because the cold in their mouth is just changing the sensations in that area.

And I see some kids, and they’ve got immaculate oral hygiene, but then they’ve got this one really gross six that’s just caked in plaque. Because moving a toothbrush over it is just so exquisitely tender that they can’t cope with it.

[Jaz]
And these teeth are difficult to numb as well, right?

[Emma]
Oh yeah. I had one the other day with sedation, with articane. I struggled to get this tooth numb. Yeah. So yeah, they can be really difficult to anaesthetise. And yeah, the way I explain it to parents is instead of having a helmet over the tooth protector, you’ve got a sieve. So everything is being transmitted to the nerve and it’s really, really sensitive. So this could, this is a whole lecture, kind of talk in itself, but just kind of briefly.

To get them out of pain, you’ve got to be working out is, is it just sensitive because it’s a kind of a happy, intact tooth that hasn’t got any irreversible pulpitis or pulpal infection. So thus you don’t need to be treating the pulp at this stage and it might need coverage because it’s just basically sensitive because the whole tooth is just a sieve. Is it a tooth that because it’s got MIH it’s broken down and you’ve got a reversible pulpitis?

And thus you need to be treating the pulp of the tooth so you need to be doing your root canal treatment your pulpotomy and those sort of things. I see more kids who’ve got just really sensitive teeth because they’ve got MIH and you can have this in ease as well If you have it in the primary dentition, so in the E’s, which my daughter does, you’ve got a one in four chance of having it in your sixes. So I always-

[Jaz]
Wow.

[Emma]
Yeah, so they’re really linked.

[Jaz]
I didn’t know that.

[Emma]
Yeah. So you always tell the kids who I see who’ve got it in their primary teeth. That when their sixes erupt, we need to have a really good look at them for signs of MIH.

[Jaz]
So let’s go with the more common one, which I see as well, MIH, a fair bit in our community. And it’s just a super sensitive six, which doesn’t have any active caries, it’s a bit yellowish in colour, and all I’m doing at the moment is just reassuring. Fluoride and that’s it. Is there anything better that could be doing to help this child’s sensitivity?

[Emma]
Yeah, so there’s some evidence for tooth mousse. So you can get children to apply tooth mousse to those teeth. This is when you’ve got your milder sensitivity. You can be using tooth mousse and I get lots of patients to use that. It’s quite expensive. It sells for about-

[Jaz]
You can get in Amazon, right?

[Emma]
Yeah, about 17, 18 pound a tube, but I tell them they only need like a finger bit every night to rub on each tooth. So that’s kind of first line. Second line would be thinking, do they need some coverage over the sensitive areas to stop, just to stop the kind of transmission of cold and hot and everything. And I use that Fuji Triage you talk about quite a lot.

[Jaz]
Okay.

[Emma]
So that can be, that is, GC advertised that for use on hypermineralised teeth.

[Jaz]
Okay, brilliant.

[Emma]
And you can use that just quite simply with cotton wool isolation either side of the tooth. One tip I would have is don’t blast cold air on these teeth because they’re so sensitive. And if you are doing treatment on one of the teeth. and you’ve anaesthetised it for whatever reason, and your nurse has got the suction, just let them know to be careful around any other teeth, because I’ve had it where the nurse has inadvertently touched another tooth that’s got MIH, and the one is numb, but the other one is, because it’s so sensitive. So, yeah, so be really careful with that. Dry it with cotton ball, and then-

[Jaz]
So this is under local anaesthetic though, right?

[Emma]
No, no, no, sorry, I’m referencing again. This is just your, kind of, your temporary measure. So you put in your cotton ball, you’re not blasting cold air. And you’re rubbing cotton wool over it to dry it, and then putting something over it to kind of seal it up, like Fuji Triage.

[Jaz]
And this is like the buccal surface?

[Emma]
Anywhere that it needs to be, but it’s less likely to last on the buccal surface. So I find it lasts better on the occlusal. If after that, you’re finding that most children after that, depending on how severe it is, will say it’s better. You probably want to then review them and see.

If they’re saying it’s better but I can still feel it in certain areas I might try and top it up. If they’re saying it’s made no difference and I can kind of tell the area of sensitivity is going areas that we can’t cover because we can’t do a crown from Fuji Triage, they might need a sort of kind of specialist assessment, and I might do something like placing a stainless steel crown as a temporary measure until we look at timed extractions of those teeth. And that’s something that can be quite useful in really hypermineralized teeth.

[Jaz]
Okay, great. I mean, that MIH could be easily a whole lecture. We’ll do the whole crown one day, hopefully. But MIH is, yeah, is this whole thing, but it’s simply the main point of mentioning it is just as a diagnosis that maybe some general dentists haven’t got at the forefront of their mind. You should remember that. I’ve been in scenarios where I’ve seen a child patient who in the past has been told off by a dentist and I had a look in the mouth, hang on, this isn’t your fault.

This is MIH. And parents like, what’s that? Well, we had never heard of this before. Was actually, this is what you, this, this is why they’ve got the white spot on their front tooth and exactly. This is why that, and they’re like, oh, it’s all making sense now. So I’d say to the patient, it’s not, you, don’t worry.

It’s the tooth, but let’s see what we can, so another lesson here is, don’t make the child, I mean, don’t make any child feel bad. It’s caries and children’s not the child’s fault. Let’s remember that. Right. In a way, ultimately, it’s a conversation that needs to be have with the parents as well, but especially for MIH don’t victimize the child. Would you agree with that?

[Emma]
Oh yeah. I see lots and they come in and they say, I can sometimes tell just from the history that it’s going to be MIH because they’ll say, he’s never had a filling in his teeth. They’ve been perfect. Suddenly he got his adult teeth and started happening and I think-

[Jaz]
That is a classic.

[Emma]
Yeah, but yes, sometimes I can say I don’t know what they feel really guilty. I don’t know what we’ve done. They don’t really have squash or juice or coke or whatever and yeah, I really agree with that. And it can happen on the primary. Yeah. So sometimes you can.

[Jaz]
Yeah. I didn’t know that. I didn’t know it could happen in the primary. So that’s been really useful for me actually. And I know I threw some really tough questions for you. Some really high-level public health matters that I threw at you. So apologies for all these curveballs that I threw at you, but thanks so much for answering so well on all of them and giving some guidelines for children with abscesses, children with reversal pulpitis in the real world emergency scenarios.

Irreversible pulpitis, how pulpectomies are very difficult to do and you just make so much sense. If you’re going to numb up a patient and do a pulpectomy, then in that child who’s got that deep of caries, they’re probably not a suitable candidate for a Pulpectomy in the first place or pulpotomy, as you said.

One last thing, actually, international variations in management children. I find in Arab countries, from what I see, my colleagues and stuff, they’re much more pro root canals in pediatric teeth and whatnot. And the mantra there is really, that’s save these teeth as much as possible, whereas in the UK, we’re more pro extraction.

Any experience that you’ve had, I just want to share anecdotally about variations culturally or internationally amongst the management of such teeth?

[Emma]
Yeah, I noticed that too. And I think in the UK, we are quite pro extraction. However, I do know that in different countries, they have different guidelines and legalities for using different methods of sedation and general anaesthetic.

So what we’ve got available to us in primary care. It’s quite limited to managed children. It’s local anaesthetical inhalation sedation, really. So you’ve got a limit of what you can achieve, whereas in, for example, the USA, they do deep, deep sedation in lots of regular dental offices. So they do do different types of treatments.

I saw an interesting case yesterday, actually, and that was from abroad. I think it was from Jordan, and it was for the MIH on the sixes. But they’d all been re treated, they’d all been crowned, and because that is the thing that lots of places like to do because they don’t want to take out teeth.

However, we were then having to take out some of these teeth when this girl was 15 because they’d failed by this point. So I just, I think extraction has its place sometimes to let that child get to a healthy mouth that they’re not having to maintain and well, they do have to maintain, but not kind of, you know what I mean? Not having root canals.

[Jaz]
Carry the baggage of a root canal for the rest of their life, right?

[Emma]
Exactly.

[Jaz]
Emma, thank you so much for sharing all the views. We’re SDCEP guidelines available for everyone. Please tell us where you work for anyone listening who wants to refer patients and learn more from you. How can they reach out to you? That kind of stuff, please.

[Emma]
Yeah. So I work in a private practice that I own with my husband in Hassocks in West Sussex we’re about 20 minutes north of Brighton, it’s called Graystone Referral Center and you can find us at graystonereferral.com or you can email me on emma@graystonereferral.com for any advice or questions.

[Jaz]
And do you do like, because I know a lot of specialists, I know you’re really busy with it with three kids and the baby, but do you do any like BDA lectures and that kind of stuff? I find a lot of specialists do that.

[Emma]
Yeah, I mainly do lectures in our practice at the minute, so we run kind of a regular lecture series. And yeah, so we do lots of our practice. They’re all advertised on our website.

[Jaz]
Amazing. Well, if you’re local to Emma, check it out. My wife actually, is doing her MSc in Paeds and she really wanted to learn more from you as well. So I’ll make sure she visits you for one of your talks at your practice as well. Emma, thank you so much for giving me your time. I really appreciate it.

[Emma]
Thanks very much.

Jaz’s Outro:
There we have it, guys. Thank you so much for listening all the way to the end. Thank you to our guest Dr. Emma Ray-Chaudhuri for sharing these real-world gems. I threw a lot of curveballs at her, very much higher-level stuff, which is beyond what you can discuss in one episode.

And I did apologize to her at the end after recording. And she said it was very difficult to answer some of those questions because it’s difficult to apply it to real world scenarios and real-world cases. And you just can offer general guidelines. So remember that we give you guidelines and you have to use your best judgment.

And so great guidelines to follow. One from this is if you haven’t read the SDCEP guidelines, we’ve got a link to them below. Do download them, do refer to them. In fact, the best thing to do right now is just go through it once, spend 15 minutes, go through it right after this episode right now. And that’ll really cement all the things that we were talking with Emma today.

If you’re part of Protrusive Premium, which is my membership section, you can access that on your laptop computer on protrusive.app or if you download the iOS or Android app, Premium subscribers can answer some CPD questions now and get your certificate. So Mari will email you a one hour CPD certificate for listening to this educational episode. All you have to do is answer a few questions.

There’s also premium notes. So, the notes that you usually see on the side, they are available as a PDF for you to download as well, which I know Protruserati love and they print them. And I like to refer to them as like a revision or summary. And lastly, I did encourage that if you have some specific scenarios, comment below, let’s discuss, let’s continue the conversation so we can help serve our patients more.

Thank you so much for listening all the end. Once again, I’ll catch you same time, same place next week.