Children and young people can present with a wide variety of symptomatic orofacial pathologies, which can often cause concern. As one presentation may masquerade in multiple pathologies, we start this chapter with a reminder of the surgical sieve used to form a differential diagnosis. An accurate history and examination are essential following which, multiple special investigations may be required. The role of the primary care clinician is recognising soft and hard tissue pathology, considering a differential diagnosis, arranging special investigations, and either initiating care for more straightforward conditions or referring for specialist input. This chapter covers common soft and hard tissue pathology, but is not an exhaustive list. This chapter aims to provide the reader with a practical guide to aid the diagnosis of orofacial pathology in the paediatric age group.

Introduction Intravenous sedation (IVS) with propofol offers an alternative to inhalation sedation or general anaesthesia (GA) for dentally anxious young people who require treatment. It offers a greater level of anxiolysis than inhalation sedation and reduced morbidity when compared with GA. Methods Data were collected prospectively from a convenience sample of children requiring IVS. Participants completed the Children's Experiences of Dental Anxiety Measure (CEDAM) at the start of every visit. Patient demographics, treatment completed, surgery and recovery time were recorded. Feedback was obtained following their first visit. Results Treatment was successful for 91.5% (43/47) of patients. The average surgery and discharge time was 32.9 (8-105 minutes) and 33.1 (5-84 minutes), respectively. The CEDAM scores were between 14 and 30 (mean score 20.8). Thematic content analysis of the feedback was carried out and themes relating to communication, environment, appointment times, service satisfaction and advice to other patients emerged. Discussion CEDAM scores may have been lower than expected due to under-reporting by patients or clinicians' perception of higher anxiety levels. Feedback was reviewed regularly and improvements made where possible. Conclusion The majority of patients successfully received dental treatment under IVS. Changes have been made to the service to improve patient experience and maximise productivity.

Severe traumatic dental injuries to permanent incisor teeth often result in replacement resorption following significant damage to the periodontal ligament. This leads to ankylosis and subsequent infra-occlusion of the traumatized tooth in a growing paediatric patient. Extraction of these teeth can lead to vertical bony defects that complicate restorative management of the edentulous space. Decoronation is a technique employed to preserve bone in the alveolar crest in an attempt to reduce these defects. CPD/Clinical Relevance: This paper aims to remind readers of the processes of replacement resorption and ankylosis and introduces the use of decoronation for such teeth.

Within healthcare services, there is increasing emphasis to incorporate patient-reported outcome measures (PROMs), rather than relying solely on clinical outcomes. A 12-item caries-specific measure (CARIES-QC) has been developed and validated for children aged 5–16 years. To date, the routine use of PROMs in paediatric dentistry new patient clinics (NPC) has not been reported. The aim was to conduct a pilot study to assess the feasibility, utility and validity of routine use of a PROM in paediatric dentistry NPC in a UK teaching hospital. Children attending NPC over a four-week period were asked to complete CARIES-QC with an additional free-text box. Interviews were held with members of staff to assess the feasibility of using a PROM routinely. CARIES-QC was completed by 99 children. Almost half of the participants had caries (n = 49, 49.5%). CARIES-QC demonstrated good internal consistency (Cronbach’s alpha = 0.9) and reliability with the global question (r = 0.75, p = 0.01). Clinical staff valued the information provided by the PROM. An electronic delivery method would be beneficial to both clinical and administrative staff. CARIES-QC was able to capture impacts for children with a range of oral conditions. Its use aided treatment planning and future studies should investigate the use of an electronic delivery system to reduce the administrative burden.

Will the coronavirus pandemic bring about change in how we manage children with caries?

Objectives: To identify clinical and psychosocial predictors of oral health-related quality of life (OHRQoL) in children with molar incisor hypomineralisation (MIH) following aesthetic treatment of incisor opacities. Methods: Participants were 7- to 16-year-old children referred to a UK Dental Hospital for management of incisor opacities. Prior to treatment (To), participants completed validated questionnaires to assess OHRQoL and overall health status (C-OHIP-SF19), and self-concept (Harter's Self-Perception Profile for Children [SPPC]). Interventions for MIH included microabrasion, resin infiltration, tooth whitening or composite resin restoration. Children were reviewed after six months (T-1) when they re-completed the C-OHIP-SF19 and SPPC questionnaires. The relationships of predictors with improvement of children's OHRQoL (T-1-T-o) and children's overall health status at T-1 were assessed using linear and ordinal logistic regression respectively, guided by the Wilson and Cleary's theoretical model. Results: Of 103 participants, 86 were reviewed at T1 (83.5 % completion rate). Their mean age was 11-years (range = 7-16) and 60 % were female. Total and domain OHRQoL scores significantly increased (improved OHRQoL) following MIH treatment. There was a significant positive change in SPPC physical appearance sub scale score between T-o and T-1. A higher number of anterior teeth requiring aesthetic treatment were associated with poor improvement of socio-emotional wellbeing at T-1 (Coef =-0.43). Higher self-concept at To was associated with greater improvement of socio-emotional wellbeing at T-1 (ss = 3.44). Greater orthodontic treatment need (i.e. higher IOTN-AC score) at T-0 was linked to worse overall oral health at T-1 (OR = 0.43). Conclusions: Psychosocial factors and dental clinical characteristics were associated with change in children's OHRQoL following minimal interventions for incisor opacities. Clinical significance: MIH is a common condition and clinicians should be aware of the negative impacts some children experience, particularly those with multiple anterior opacities, poor tooth alignment and low selfconcept. However, simple, minimally invasive treatments can provide good clinical and psychosocial outcomes and should be offered to children reporting negative effects.

Aim Service evaluation of our dental hospital paediatric liaison nursing (DH-PLN) service which provides an additional route for information sharing about safeguarding concerns via an agreed pathway for two-way communication with public health nurses.Method Retrospective analysis of clinical records of all children referred by DH teams to PLN in the three months October-December 2016.Results One hundred and four children were referred; mean age was 6.2 years, 89.4% from Index of Multiple Deprivation (IMD) quintiles 4 and 5, and 70.2% were attending for dental general anaesthesia. The most common referral reason was dental neglect in 66.3%, followed by missed appointments in 50.0%. The PLN checked child health databases and shared information with health visitors and school nurses (46.2% and 53.8% respectively). Feedback retrieved included known child maltreatment risk factors in 7.7%. This prompted additional child protection referrals to children's social services for seven children (6.7%). Dental outcomes six months later were: treatment complete in 50.0%, treatment ongoing 28.8%, discharged to original referrer with treatment incomplete in 21.1%.Conclusion This DH-PLN service promotes integrated multidisciplinary working, helping overcome barriers to dentistry's involvement in safeguarding. It facilitates more accurate assessments of risk of harm to children receiving dental care and prompts additional child protection referrals to social services.

Abstract: Lichen Planus (LP) is a chronic, inflammatory disease of the skin and mucous membranes. It is more frequently seen in the middle-aged and elderly population but can be present in children, although this is relatively rare. This paper describes the presentation and management of lichen planus in children, illustrated by seven cases seen within the Paediatric Dentistry Unit. Dentists should be aware of the condition and understand when referral to a specialist centre is required and the need for multidisciplinary management of complex cases. CPD/Clinical Relevance: Although oral lichen planus is rare in children, it is important that dentists are able to identify its clinical presentation and abnormal changes to the oral mucosa, as well as being aware of possible local and systemic causes of the condition so that reassurance and correct management pathways can be implemented in primary care practice.

The process of guideline production began in 1994, resulting in first publication in 1997. Each guideline has been circulated to all Consultants in Paediatric Dentistry in the UK, to the Council of the British Society of Paediatric Dentistry, and to people of related specialties recognised to have expertise in the subject. The final version of the guideline is produced from a combination of this input and thorough review of the published literature. The intention is to encourage improvement in clinical practice and to stimulate research and clinical audit in areas where scientific evidence is inadequate. Evidence underlying recommendations is scored according to the SIGN classification and guidelines should be read in this context. For those wishing further detail, the process of guideline production in the UK is described in the International Journal of Paediatric Dentistry 1997; 7: 267-268.

Molar incisor hypomineralisation (MIH) is a common enamel condition, presenting with incisor opacities, which may be of psychosocial concern to children. This clinical study sought to determine whether minimally invasive treatment, aiming to improve incisor aesthetics, would also improve children's oral health-related quality of life (OHRQoL). 111 MIH patients, aged 7⁻16 years, referred to a UK Dental Hospital, were invited to complete the Child Oral Health Impact Profile (C-OHIP-SF19) prior to any intervention (T₀) and again at one-month following the intervention (T₁) for MIH. Treatment regimens included one or more of the following: Microabrasion; resin infiltration; tooth whitening; resin composite restoration. Data were obtained for 93 children with a mean age of 11 years. Mean total C-OHIP-SF19 score at T₀ was 47.00 (SD = 9.29; range = 0⁻76) and this increased significantly at T₁ to 58.24 (SD = 9.42; range = 0⁻76; p < 0.001, paired t-test), indicating a marked improvement in self-reported OHRQoL. There were no statistically significant differences according to gender. This is the first study to show that simple, minimally invasive dental treatment, to reduce the visibility of enamel opacities, in MIH, can have a positive impact on children's wellbeing.

Oral candidosis can present in childhood with recognizable mucosal changes. It may be associated with predisposing factors or suggest underlying systemic disease such as poorly controlled diabetes or an immunosuppressed state. Investigations are often required and management includes addressing predisposing factors in addition to prescribing topical or systemic antifungal therapy. CPD/Clinical Relevance: It is important for general dental practitioners to recognize oral mucosal changes related to candidal infection and refer to secondary care for further assessment when appropriate.

Background and aim: It is widely acknowledged that children should participate in healthcare decisions, service development and even setting research agendas. Dental traumatology is a major component of paediatric dentistry practice and research. However, little is known about young patients' contribution to new knowledge in this field. The aim of the study was to establish the extent to which children are involved in contemporary dental trauma research and to evaluate the quality of the related literature. Material and methods: A systematic review of the dental trauma literature was conducted from 2006 to 2014. The electronic databases, MEDLINE and Scopus, were used to identify relevant studies. The selected papers were independently examined by five calibrated reviewers. Studies were categorized by the degree of children's involvement and appraised using a validated quality assessment tool. Results: The initial search yielded 4374 papers. After application of the inclusion and exclusion criteria, only 96 studies remained. Research on children accounted for 87.5% of papers, and a proxy was involved in 4.2%. Children were engaged to some degree in only 8.3% of studies, and there were no studies where children were active research participants. In the quality assessment exercise, papers scored, on average, 57% (range = 14-86%). Conclusion: There is scope to encourage more active participation of children in dental trauma research in the future. Furthermore, there are some areas where the quality of research could be improved overall.

Recurrent oral ulceration is common and may present in childhood. Causes of recurrent oral ulceration are numerous and there may be an association with underlying systemic disease. Recurrent aphthous stomatitis (RAS) is the most common underlying diagnosis in children. The discomfort of oral ulcers can impact negatively on quality of life of a child, interfering with eating, speaking and may result in missed school days. The role of the general dental practitioner is to identify patients who can be treated with simple measures in primary dental care and those who require assessment and treatment in secondary care. Management may include topical agents for symptomatic relief, topical corticosteroids and, in severe recalcitrant cases, systemic agents may be necessary.

BACKGROUND:Chronic oral mucosal conditions, including oral ulcers, commonly affect children and young people and are capable of significant pain and morbidity. Little is known about patient perception of paediatric oral medicine services offered in relation to these conditions. The concept of a diary is increasingly recognised as a valuable way to capture patient events and perspective in healthcare research.AIM OF THE PAPER:This article provides the background to the use of solicited diaries as a method of accessing the perspective of children and young people and describes a service evaluation that aimed to explore the experiences of young people with chronic oral ulcers attending the paediatric oral medicine clinic in a UK Dental Hospital.RESULTS:Chronic oral ulcers were found to significantly impact on a variety of physical and psychosocial aspects of young people's lives. Overall, feedback regarding the specialist service was positive but suggestions were made for improvements.CONCLUSION:This article reviews the use of the solicited diary within healthcare research. It also illustrates the value of the diary in exploration of children and young people's perspective on their chronic oral mucosal disease. In addition, a need for further research in this area has been highlighted.

BACKGROUND:Auriculotemporal nerve syndrome is characterised by recurrent episodes of facial gustatory flushing and/or sweating along the cutaneous distribution of the auriculotemporal nerve. The condition is rare in children and is normally a sequel of perinatal birth trauma. We report a case of a sixteen-month-old boy referred by paediatric oncology with recurrent, unilateral facial flushing of the left cheek which had been present for 2 months. The flushing only occurred during mastication. The patient had also received treatment for a rare vascular tumour, congenital haemangiopericytoma, of the left cheek and parotid region. The possible association between auriculotemporal nerve syndrome and congenital haemangiopericytoma is discussed. Knowledge of the presentation, aetiology and management of Auriculotemporal Nerve Syndrome can provide much needed reassurance to those suffering with this condition.

Aims: In studying aetiological interactions of genetic, epigenetic and environmental factors in normal and abnormal developments of the dentition, methods of measurement have often been limited to maximum mesio-distal and bucco-lingual crown diameters, obtained with hand-held calipers. While this approach has led to many important findings, there are potentially many other informative measurements that can be made to describe dental crown morphology. Advances in digital imaging and computer technology now offer the opportunity to define and measure new dental phenotypes in 3-D that have the potential to provide better anatomical discrimination and clearer insights into the underlying biological processes in dental development. Over recent years, image analysis in 2-D has proved to be a valuable addition to hand-measurement methods but a reliable and rapid 3-D method would increase greatly the morphological information obtainable from natural teeth and dental models. Additional measurements such as crown heights, surface contours, actual surface perimeters and areas, and tooth volumes would maximise our ability to discriminate between samples and to explore more deeply genetic and environmental contributions to observed variation. The research objectives were to investigate the limitations of existing methodologies and to develop and validate new methods for obtaining true 3-D measurements, including curvatures and volumes, in order to enhance discrimination to allow increased differentiation in studies of dental morphology and development. The validity of a new methodology for the 3-D measurement of teeth is compared against an established 2-D system. The intra- and inter-observer reliability of some additional measurements, made possible with a 3-D approach, are also tested.Methods and results. From each of 20 study models, the permanent upper right lateral and upper left central incisors were separated and imaged independently by two operators using 2-D image analysis and a 3-D image analysis system. The mesio-distal (MD), labio-lingual (LL) and inciso-gingival (IG) dimensions were recorded using our 2-D system and the same projected variables were also recorded using a newly developed 3-D system for comparison. values of Pearson's correlation coefficient between measurements obtained using the two techniques were significant at the 0.01 probability level for variables mesio-distal and incisal-gingival with labio-lingual significant at the 0.05 level for the upper left side only, confirming their comparability. For both 2-D and 3-D systems the intra- and inter-operator reliability was substantial or excellent for variables mesio-distal, labio-lingual, incisal-gingival actual and projected and actual surface area. The reliability was good for inter-operator reliability measurement of the labio-lingual dimension using 3-D.Conclusions: We have developed a new 3-D laser scanning system that enables additional dental phenotypes to be defined. It has been validated against an established 2-D system and shown to provide measurements with excellent reliability, both within and between operators. This new approach provides exciting possibilities for exploring normal and abnormal variations in dental morphology and development applicable to research on genetic and environmental factors. (C) 2008 Elsevier Ltd. All rights reserved.

Cementoblastoma is a benign ectomesenchymal odontogenic neoplasm that forms a mass of cementum or cementum-like tissue continuous with the tooth root, usually a mandibular premolar or first molar. 1 Barnes L. Eveson J. Reichart P. et al. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of the Head and Neck. in: IARC Press, Lyon, France2005: 318 Google Scholar It has been considered analogous to osteoblastoma and can be very destructive of tissue. 2 Fletcher C.D.M. Unni K.K. Mertens F. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Soft Tissue and Bone. in: IARC Press, Lyon, France2002: 427 Google Scholar This lesion clinically presents as a tender, sometimes painful swelling at the buccal and lingual/palatal aspect of the alveolus. 1 Barnes L. Eveson J. Reichart P. et al. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of the Head and Neck. in: IARC Press, Lyon, France2005: 318 Google Scholar It generally affects persons under age 30 years and has a higher prevalence in males (1.2:1). Radiographically, it appears as a radiopaque mass with a thin radiolucent rim attached to the roots of a tooth. The mass may be rounded or irregular in shape and mottled in texture. 3 Brannon R.B. Fowler C.B. Carpenter W.M. et al. Cementoblastoma: An innocuous neoplasm? A clinicopathologic study of 44 cases and review of the literature with special emphasis on recurrence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 93: 311 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Several cases of tooth resorption, loss of root outline, and obliteration of the periodontal ligament space have been reported. 1 Barnes L. Eveson J. Reichart P. et al. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of the Head and Neck. in: IARC Press, Lyon, France2005: 318 Google Scholar Histologically, the lesion is composed predominantly of sheets or trabeculae of cementum-like calcified tissue with variably prominent reversal lines, sometimes with a pagetoid appearance. 1 Barnes L. Eveson J. Reichart P. et al. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of the Head and Neck. in: IARC Press, Lyon, France2005: 318 Google Scholar Cells including cementoblasts and cementoclasts are enclosed within the hard tissue or around the periphery of the trabeculae.

A macrodont permanent central incisor tooth with unusual root canal morphology became non-vital 18 months following trauma. Two root canals were initially identified and filled, but the patient continued to have symptoms and radiographic examination indicated apical periodontitis. Careful radiographic and clinical examination revealed a third root canal, which was subsequently treated, resulting in the resolution of symptoms and periapical healing.