Why is pediatric dentistry even a specialty, and why does it take two to three years to train? Aren’t fillings on primary teeth the same process as on permanent teeth? What could take so long to learn? Isn’t prevention the same for children as adults—just brush your teeth? Aren’t illnesses the same?
Most of the referrals I received over more than 40 years of practice were for the wrong reason. Children were sent because the dentist could not physically manage the child. Many referrals also came too late, when the disease process was already well advanced. Most dentists receive little practical, hands-on experience in treating young children during dental school—often no real experience below the age of three. As a result, once in practice, they are on their own, learning unsupervised and without guidance.
So, what is taught in a pediatric specialty program?
First of all, pediatric dentistry (PD) is fundamentally about growth and development. It involves learning to manage both normal and abnormal dental development, understanding the long-term effects of treatment—or lack of treatment—and recognizing how childhood diseases can affect both dental and general health later in life. You learn how medications affect children differently, the potential long-term side effects, and how reduced safety margins can lead to serious complications. Children with special needs present additional challenges that require specific considerations. Paramount is the study of facial and jaw growth and development, along with the mental and psychological development of the child as they mature.
In PD, it is not only about knowing how to do procedures, but when to do them optimally. Treatment options must be evaluated in terms of their long-term impact on the child’s health and development. For example, in a two-year-old where the choice is between restoring or extracting maxillary incisors before canine eruption, extraction can result in severe and problematic side effects. These include significant space loss and negative effects on premaxillary development. Similarly, premature extraction of primary molars at a young age can have long-term consequences. This is why “heroics” to save these molars—even if the restoration lasts only three to four years—can greatly enhance proper growth, development, and eruption patterns.
When presenting a treatment plan, proper informed consent requires discussing possible outcomes and the negative side effects of not treating. These discussions must be clearly explained to parents and thoroughly documented in the chart.
When treating young children, radiographic exposure should be kept to a minimum, and standard screening X-ray rules should not automatically apply. Radiographs should be taken only as needed to confirm a diagnosis. Medications should not be prescribed indiscriminately. We all know tetracycline discolours and affects developing permanent dentition. Even penicillin should be reserved for active infections. Wanton use of penicillin contributes to antibiotic resistance and can adversely affect the entire microbiome, not just the oral cavity. This does not mean antibiotics should be withheld when they are necessary—but they are not appropriate for toothaches or draining fistulas. In these cases, treatment is extraction of the offending tooth. A swollen face, of course, requires a full course of antibiotics.
Treatment of rampant decay often requires comprehensive care, including restorations and extractions, possibly under general anesthesia or sedation. A practitioner must be able to restore extensive caries, which often involves pulp therapy and full-coverage stainless steel crowns for posterior teeth, and zirconia or other aesthetic crowns for anterior maxillary teeth.
When extensive treatment is planned, the long-term pros and cons of different treatment modalities and the safety of each sedation option must be explained—from oral sedation to nitrous oxide (N₂O), N₂O with oral sedatives, IV sedation, and finally general anesthesia. Parents must understand why restoring teeth benefits the development of the oral complex, both functionally and aesthetically.
Some children require early orthodontic intervention, even before permanent teeth erupt. The effects of thumb sucking on jaw growth and the importance of early therapy must be addressed. Posterior crossbites are best treated as early as possible; waiting until a child is old enough for full braces may lead to asymmetric condylar growth and more complex treatment. Anterior crossbites and functional shifts should be corrected as soon as possible. The earlier space loss occurs due to premature extractions, the greater the resulting space loss.
Prevention
It is relatively easy to predict who will develop dental caries. Numerous carious lesions at a young age often predict a lifetime of dental problems. This risk can be mitigated with strict and comprehensive oral hygiene initiated early. If a young permanent dentition already contains numerous restorations, the long-term prognosis is poor, as fillings require repeated replacement, and each replacement becomes more complex and invasive.
Early prevention is therefore paramount. During cavity-prone stages, children require regular and frequent recall visits. Sealants should be placed at the appropriate time—usually as soon as the occlusal surface erupts. Regular topical fluoride applications are essential to arrest and remineralize incipient lesions.
This article is not a call for referrals, but a call for proper treatment. Approximately 95% of pediatric dental care is provided by general practitioners, as there are relatively few pediatric dentists available, particularly in rural communities. Do not rely on the internet for guidance, as much of the information is misleading. If you enjoy working with children, pursue appropriate university-based courses—not courses designed to sell products or “miracle” medications. Comprehensive lists of courses are available through your local university, the CDA, or the AAPD.
Ultimately, pediatric dentistry is about treating children—not just teeth. If you would like to discuss or have me elaborate on any of the points raised in this article, please feel free to contact me.
About the author
Dr. Jack Maltz is a Pediatric Dentist providing dental care to children in Brampton for over 40 years. Dr. Maltz is the former head of the OSPD and Head of the Brampton Civic Hospital Department of Dentistry. He can be reached at Drjdentistry5@gmail.com.