Paediatric Dentistry in Ukraine

Paediatric dentistry is the branch of dentistry that looks after the teeth and the bite from the eruption of the first incisors until the change to permanent teeth is complete. Children are seen by a doctor specialising in "Paediatric Dentistry", a separate specialty acquired during internship, the postgraduate training that follows basic dental education. It differs from adult dentistry in more than the knack of winning a child over: a baby tooth is built differently and is treated to different protocols, with different materials and on a different timescale.

Every paediatric dentist hears the same question: why treat them if they are going to fall out anyway? A baby tooth really is temporary, but until it falls out it does a job nothing else will take over. It holds the space in the dental arch for the permanent tooth erupting beneath it; it is used for chewing, which drives jaw development; and it helps the child pronounce sounds correctly. When a tooth is lost early, through complicated caries or an injury, the neighbouring teeth tilt into the empty space and take up the room. A few years later the permanent tooth no longer has enough space and erupts outside the arch or rotated. This is the source of some of the crowding that later takes months of orthodontic treatment to correct; to avoid it, a simple space maintainer is fitted after an early extraction.

The second reason is more serious than the first. The bud of the permanent tooth lies directly beneath the root of the baby tooth, and chronic inflammation at the tip of that root reaches it. The result can be damage to the enamel of the permanent tooth, ranging from white and yellow spots to marked hypoplasia, where the tooth erupts with a defect already present in its hard tissues and needs restoring straight away. In other words, an untreated baby tooth is not "a tooth that will fall out" but a risk to the one that will replace it.

Do not wait for pain before booking a visit. Reasons for a planned visit are a white or brown spot on the enamel, food getting stuck between the teeth, complaints about cold and sweet things, bleeding gums, mouth breathing, thumb sucking after the age of three, or simply reaching the age for the next check-up. Pain, a swollen cheek, an abscess on the gum or an injured tooth (chipped or dislodged) need a same-day visit, without waiting for a booking. A standard appointment in the chair is not right for every child. For a child who, because of age, the amount of work or their health, cannot cope with treatment while awake, sedation or treatment under general anaesthesia is discussed rather than insisting on an ordinary visit.

MediUkraine is a treatment search and coordination service, not a clinic. We find the clinic and a doctor with the right specialism, arrange the visit dates and support the family throughout, including families travelling from abroad. Our partner clinic in this field is Vidnova Dental Clinic in Lviv, 10 Ivana-Teodoziia Kurovtsia Street. The decision on what to do with a particular tooth is made by the doctor after an examination and an X-ray.

The main work here is preventive, and it starts before any treatment. Parents should brush the child's teeth until the child can write confidently, roughly up to 7–8 years of age, and for several years after that they supervise evening brushing. In the surgery, professional hygiene is scheduled once every 6 months, along with fluoride varnish and, where indicated, remineralising therapy with calcium and phosphate preparations. Fluoride toothpaste is used from the eruption of the first tooth; the fluoride concentration and the amount both depend on age: a smear the size of a grain of rice up to the age of three, and a pea-sized amount after that.

Fissure sealing closes the natural grooves on the chewing surface, the place where caries in children most often begins. Fissures can be so deep and narrow that a bristle cannot reach into them, and the enamel of a newly erupted tooth is not yet mature and dissolves in acid more easily than mature enamel. The groove is cleaned and filled with a flowable sealant, sometimes after minimal opening with a bur. It is best done straight after eruption, while the fissure is not yet affected: the first permanent molars, the so-called six-year molars, erupt at 6–7 years, the second ones at 11–13. Sealant wears and chips over time, so its condition is checked at every preventive check-up and renewed if needed.

Caries at the white spot stage is treated without a drill. Demineralised but not yet broken-down enamel can recover: remineralising agents are used, or silver diamine fluoride, which stops the process but leaves a dark stain at the affected site, or resin infiltration, where the spot is impregnated with material without drilling. Each method has its limit: once a cavity has formed, none of them will work and a filling is needed.

Filling materials for baby teeth are chosen with two things in mind: the tooth will last a few more years, and the child can manage 20–30 minutes in the chair. Glass ionomer cements release fluoride and tolerate a little moisture, so they are placed where perfect isolation cannot be achieved. Compomers and composites are stronger and more aesthetic, but require a rubber dam and a dry field. Coloured children's composites are sometimes used, not for appearance but so that the child sees "their own" filling and is more willing to agree to the work. A filling in a baby tooth has a shorter service life than in a permanent tooth, and this is built into the plan: its task is to see the tooth through to its natural replacement.

When caries has reached the pulp, the approach depends on how far the inflammation has spread. Where the damage is limited, a pulpotomy is performed: the crown part of the pulp is removed, and the root part is left alive under a protective material, mineral trioxide aggregate, bioceramics or ferric sulphate. If the pulp has died, a pulpectomy is done: the canals are cleaned and filled with a paste that resorbs together with the root, based on zinc oxide and eugenol or on calcium hydroxide with iodoform. A baby tooth is not filled with permanent materials such as gutta-percha: they do not resorb, they interfere with the natural replacement of the tooth, and a hard mass in the canal can deflect the permanent tooth as it erupts.

A badly broken-down baby tooth cannot be saved with a filling, so a crown is placed. Preformed metal crowns for molars come in ready-made sets of sizes, so the doctor selects and fits a crown in a single visit. There is the Hall technique, in which the crown is seated on glass ionomer cement with no drilling and no anaesthesia at all: it is not suitable in every case, but it helps with children who cannot cope with long procedures. In the front of the mouth, paediatric zirconia crowns are used. Extraction remains a last resort, not a way to save time: it is done when the tooth is broken down to gum level, when there is a chronic focus of infection near the root that threatens the bud of the permanent tooth, or when the tooth is already loose before being replaced. If more than a year remained before the natural change, a space maintainer is discussed after the extraction, a simple appliance that stops the neighbouring teeth from taking up the room.

Early childhood caries, more often called bottle caries, affects the upper incisors in children under three and develops quickly: it can take only a few months from the first spot to a broken-down crown. The cause is not "weak enamel" but the feeding pattern: milk, formula, juice or sweetened water from a bottle in bed and frequent night feeds leave carbohydrates on the teeth just when saliva is hardly produced and cannot neutralise the acid in time. The enamel of a newly erupted tooth is especially vulnerable to this. What to do in practice: after the age of one, gradually wind down night feeds and the bottle in bed, do not give sweet drinks instead of water, teach the child to drink from a cup, and make evening brushing the last thing of the day, with only water after it. Early caries is treated according to its depth, from fluoride varnish and silver diamine fluoride to crowns, and when there is a lot of work and the child is two years old, treatment under general anaesthesia is discussed.

Working with fear is as much a part of treatment as the filling. The basic method is called "tell, show, do": the doctor explains in simple words what they are going to do, lets the child hold and look at the instrument, shows how it works on a finger or a toy, and only then begins. The child keeps a sense of control: an agreed "stop" signal, pauses on request, several short sessions instead of one long one. Where fear is marked, an adaptation visit without treatment is arranged: to see the surgery, sit in the chair, meet the doctor and go home. Parents are asked not to intervene or comment on the process, because a child responds worse to two adults at once than to one.

When behavioural methods do not work, medication-based support is discussed, and the indications for it are quite specific. Nitrous oxide sedation means breathing a gas mixture through a nasal mask: the child remains conscious, hears the doctor and answers, while anxiety is reduced; sedation does not replace pain relief, so local anaesthesia is still given. Treatment under general anaesthesia is considered when a lot of work is needed in a young child, in early childhood caries affecting many teeth, in children with autism spectrum disorders or neurological conditions, and when attempts at treatment in the chair have already failed. It is not a convenience option but a medical intervention: it requires an examination by an anaesthetist, tests, an empty stomach and several hours of observation after waking.

Alongside this the doctor keeps an eye on the bite and on the habits that shape it. Sucking a thumb or a dummy after the age of three, prolonged mouth breathing with enlarged adenoids and an infantile swallowing pattern gradually change the shape of the jaws. Some problems are resolved by removing the cause in time, some are corrected with removable plates or myofunctional trainers during the mixed dentition, and some are treated with braces after the teeth have changed. That is why the first orthodontic check-up is advised at around 7 years, when the first permanent molars and incisors have erupted and it is clear whether there is enough room in the arch.

After a filling the child returns to their usual activities the same day, and there is no recovery period as such. The restrictions concern the next few hours: if local anaesthesia was given, the child should not eat until the numbness has worn off, and should not be given anything hot. A composite filling sets under the curing light straight away, so it can be chewed on immediately; a glass ionomer one takes longer to mature, and the doctor will tell you how long to spare the tooth.

Numbness after local anaesthesia lasts 1.5–3 hours, and this is the riskiest part of the day. Children bite the numb lip, cheek or tongue, often until it bleeds, without noticing. So keep an eye on the child until sensation returns, warn them: "your lip is asleep, no biting", and do not let them have a snack at school. A wound from such biting heals within a few days and usually needs no treatment.

After an extraction a gauze pad is held in place for 15–20 minutes and then removed. That day, do not rinse the mouth, do not warm the cheek, and do not give hot food or drinks, and do not let the child drink through a straw; food should be soft and warm. Slight swelling and tenderness in the first day or two are expected, but increasing pain, swelling that grows on the third day or a raised temperature are a reason to phone the clinic rather than wait for the scheduled visit.

After a pulpotomy or pulpectomy the tooth is kept under observation. A control X-ray is usually taken after 6 months and then once a year until the tooth is replaced: it shows whether there is a focus of infection near the root and whether root resorption is proceeding normally. Some of these teeth still need extracting before their time; this cannot be predicted in advance, and the doctor warns about that scenario from the outset.

Realistic expectations look like this. A filling in a baby tooth does not last as long as one in a permanent tooth and may fall out or chip; recurrent caries under a filling develops more often the poorer the hygiene at home remains. The most common reason for re-treatment is not the quality of the material but the fact that nothing has changed at home: the same snacks, the same sweet drinks, the same hurried brushing. Only a doctor can forecast the outcome for a particular child after an examination, and that forecast is always conditional.

A routine check-up is scheduled once every 6 months, or once every 3–4 months where the risk of caries is high. At it, the condition of fillings and sealants is checked, plaque is removed, eruption and the change of teeth are assessed and home care is reviewed. These check-ups are where the result of treatment is assessed: between them there are mostly no visible changes, and an early spot cannot be seen without magnification.