Pediatric Dentistry


Course Director

• Dara T. Cunnion, DMD, Assistant Professor, room G-613, Ext. 8-4769

• Lina Al-Aswad, DMD
• Dara Cunnion, DMD
• Maria Liliana Gomez, DMD
• Jennifer Soncini, DMD
• David Gabelman, DMD
• Emrey Moskowitz, DMD

Department of General Dentistry Chair

• Judith Jones, DDS , MPH, room G-432

Pediatric Dentistry: Orthodontics

• Christopher Hughes, DMD, Ph.D, Associate Professor and Chair, Department of Pediatric Dentistry, 801 Albany Street, Room S-216

Clinic Coordinator

• Ms. Brenda Bly, Room G-619, ext. 8-4690

Location

• sixth loor

Meeting Times

• See calendar

Introduction

The primary objective of the clinical aspect of the program in pediatric dentistry-orthodontics is to provide the student with the opportunity to develop a comprehensive treatment plan on a pediatric/adolescent patient. The next step is for the student to provide high quality dental care for this patient which may include any of the following: preventive dentistry, nutrition, growth and development, behavior management, oral surgery, oral pathology, specialized operative and prosthodontic procedures, space management, minor orthodontics, periodontology and pulp therapy in the primary and immature permanent dentition.

There are approximately 1,400 hours of total available clinical time (fifth-floor clinic, South Boston Community Health Center, and South End Community Health Center).

Text and Materials

Required Texts

• McDonald, R.E. and Avery, D: Dentistry for the Child and Adolescent. CV Mosby, St.Louis, 1993

Supplemental Texts

• Braham, R.L. and Morris, M.: Textbook of Pediatric Dentistry, Williams and Williams CV., Baltimore 1985
• Gianelly, A.A: Orthodontic Principles, Boston University, 1980

Entry-Level Requirements

• Successful completion of the predoctoral pediatric dentistry - orthodontic technique course.
• Certification of eligibility by the second year promotion committee to treat patients.

Course Outline, Course Calendar, and Course Activities Patient Care Times Pediatric Rotation at Dimock Community Health Center

• Monday 9 a.m.-7 p.m.
• Tuesday 9 a.m.-5 p.m.
• Wednesday 1-6 p.m.
• Thursday 9 a.m.-5 p.m.
• Friday 1-6 p.m.

Pediatric Patients in Fifth-Floor Clinic

• Check with faculty coverage schedule by month for pediatric patient care times.

Clinic Regulations Patient Assignment

1. All new pediatric patients will be seen for a pre-consultation appointment with the Course Director. Appointments are available on Monday mornings from 9am to 11am in Oral Diagnosis. New pediatric patients should schedule their pre-consultation appointments with the Clinic Coordinator.
2. Third year and Fourth year students are assigned pediatric dental patients.
3. Faculty members will assign pediatric patients to students. Students will be responsible for the comprehensive care of their patients and for making referrals to specialty departments when appropriate.
4. Students are responsible for coordinating appointments with the parent/legal guardian of the patient and the appropriate faculty members. A parent or legal guardian must accompany the patient to the appointment.
5. The clinical sessions available to treat pediatric patients will be made available to students.
6. Postdoctoral pediatric dental residents will treat emergency patients.

Equipment and Supplies

1. The student should have all necessary instruments and supplies for the planned procedure.
2. A number of materials will be supplied by the Pediatric Dentistry-Orthodontic department for student use. These supplies and their location will be discussed with students before beginning.
3. Any units not functioning properly should be reported to a faculty member.
4. Students on their pediatric rotation at South Boston Community Health Center and South End Community Health Center will have all supplies and instruments provided for them by the clinic except for handpieces, protective eyewear, and lab coats.

Patient Management

1. The “Patient Authorization for Treatment” form must be signed by a parent or legal guardian before any treatment is started.
2. The dental and medical questionnaire form must be filled out by the parent or guardian and then reviewed by the student. Any significant medical problems must be pursued in greater detail and then recorded on the form. Other forms or cards routinely used by the Pediatric Dentistry-Orthodontic Department will be explained on an individual basis or on a class basis. These cards or forms may be modified on a year-to-year basis.
3. A complete extra-oral and intra-oral examination should be made and findings recorded on the dental record chart.
4. When radiographs are needed, the student must determine the radiographic survey needed and then take the appropriate survey (see Guidelines for Prescribing Dental Radiographs). Panelipses may be taken in certain cases, but prior approval is necessary. In the case of recall patients bitewings and selected periapical radiographs may be indicated.
5. New patients are to be given an oral prophylaxis and topical fluoride application, plaque survey, oral hygiene instructions, and nutritional awareness instructions. Students should speak to parents or guardian about nutrition and oral hygiene when possible.
6. Once all the information has been accumulated, the active problems are diagnosed and a treatment plan is formulated in the order of greatest priority. Orthodontic treatment plans will be done under the guidance of the appropriate instructor.
7. The final diagnosis and treatment plan is to be entered in ink after approval by the instructor. Fees must be indicated to the right of the treatment procedures listed. The parent or guardian must be shown the treatment plan for approval and he/she must sign it. The instructor must also sign approval of the treatment plan and the medical history.
8. It is the responsibility of the student to have approved what is to be done for each visit before he/she begins, and to use his/her time efficiently when in the clinic. It is also necessary for the student to obtain a check before beginning as well as a check of the final finished procedure performed. If a lengthy or a complicated procedure is anticipated, and/or the student does not know how to proceed, the procedure should be discussed in detail with the instructor before beginning and during the procedure.
9. At the end of each treatment session it is necessary to indicate under "Treatment" exactly what was done and what materials and quantities were used. Completed procedures are checked off on the treatment plan and signed on the treatment record sheet by both the instructor and the student. It is also necessary to indicate what procedure is anticipated for treatment at the next visit.
10. The instructor will fill out the appropriate formative or summative evaluation form for the treatment performed. Payment Procedures: All patients must remit payment at the time of treatment. No patient with an outstanding balance will be seen. Cheri will bill insurance in the Finance office, but the patient must pay for the procedure first. Procedure for Obtaining Prior Approval for Third Party Payment Prior approval from Mass Health is necessary for some appliances and orthodontic procedures. See the Course Director for the necessary paperwork.
    

Clinic Instructional Objectives

1. Demonstrate the ability to guide a child through a routine dental procedure, utilizing behavior guidance when necessary.
2. Perform a thorough clinical and radiographic examination, when indicated, recognizing and recording any pathology within the oral cavity.
3. Make a complete diagnosis of the oral health needs of a child, write a logical treatment plan to meet these needs, and demonstrate an understanding of these procedures by answering orally, questions posed by the instructor.
4. Record a medical and dental history on a questionnaire provided by the Department of Pediatric Dentistry-Orthodontics and be able to identify points significant to the planning of dental treatment.
5. Do a thorough prophylaxis for a child, removing all deposits from the teeth and polishing the teeth.
6. Understand and implement current practices of preventive dentistry, including:
   • the use of fluorides
   • diet evaluation
   • instruction of the child and parents in principles of good oral hygiene.
7. Administer local anesthesia for operative procedures.
8. Apply and utilize the rubber dam, while performing operative procedures.
9. Obtain impressions of the mouth and prepare diagnostic models when necessary.
10. Prepare and restore Class I and Class II cavities in primary and young permanent molar teeth in a manner acceptable for the oral environment. This will be demonstrated by:
    • complete removal of carious tooth structure and unsupported enamel
    • placement of the pulpal floor into dentin at a depth to sufficient bulk of alloy to resist fracture
    • placement of proximal margins in self-cleansing areas
    • preparation of the occlusal outline form for adequate cavity width at the isthmus and for the placement of these margins into areas subject to minimal effects from occlusal forces
    • restoration of an adequate proximal contour and contact
    • restoration of adequate occlusal contour including proper marginal ridge and occlusal relationships
    • proper condensation, carving and polishing of the alloy.
11. Prepare and restore a primary tooth with a stainless steel crown as demonstrated by:
    • clinical and radiographic evidence of the placement of cervical margins in close proximity with the tooth .1-.5 mm below the free gingival margin
    • correct proximal contact with adjacent teeth
    • normal occlusion and relationship with the opposing teeth.
12. Recognize the indications for a fixed and removable space maintainer and construct and insert one.
13. Identify indications for gross caries removal and indirect pulp capping procedures for primary and young permanent teeth. Implement these procedures in an acceptable manner and demonstrate an understanding of this approach to indirect pulp therapeutics by answering the questions posed to him/her by the staff member.
14. Properly examine and evaluate traumatized anterior teeth and apply proper emergency treatment procedures.
15. Recognize indications for orthodontic procedures and design and construct appliances for treatment with the consultation of a staff member.
16. Recognize developing complex orthodontic problems and properly refer them to a specialist.
17. Recognize abnormalities in growth and development patterns of children and refer those children requiring complex treatment considerations to a specialist.
18. Recognize the indications for the placement of unfilled and filled resin restorative materials in primary and permanent teeth. Prepare cavities and place these materials in a manner that is biologically acceptable to the tooth in the oral environment as demonstrated by:
    • adequate depth of the cavity floors for retention and proper protection of the pulp.
    • placement of margins in areas with minimal susceptibility to caries and fractures from trauma resulting from the forces of occlusion with the opposing teeth.
    • polishing the surfaces and finishing the margins of these teeth so that staining and attachment of debris is minimal.
19. Have an appreciation for the problems of the handicapped. Recognize those children requiring treatment beyond the scope of his/her capabilities and refer them to the proper specialist.
20. Understand the principles of direct pulp therapy for primary and young permanent teeth. Demonstrate this by answering questions posed by a staff member and by:
    • recognition of the indications and contraindications for direct pulp capping, pulpotomy and pulpectomy procedures.
    • planning and implementing of these procedures in a satisfactory manner.
21. Gather information for a child's diet survey. Process the information and discuss it with the parents of the child. Demonstrate an understanding of this procedure by discussion with a staff member.
22. Plan and carry out an illustrative discussion of the dental needs of a child and the planned treatment for those needs with the parents in the presence of a staff member.
23. Recognize and have an understanding of the common gingival disorders of children and demonstrate this ability by the answering of questions posed by the instructor and by the implementation of proper treatment procedures for these disorders when they present themselves.
24. Demonstrate the ability to guide a child through a routine dental procedure. Student Evaluation Evaluation Components Rotation at South Boston Community Health Center and South End Community Health Center
    • Duration: two weeks at approximately 35 hours per week
    • Evaluation:
      • Clinical Performance Summary at end of each rotation.
      • Summative Evaluation: Performance on selected procedures assigned on last 2 days of rotation.
      • Formative Assessment forms shall be filled out by procedure and will NOT be used for grading

Treatment of Pediatric Patients in Predoctoral Clinic (DMD III, DMD IV, AS II)

• Student shall provide comprehensive care for at least one pediatric patient and follow up for the duration of at least 6 months.
• Evaluation:
• Case Review
• Completion of comprehensive care of assigned pediatric patient(s) (not including orthodontic treatment) for a duration of not less than 6 months.
• Chart review of treatment plan, procedures completed, radiographic quality/interpretation, and proper documentation (charting, medical history updates, consent, progress notes, and referrals).
• Summative Evaluation
• Performance on procedures assigned at discretion of faculty (faculty to review applicable Clinic Journal formative evaluations before start of procedure).
• Students shall complete two recall / treatment planning appointments in summative mode per academic year.
• Students shall complete one operative appointment in summative mode per academic year. Complexity of procedure chosen for summative evaluation shall be weighted accordingly.
• Formative Assessment forms shall be filled out by procedure and will NOT be used for grading.

Externship (DMD IV, AS II)

• Students treating pediatric patients on externship should document procedures on the pediatric dentistry externship evaluation form.
• Evaluation:
• Summative Evaluation: Performance on pediatric dentistry procedures while on externship as recorded on externship evaluation form.
• Formative Assessment forms may be filled out by procedure but will NOT be used for grading.

All summative evaluation forms and externship evaluation forms shall be submitted together for grading at the end of each academic year.

Responsibilities by Class

DMD III

• In-house pediatric patient(s): 100%
• Case Review
• Summative Evaluation

DMD IV

• In-house pediatric patient(s): 20%
• Case Review
• Summative Evaluation
• Pediatric Rotation: 80%
• Performance Summary
• Summative Evaluation
• Externship: variable
• Summative Evaluation

AS II

• In-house pediatric patient(s): 20%
• Case Review
• Summative Evaluation
• Pediatric Rotation: 80%
• Performance Summary
• Summative Evaluation

Performance Evaluation

1. After a procedure is completed and during the procedure/patient visit, if necessary, the instructor will discuss/comment on the students progression/performance.
2. Students will be presented formative feedback on a daily basis in the form of verbal communication and formative evaluation forms found in the students’ Clinic Journal. Intellectual preparation, quality of the clinical procedures performed, professionalism, patient and parent communication, ability to work independently and consideration of the needs of the patient will be factors taken into consideration.
3. At the end of procedures performed in summative evaluation mode, summative feedback forms will be completed by the instructor and returned to the student. All summative evaluation forms shall be submitted for grading at the end of each academic year.
4. Summative evaluation forms and patient charts will be reviewed at the end of the grading period. Grades will be generated after a review of the all evaluation forms (excluding formative evaluation forms) and patient charts with emphasis on improvement of performance leading towards competency and beyond. A performance of “competency” will be equivalent to a “C” grade. Degrees of performance above competency will merit higher grades.

Grade Criteria

Summative evaluation forms will be used to monitor the progress of students in the demonstration of competence. Competence is defined as meeting the requirements of knowledge, skill and attitudes necessary to provide care of acceptable quality independently.

The course director evaluates progress with emphasis on improvement as the year progresses and determines grades according to the following criteria:

At the End of the Third Year

• A-, A
• Demonstration of acceptable performance on a consistent basis for level I procedures.
• Demonstration of progress towards competency for level II procedures
• The student makes few mistakes but if they occur, can self-evaluate and correct them.
• B-, B, B+
• Demonstration of acceptable performance in level I procedures and some level II procedures but has not yet demonstrated competency
• Recognizes problems and shows steady improvement in solving them
• C-, C, C+
• Makes frequent mistakes and requires faculty intervention even for level I procedures but demonstrates potential for improvement.
• D
• Repeatedly makes mistakes and requires faculty intervention.
• F
• Consistently makes mistakes and requires faculty intervention.
• Shows no evidence of improvement.

At the End of the Fourth Year (and AS II Program)

• A-, A
• Demonstration of competency in level I and level II procedures.
• Demonstration of progression towards proficiency in most procedures.
• Consistently and accurately assesses clinical work.
• B-, B, B+
• Demonstration of competency in level I procedures and many level II procedures.
• Requires some faculty guidance in level II procedures.
• Capable of self evaluating clinical work.
• C-, C, C+
• Demonstration of competency in level I procedures but has not demonstrated competency in many level II procedures.
• Requires faculty intervention in most level II procedures.
• D (cannot sign out)
• Makes frequent mistakes in many level I procedures and most level II procedures.
• Requires faculty intervention but demonstrates some improvement and potential to reach minimal competency with supervision.
• F (cannot sign out)
• Consistently makes mistakes in most level I procedures and all level II procedures.
  Consistently requires faculty intervention and shows no evidence of improvement or potential for improvement.

Level I procedures include:

1. Medical history evaluation and update at six-month intervals
2. Uncomplicated examination and charting
3. Simple prophy and fluoride
4. Uncomplicated problem solving and routine diagnosis and treatment planning
5. Explanation of treatment plan to parent in an understandable manner
6. Explanation to patients of procedure to be performed in a language that is appropriate for age and ability to understand
7. Delivery of a local anesthetic including topical placement
8. Bitewing and periapical radiographs
9. Simple impressions
10. Simple rubber dam placement
11. Uncomplicated amalgams and composite restorations and the placement of sealants
12. Simple extractions
13. Rendering care in a reasonable time period appropriate for the procedure and the age of the patient

Level II procedures include:

1. Discussion and participation in prescribing medications
2. Behavior management (may involve the use of a pedi-wrap, mouth props and medications)
3. Complicated problem solving and complicated diagnosis and treatment planning some of which may involve consultations and referrals
4. Emergency diagnosis and treatment
5. Pulp treatment
6. Complicated scaling
7. Multiple surface amalgams, stainless steel crowns and complicated composite restorations which may involve the incisal edge
8. Band placement
9. Impressions followed by construction of appliances (space maintainers and retainers)
10. Mixed dentition analysis
11. Complicated extractions
12. Management of handicapped patients

Pediatric Dentistry Department Emergency Schedule

BU Clinic FacilityDay Coverage

The pediatric resident assigned to the 930 Commonwealth Avenue facility will be responsible for emergency treatment of University Dental Plan patients on Tuesday, Wednesday and Thursday afternoons. When the pediatric resident is not available emergency dental plan patients will be seen by general practice residents in the AEGD program on the seventh-floor.

Self paying patients and Mass Health patients that require emergency treatment will be seen by predoctoral students assigned to the pediatric rotation during clinic hours on Tuesday, Wednesday and Thursday afternoons. When there are no pediatric rotations these emergency patients will be seen by senior predoctoral students in Oral Diagnosis on the 1st floor.

Evening and Weekend Coverage

The resident assigned to emergency will carry a beeper 617/465-5734 from Friday evening through the next Friday. Calls received after clinics are closed in the evening will require the resident to call the patient, screen the call and make the appropriate arrangements to have the patient seen the next day at the school or if the patient requires immediate treatment at night or on weekends, meet and treat the patient at Franciscan Children’s Hospital in the dental clinic.

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