The phone rings. Dr. Cooper is calling. One of his patients, a four year old, has a severe toothache. The little boy, and his mum, slept little the night before. The tooth needs to be extracted, but the child adamantly refuses the needle. “Could a dentist at the MCH see him?” asks Dr. Cooper. Absolutely. After all, the child has nowhere else to go and mom isn’t looking forward to another sleepless night.

The MCH dental team uses a variety of techniques to help children and adolescents overcome their fear of the dentist, including behaviour modification, restraints at different levels (always with parental consent and assistance), mild sedation, or when all else fails, general anesthesia. General anesthesia is certainly not what this four year old needs. He just needs a little self-confidence and to learn to trust in his dental team. Sure enough, a little while later, he leaves the clinic with his tooth in his hand, a big smile on his face and a surprise under his arm (the Montreal Children’s Hospital Foundation makes sure the Dentistry Department has a supply of stuffed animals for patients).

This is not the only emergency on this Friday afternoon. A nearby hospital emergency service sends over an older boy. His two front teeth collided with the bottom of a municipal pool after an unlucky dive. The teeth are broken, mobile and painful. They need immediate attention.

Soon afterwards, worried parents bring their little girl to the clinic. Her gums are bleeding and she refuses to eat. The parents are concerned because the child is severely developmentally delayed and cannot express herself. She also has a heart defect and her pediatrician wants to prevent any potential infection.

Friday, for some reason, always seems busier than other days when it comes to dental emergencies.

The Montreal Children’s Hospital Dental Department is a full service, 20-chair treatment centre. Each day, between 80 and 100 patients are treated, totaling more than 14,000 patient visits per year, including 1,520 emergency visits. The clinic has more than 25 clinicians who provide comprehensive treatment for traumatic injuries, early childhood caries, cleft palate and maxillofacial deformities, and an array of other oral problems. Preventive services and pediatric operative dentistry as well as periodontics, endodontics, prothodontics, and oral surgery are also available. The clinic, which is open five days a week for scheduled appointments and available 24-hours a day, seven days a week for emergencies, provides highly specialized care in very modern facilities to patients from across Quebec, Ontario and the United Sates. Clinicians also gladly respond to professional enquiries and consult with colleagues worldwide.

From humble beginnings to international renown

The Department of Dentistry was established in the early 1960s. By 1973, there were a mere five chairs. Although there were plenty of healthy children to treat, Department Director Dr. Stephane Schwartz was interested in exploring the dental physiology of children with special needs, including those with developmental delays. “We became aware that many dental defects were associated with certain genetic syndromes.”

In 1984, she published groundbreaking research demonstrating that the jaws and teeth of children with the bone disorder osteogenesis imperfecta (OI) or brittle bone disease, developed abnormally causing misshapen teeth or oral cavity problems such as overbites or impacted teeth. The findings were similar for children with hypophosphatemia, a blood disorder where the mineral phosphate is abnormally low.

Because of this research, the department began to evaluate and offer treatment to children with bone and muscular abnormalities. In 2004, Dr. Schwartz was invited to present her strategies and successes at the annual meeting of the Osteogenesis Imperfecta Foundation in Baltimore and again in Chicago in 2007. She also wrote a chapter on the dental needs of OI children in the book: “Interdisciplinary Treatment Approach for Children with Osteogenesis Imperfecta”, published by the Shriners Hospital.

It made a difference. The focus of the Shriners has always been on fixing bones. Now they know maxillofacial complex shows defects that are definitely caused by OI and need to be addressed like all other body defects. Today, there is a great deal of controversy about providing dental treatment for children with OI. Many dentists and oral surgeons refuse to treat these patients. Whenever possible, the MCH dental clinic steps in and provides care for these children.

The MCH clinic has become an important dental reference centre for the Shriners; the clinic provides evaluation and counseling for patients in Mexico, Europe, Middle Eastern countries and Israel.

Teamwork

Over the last decade, the Department of Dentistry has begun working with other MCH departments and health care institutions, for example, the MCH Hematology-Oncology Service. Cancer patients are at risk for developing oral infections and consequently dental caries due to the immuno-compromising effects of chemotherapy. “Our job is to make sure these patients’ mouths are healthy,” says Dr. Schwartz. “We adjust our schedules to make sure we see these children between their chemo sessions.” According to Dr. Schwartz, flexibility, adaptability and respect for the patient’s schedule are the keys to the clinic’s success.

The dental clinic also cares for children with cerebral palsy. These patients often have problems with their food intake because they cannot chew properly. Dr. Schwartz worked with the McGill School of Physical and Occupational Therapy to develop and test an oral appliance, which helps this special group of children.

Specializes in treating children with autism

The clinicians within the Department of Dentistry have become known for their ability to treat children with behavioural problems such as autism. The clinic has gone from treating a few autistic children to developing this as a subspecialty. The key to the dentists’ success is patience and expertise. “We have the knowledge and skill to make this a positive experience for all,” says Dr. Schwartz.

Another subspecialty is the Sedation Clinic, the only clinic in Quebec providing conscious sedation to pediatric patients. It was initially created by pediatric dentist, Dr. Vu, Associate Director of the MCH Department of Dentistry, to treat healthy children who have phobias about needles and dental work. The facility is also the only clinic to provide accelerated services for extractions and pulpotomies under general anesthetic for toddlers and handicapped children who are in pain with deep caries and dental abscesses.

In addition, the Sedation Clinic is part of a multidisciplinary team, which includes Pediatrics, ENT, Speech and Occupational Therapy and Social Work to treat children who suffer from hypersalivation. With the guidance of ENT physician Dr. Sam Daniel the exact needs of the children are assessed and a tailored treatment plan is determined. The MacKay Rehabilitation Centre in Montreal generally provides the follow-up care of these patients.

The department also has ties with the MCH Neonatal Clinic, the dentists follow children born prematurely. “Babies who are premature have thinner enamel than term babies. We see these children around their first birthday to establish their risk for caries,” says Dr. Schwartz.

Continuing the tradition of excellence

Teaching and outreach are also important priorities of the Department of Dentistry. Those training to be dental assistants complete a two-month internship at the clinic. “They come here because we treat children; the students do not have many opportunities to get acquainted with this population,” says Dr. Schwartz.

The department also mentors four to five post-grad trainees each year, who acquire proficiency in pediatric dentistry. And it also offers continuing health education courses to clinicians locally and throughout the province.