All Things Paediatric with Dr Tim Keys - Part Two

In Part 2 of this candid chat with Dr Tim Keys, paediatric dentist, our host Dr Jill Fisher, discusses a number of topics including:

- Understanding hypermineralised teeth

- How smart, long-term planning for young patients can reduce the financial and emotional burden of dental care over a patients life.

- Referral pathways for paediatric care

- Innovations in "Auto Transplantation"

- Guidelines for managing dental trauma

- Addressing missing teeth in paediatric patients

If you would like to get in touch with Dr Tim Keys or access the free resources on his website, visit www.dentistryforkids.com.au

To purchase a copy of the Trauma Guidelines visit the IADT website https://iadt-dentaltrauma.org/guidelines-and-resources/guidelines/

Explore our CeoDental courses, including the Bridgework course led by specialist prosthodontist, Dr Michael Mandikos at www.ceodental.com.au

View the Zirconia Maryland and other informative courses on www.correctdentistry.com - our subscription base online educational platform for dentists.

For any other information email info@ceodental.com.au

This podcast is brought to you by CORRECT DENTISTRY

Transcript

SPEAKER_01 0:11

Welcome back to the Correct Dentistry Podcast. And we're joined again by Dr. Tim Keys, Pediatric Dental Specialist. If you didn't listen to part one, please find it on the feed. There's a lot of great information on there. And at the end of part one, we were talking about hypermineralised molars or hypermineralised teeth. And in your program, you've got Dr. Liz Fisher, my sister, talking on this topic as we speak, and the orthodontic ramifications of it. But can you talk us through what you're observing? Obviously, you said before, one in five children are afflicted by this terrible problem. What you're observing, how you treat it, multidisciplinary care, and what we can do as referring general dentists to support you with these patients.

SPEAKER_00 0:58

It's a big topic, hypermine. It's actually much more unpredictable and harder to treat than decay, which is what we're used to treating. So our research is showing it's about one in five, one in six kids. To be honest with you, I think it's so much higher than that. I think everyone's got some vague form of developmental defect even now. Well, not everyone, but a lot of people do. Obviously, the severe cases are probably not as high as that. Then maybe they're 10% or so. And I think you get this one sort of opportunity in life where if we plan properly, we can actually help patients resolve a genetic and therefore unfortunate hand that they got dealt, condition, and get a good outcome. And so, for example, there, what we might be talking about is extraction of first adult molars, which are the most heavily affected teeth. You know, at the right patient at the right time, maybe 10, can mean that they don't have a lifelong burden of crowns and root canals and implants. And what it all comes down to, like I pretty much bang through all things, is it's all planning. You know, my I'm actually a far less skilled dentist than you are, Jill. I do five things. You know, really. You know, I do extractions and sealants and crowns and polpotomies and the old root canals, you know, whatever, but I don't do the remit of what you do. So my job clinically is generally not too hard. But the treatment planning's hard. Yeah. And getting that right is so important.

SPEAKER_01 2:32

Yeah. And I think I remember in your program you spoke about when you speak of burden, I think there was actually a tangible amount from an American study talking about what that financial burden looked like. What what can you go back into that a little bit?

SPEAKER_00 2:46

Yeah, it's about$12,000 a tooth.

SPEAKER_01 2:49

Yeah.

SPEAKER_00 2:49

Yeah. So if you've got a heavily restored six and a 10-year-old that then ends up undergoing, you know, they get a crown maybe, then it goes necrosis 20, 30 years later, they get a root canal and a crown. It's like another five, six grand. And then eventually 20 years later that fails. So then you get an implant put in, that's seven, eight grand. You know, you're looking at$12,000 for a tooth, where a lot of the cases the patients have actually had surgical extraction of their wisdom teeth. Yeah. And then we could have extracted this tooth at the right time in conjunction with our lovely orthodontic colleague Liz. Uh, and and we could have saved the patient, I don't know,$11,500. Yeah. Plus the multiple hours in the dental chair.

SPEAKER_01 3:29

Yeah, I think that's the point, isn't it? You see a lot of children, I see a lot of anxious adults and um and treat many of them under general anesthetic because of the trauma they recall from their childhood. And when you look in some of these mouths, they're essentially an unrestored mouth with two, one, two, three, or four really bond sixes. And they they don't really understand why. But if you're clever, I suppose you could look back and think, well, they have to have been hypermedical. It just doesn't make sense otherwise. So the emotional burden is is huge as well, isn't it?

SPEAKER_00 3:58

Yeah. Yeah. The reason is they're hard to get numb.

SPEAKER_01 4:00

Yeah.

SPEAKER_00 4:01

You know, they're really hard. They're like inflamed, irreversibly pulpitus teeth. So then we end up, you know, particularly back in the day, we just force people through things, didn't we?

SPEAKER_01 4:08

Yeah, we didn't know better.

SPEAKER_00 4:09

No, and now we do. Now we do.

SPEAKER_01 4:11

Yeah.

SPEAKER_00 4:12

Yeah.

SPEAKER_01 4:12

Um, so I've got some questions that have been sent in from Dr. Michael Mandikos, so I hope it's okay that I ask away. So Michael asks, we see lots of patients with lots of tooth decay, and obviously we refer them on to our pediatric dental specialists. But what about um the patients that you see that haven't come by referral? How do people find you? Do you have a lot of patients that just come in because you're a kid's dentist?

SPEAKER_00 4:39

Yeah, we do. Um, not all practic all practices are set up a little bit differently. I'm conscious that we're not trying to be seen as a competitor to like our general dental colleagues and things. Um, but we've got um, like once again, we work as part of a team, so I generally only see referred patients, but then we've got some moral health therapists and general dentists within our clinics uh that will see uh self-referred patients. So a lot of the time it might be uh the sibling of someone we've seen before, uh, or we do see a lot of like neurodiverse patients or patients where perhaps a general dental clinic might not have the resources to help them. So, you know, they need longer appointments or less stimulating appointments or a lot more sort of behaviour management strategies.

SPEAKER_01 5:23

Yeah, so where does pediatric dentistry end and special needs dentistry begin?

SPEAKER_00 5:28

Oh, that's a good question. Yeah, I think the oldest patient I've got the book's about a six-year-old. Uh uh unfortunately, I think the um uh the one of the specialties we need the most of in Australia is actually special needs. Yeah and actually like geriatric clinicians. But they're they're the smallest specialty in Australia.

SPEAKER_01 5:45

Yeah.

SPEAKER_00 5:46

Uh they're they're tiny. I think there's like sub-30 of them. So a lot of pediatric dentists, we sort of still treat adult special needs patients like, you know, no non-verbal autism, down syndrome, or genetic conditions. Um, but I think our um special needs colleagues just are like the they're such a good job, you know. And I I fear like when our grandparents went to aged care homes, they went with dentures.

SPEAKER_01 6:12

That's right.

SPEAKER_00 6:13

We are now sending this like wave of old people to aged care homes where they don't clean teeth and they've got highly complex dentistry in their mouths. Yeah. And they're not suitable, they can't, they've got dementia, they can't tolerate treatment, they're not medically suitable for GA. What do you do?

SPEAKER_01 6:33

Yeah, what do you do?

SPEAKER_00 6:34

I don't know. It's a huge problem.

SPEAKER_01 6:36

Not my asks, and it and it goes to that point beautifully. You often hear stories of 20 and 30 year olds who still go to their pediatric dentists because that's their dentist. Like, are there any rules? Can you just keep seeing your pediatric dentists when you grow up or do you boot them out?

SPEAKER_00 6:54

No, you know, we um we we're still registered as general dentists and pediatric dentists. So we can still see them. Most of them, to be honest with you, um, most of the patients we see, they do tend to want to move out. You know, the 20-year-old normal, fit, healthy, non-neurodiverse patient isn't as thrilled about watching Bluey on the TV all day. Uh but but you do get the odd one that sort of stays around. We we end up too with sometimes some really anxious adults, probably a bit like yourself, yeah, um, where uh they are really, really, really anxious. And so they just come to see us for some stuff as well.

SPEAKER_01 7:25

Yeah, I suppose a lot of the strategies are very transferable, aren't they?

SPEAKER_00 7:28

Yeah, I actually think, for example, giving local to kids is one thing that is really terrifying for practitioners. But to be honest, it should be one of the easier parts of our job. But the techniques you learn, if you can give local to kids well, you need to use those same strategies for adults. Because and that's a game changer for your practice. Yeah. If you can give local well without people feeling it, it's a game changer.

SPEAKER_01 7:49

Yeah, it builds trust, doesn't it? Yeah. Um, as far as you know, what referral pathways are concerned, where do you think the line sits? If a patient has complex needs, pediatric specialty type stuff, lots of caries or hyper-mineralized teeth and a few missing teeth or developmental problems. And and the patient is probably going to need pediatrics and orthodontics. Who do we send to first? Do we do we send a letter to both of you? How does that referral pathway look? And is it more that we send to you and you send to the author, or what's what's the best way to do it?

SPEAKER_00 8:24

Generally, the cleanest way to do it is to send to us first. So we're a bit like a pediatrician for kids. We're a bit like the case manager.

SPEAKER_01 8:32

Okay.

SPEAKER_00 8:33

Right? And so then what we can do is make some assessments and things and think, look, you know, compliance for this is X, you know, prognosis for this is whatever. And then we can send to author if we need to and get their input. It doesn't mean that we necessarily need to do all the work. You know, that's where I think all of us working together as a team can get good outcomes. But I think um having, you know, in the general dental world, ultimately it will be your name that might sign off on something. So I'm thinking hyperimmunized sixes, right? I I think getting an input from a PEDs or an ortho is helpful. You could just send that straight to ortho and manage that yourself. But I think sometimes, you know, these patients generally, 10-year-old full extraction of sixes is probably going to benefit under gel anesthetic. You know, sending to PEADs and just let them sort it, let them do all the communication, and then the patient goes back to you, and then you keep on that long-term family relationship can work quite well. Yeah. But it's each for their own. No approaches right or wrong.

SPEAKER_01 9:28

Okay. Um, there's a bit of a new, well, it's not new, but it's it's up and coming treatment um in Australia, auto-transplantation. Have you been involved much in this? I know Liz speaks a little bit on it in her hyperimmunalization lecture with uh removing a six, but what's your knowledge or experience in that field?

SPEAKER_00 9:50

We've got a few on the cards at the moment. I won't do molars to sixes, for example. Um you don't want me taking your wisdom tooth out. Um, but we'll do premolars to anteriors, so from trauma. And in the right case, it's a really wonderful option. Once again, the success rate sits between 92 and 97%. Keep in mind that a root canal on an immature anterior tooth is not super fantastic. And the reason we're sometimes replacing these is these teeth are they they're cactus, you know, they're fused to the jewel, they're not a viable option for life. So, in the right candidate, what we do is we we get the right stage of development, about half to two-thirds root development, and we take their premolar and we put it in the front. And um, yes, you still need to prosthetically reshape it, um, but you have the patient has their own tooth and the mouth, which means it can be moved orthodontically. It can it doesn't need root canal, it maintains bone, and the success rate's just 90%. And all that costs about sub sub a thousand dollars.

SPEAKER_01 10:55

And am I right in understanding if it fails the implant is still available.

SPEAKER_00 10:59

Yeah.

SPEAKER_01 10:59

So how do why does the tooth not enclose if it's been extracted and replanted?

SPEAKER_00 11:04

It can, but what we do when we do this procedure is we 3D print up that tooth. So we have uh 3D printed tooth, and then when we take out the failed tooth at the front, this that's the one, we then prepare the socket to fit the 3D printed tooth. And this has been the game changer. So then we muck around with that. And once we've got it fitting where we want it, then we take the tooth out down the bottom as delicately as we can, and then it's extra oral or extra socket time should be twenty seconds.

SPEAKER_01 11:39

Right.

SPEAKER_00 11:39

So we pick it up, put it straight in and suture over the top.

SPEAKER_01 11:42

Oh, so you bury it.

SPEAKER_00 11:44

Well, no, no, no, you won't I'm sorry not suture over the top, suture, and then you put sutures over the top of the tooth. Right. Right, you can use a splint, but a lot of the time you'll see on if you look into papers and images, there's like silk sutures sitting over the top of the tooth. Right. Because you see that sort of sub out of the bite, so it sits down a bit and then it can it will extrude or you can orthodontically extrude it. Um but yeah, so you you suture the gum back closed, and then usually you've got to anchor the tooth because it will be it's gonna be a little bit wobbly.

SPEAKER_01 12:09

A little bit wobbly. For how long?

SPEAKER_00 12:11

Uh usually it's a bit wobbly for you. You might suture for a couple of weeks. Yeah. Um, same as like a normal evulsion or splintered, and then after that, um, you will hope to see root development within a short period of time, three to six months. It will grow bone. Phenomenally, it will grow bone. We've got a patient who had no bone on the buckle, zero. There's no bone on the buckle. And we got this tooth, we thought, this isn't gonna work, but we'll see what happens. Put it in there and then the entire buckle plate's reformed. Why? Periosteum. Yeah. Periosteum grows bone. You put periosteum on PDL, you will grow bone. So you can regrow bone.

SPEAKER_01 12:44

So when at what stage can that patient have some aesthetic um reshaping or prostodonic work?

SPEAKER_00 12:51

From about six months afterwards.

SPEAKER_01 12:53

So it looks like a premolar in the front for six months.

SPEAKER_00 12:56

Well, you can. We've got a couple of, you know, unfortunately that some of the ones we've done are quite young girls.

SPEAKER_01 13:02

Yeah.

SPEAKER_00 13:03

And having a premolar front tooth's not ideal. So um, yes, it doesn't quite meet the guidelines, but we've just sort of tried to reshape it with bog it up with a bit of composite. Yeah, it doesn't look perfect, but it looks a bit more like a tooth shape. You really want to wait for at least a little bit of healing and stability before you do that. Full prosthetic, like when we would send them to Michael, for example, to redo, um, might not occur until really you're getting close to like the end of orthodontic treatment.

SPEAKER_01 13:29

Yeah.

SPEAKER_00 13:30

You know, you're getting the sizes and everything ready, and we'll get my I I you know, you want to really, I think you want a quite a skilled general dentist or specialist prosodonist that's going to do that final restorative part because it can be hard to manage.

SPEAKER_01 13:43

So, what happens if that patient has a deep bite or no space for premolar-shaped tooth in that area? And, you know, how are you going to keep it out of the occlusion?

SPEAKER_00 13:55

So not everybody's a candidate for it. And there might be other options that are available to us, such as decoronation of the failing tooth or, you know, uh substitution, moving laterals across. Um, but a lot of the time you will bury it below the bite anyway, so on a deep bite. And then you're doing this generally in conjunction with an orthodontist. Right. And so we're coming to a solution. You might need to, you know, remove the palatal cusps, and there's there's things you can do to get around it. Yeah. But not everybody's a candidate. We see, I don't know, I reckon I see 50 or 60 traumas to anterior teeth a year. Oh wow. And of them, a portion, 10%, will fail. Yeah. And we probably do one or two autotransplants per year.

SPEAKER_01 14:31

Yeah.

SPEAKER_00 14:32

So there's not everybody's a candidate for it.

SPEAKER_01 14:34

Yeah.

SPEAKER_00 14:34

It depends. Yep. Yep.

SPEAKER_01 14:36

Obviously, you know, my history, and I'm a child of dental trauma and you know, lost my central incisor. So that's one of the reasons I became a dentist because of all of the dental work I had. And luckily for me, it didn't send me in the trauma direction. Uh I mean uh personal and dental anxiety direction, it made me interested in the topic. But do you recommend any specific trauma guidelines? I know there's several out there that are available. Some may be outdated, um, some maybe not uh what you recommend. But you said you see a lot of trauma. I think general dentists, we see a lot less of it. But when it comes in, because it's not so frequently done in our clinics, we we can panic a little bit. If we want to help that patient right then and there and not send on to refer, are there good guidelines we can access?

SPEAKER_00 15:23

Absolutely. The dental trauma guidelines, I think everyone should pay for it. Why? It's cheap, sub a hundred bucks, I think, so 70 bucks. It's not for profit. The money goes to research on trauma. And I think if you're not doing it and you're not following those guidelines, you're actually putting yourself at a high risk of getting sued. Like if something went wrong that could have been managed better and you managed it not in accordance with guidelines, like you've got to justify it. Not that I think, like, fortunately, pediatric dentistry in that age group doesn't seem to get too much legal challenges compared to like ortho and pros and maybe some other things. But I think most people want to do the right thing.

SPEAKER_01 16:00

Yeah.

SPEAKER_00 16:00

Yeah. Other option is hopefully you've got a good relationship with your local PEEDS dentists.

SPEAKER_01 16:05

Yeah.

SPEAKER_00 16:05

Like, probably some of us are pricks. Most dress are generally pretty nice, I reckon. Give us a call. Yeah, yeah. You know, we're here to help.

SPEAKER_01 16:12

Yeah. Um, so those guidelines, I'll get a link to them and we'll put them in the show notes today so you can have a look at those. Um, another question from Michael is missing teeth. So you spoke before about you know, laterals moving across and things like that. But what about the missing lateral? Yeah. We see heaps of it. Do you have specific guidelines that you like to work towards for those type of patients? Can you share your approach?

SPEAKER_00 16:36

Like a lot of things, unfortunately, I've got to say it's patient to patient, right? Yeah. I generally prefer a biological solution when achievable. So if we can move the canine across, for example, or whatever, I generally find that's a much more stable option for the parent, um for the patient throughout the rest of their life. I don't really love the idea of setting someone up for an implant because even that can have complications. Now, you still need implants occasionally. So, for example, if you're missing ease, we we could auto-transplant. Or if we planted early, you could arguably extract and move sixes in and other things, right? But for lateral incisors, they can be trickier because if you're going to move the canine across, we've got to reshape that. And that's hard to make a canine look like a lateral. And then you've got to make the pre-model look like a canine, so that can be challenging. So if we decide that person's not a suitable candidate for biological replacement, I think one of the most underutilised, beautifully aesthetic, highly successful treatments we've got is a zirconia Maryland Bridge. And um, I get nothing for saying this. Michael runs a great course that's available online, which is probably you've probably got access to because you're in this, um, on zirconia Maryland Bridges. The ones that I've done have been with his assistance, and I'm I'm very grateful for his assistance. They look fantastic. You cannot tell. They have a success rate in the high 80% at 10 years, with the principal cause of failure being a debond. Yeah. So you just get your glue out again and stick it back on. Yeah. We'll get another 10 years out of it. Yeah. Yeah. And then guess what? What can we do if ultimately it fails and we can't for some reason it's no longer useful? What can we do? Implant. Implant. Let's delay implant as long as possible.

SPEAKER_01 18:21

Yeah.

SPEAKER_00 18:21

Yeah.

SPEAKER_01 18:22

That program that Tim is referring to, there's there's a few different lectures you can get your hands on on our online library, www.correctdentistry.com.au. We also have the bridgework program coming out later this year in 2026. So have a look on our website, CEODental.com.au. We love the shout out. Thank you, Tim. And I agree with you. I think it's an underutilised treatment. We we are all about the implant now, and it's I have an implant in my mouth, but if if I was missing a lateral or if one of my children were missing a lateral, I would be sending them to Michael, that's for sure.

SPEAKER_00 18:56

Yeah, I would absolutely be putting a um zirc. I think the game changer was changing it to zirc zirconia.

SPEAKER_01 19:01

Yeah.

SPEAKER_00 19:01

Right? So instead of having a metal wing on the back, which which sort of compromised aesthetics, that zirconia has made it into undetectable.

SPEAKER_01 19:09

Yeah.

SPEAKER_00 19:09

Yeah.

SPEAKER_01 19:10

So what's next in Peds? I think zirconia coming in was kind of cool and interesting. Stainless steel crowns went, I mean, they've been around a long, long time, but I think they're being used a lot more prevalently than they ever were. I if you look around any prep classroom in Australia, you'll see lots of kids with them, which I always think is a good and a bad thing. It makes me think you had a good dentist because I think they're they're treating well. Um, but I also think we've got a lot of tooth decay, obviously. Um one thing that's uh happened, I think, is that there's cool toothpaste flavours now that are coming out, which I I really wish I'd invented it. I wouldn't be working as a dentist, perhaps. But that's been a big problem for a long time is the taste of the toothpaste with the appropriate amount of fluoride. But do you have any forecasts of what else is coming in the pediatric space?

SPEAKER_00 20:01

Not really. I mean, we've actually had massive change the last 10 years, if you think about it. Um, because we've gone with the advent of silver diamine fluoride, whore crayons, zirconic crayons, and MTA, or calcium silicate cements. You put those in, they're huge game changers for our industry. We've actually had a lot of disruption. So we're now putting, we're fixing teeth really reliably without local and drilling. We're able to prevent a lot better with silver fluoride or silver diamine fluoride. Our pulpotomies, there's a guideline that came, not a guideline, a paper that came out last year from the American Academy of Pediatric Demistry, and one that just came out this year about polpodomies, whether for primary or permanent teeth. And it's now irrefutable that you have to use a calcium silicate cement. So MTA biodentine doesn't matter. If you're using anything else like ferric sulfate or calcium hydroxide, I'm going to be quite strong on this. You're doing the wrong thing, unfortunately. And I'm not trying to look for blame. We need to change the way we manage things when new evidence comes available. And the yawning gap on success rate of 70% for calcium hydroxide and 99% for polpotomies, uh NTA-based polpotomies, is just too big. You know, if you're doing a hundred polpotomies, you have one failure or 30. Yeah. Right now, cost was a big problem, but now you can get the cost below$10 a polpotomy. Yeah. Whether that's for primary or adult teeth. So those have been baked, massive game changers. Where are we going to go? I don't know. I don't know. You know, to be honest with you, I reckon that's a fair whack of disruption. And to be honest with you, I, you know, we didn't think like Hall Crans wasn't there.

SPEAKER_01 21:37

Yeah.

SPEAKER_00 21:37

And now it is. Yeah. But I c you know, and you know, it's a bit like remember when you did your chemistry class back at school and they said in the early 1900s, all the the professors sat down and said, There's nothing left to discover. You know? No, that's where we're at. And then the world changed, you know? Yeah. So anyway, I don't know.

SPEAKER_01 21:59

I don't know. I think the um the different fluoride like for me with pediatric dentistry, I just think the things that make my life easier, I think the better flavored fluoride varnishes, you know, Jura fat, I still every time I smell Jurafat, it just reminds me of my mum and dad because that was the smell of their clinic. But people don't like it.

SPEAKER_00 22:20

Nice.

SPEAKER_01 22:20

And if you and if you want to use a good fluoride varnish, which of course we do want to use instead of the gel and the foam and all of the things we shouldn't be using, then it's got to taste good.

SPEAKER_00 22:29

Yeah.

SPEAKER_01 22:29

So they're the things that really are impactful for me, but I'm not auto plant transplanting teeth either. So small things.

SPEAKER_00 22:37

But you know, they're big things for us too. Yeah. Honestly. Auto-transplant four or five times a year. Yeah. You know. Fluide vanish. Three times an hour. Yeah. Yeah.

SPEAKER_01 22:49

Thank you, Tim. That was just an excellent chat. I always enjoy catching up with you. We've got heaps of resources that we can add to the show notes. We'll add your website. You have a lot of information freely available to dentists. Can you give us a quick uh summary of what you have?

SPEAKER_00 23:05

Yeah, it's pretty much got sort of all topics of uh kids' dental stuff. There's some free uh webinars or lectures you can watch on them. Uh and then pretty much we put out like a I don't love the term blog, but anyway, it's a I guess it's an information blog that goes out about once a month and just covers all sorts of topics. Um so that's all free to access as well. Yeah. And then obviously we run some courses like a two-day restorative course, trauma course, hypomine course, um zirconi crown course, and we're looking to add a nitrous oxide course as well. Great um over the next year. Yeah.

SPEAKER_01 23:36

Yeah, do look Tim's courses up and the website. You're you're very generous with your knowledge, and obviously, this is a passionate topic for you and it's your life. So we really appreciate the chat. Thanks.

SPEAKER_00 23:47

Cheers. Thanks for having me.