Dr. Venkatesh Bhardwaj, Paediatric Dentist, Suite 1, 1-23 Elizabeth Street, Camden, Sydney (2026)

02/07/2026

Last week I shared the case of an 8-year-old with a hypomineralised lower left first permanent molar.

In the same week I saw an 11-year-old with an enamel defect on tooth 26.
Significant loss of coronal tooth structure. The OPG corroborated the clinical findings.

Clinically >> there was extensive cavitation, undermined walls, poor retention and resistance form. Second molars still unerupted with roots in later stages of development.

The plan is >> to extract tooth 26 with an orthodontic opinion.

The amount of coronal tooth structure remaining in this case determined the decision to extract the tooth rather than maintain it.

This brings me to something I want to be clear is a clinical observation, not an evidence-based position. In my experience, as a profession, we extract first permanent molar teeth more readily than the clinical picture sometimes warrants.

It is always worth asking if a first permanent molar can be restored before deciding to extract it.

For me these two cases reinforce two things:

Restorability is an active clinical assessment: retention form, resistance form, remaining wall structure, pulpal status.

It is important to have an orthodontic opinion prior to treating so that parents can make informed decisions about whether other extractions are also required.

25/06/2026

I recently saw an 8-year-old referred with a hypomineralised lower left first permanent molar. There was post-eruptive breakdown on the occlusal surface and marginal ridges. The tooth was sensitive to cold on presentation, resolving within seconds on stimulus — consistent with reversible pulpitis, which in MIH teeth reflects hypersensitisation of the pulpal fibres rather than pulpal compromise.

Radiographs confirmed no periapical pathology, no furcation involvement, and a pulp chamber within normal limits. Root formation appeared to be progressing normally. On clinical examination the remaining walls were structurally sound with adequate retention and resistance form and the tooth was restored with a stainless steel crown (SSC).

In such cases informed consent with the family is important. The SSC is a short/medium-term solution. If the decision is made to keep this tooth long-term, the crown will need to be replaced with a definitive indirect restoration as the child reaches adolescence. Parents need to be aware that endodontic treatment may become necessary in future given the nature of MIH-affected enamel and the degree of breakdown already present.

For me this case is a useful illustration of two things that are part of managing MIH-affected first permanent molars well:

Clinical and radiographic findings together determine the management decision. Not the clinical situation alone.

Informed consent is part of the management. An SSC buys time. It is not a permanent solution and families need to understand that from the outset.

Tomorrow: same diagnosis, an 11-year-old, and a different management decision.

30/04/2026

A question I get asked often is what material I use for pulpotomies in primary teeth? Whether I do pulpotomies or pulpectomies or indirect pulp therapies (IPT) ?

Pulp therapy in primary teeth is about diagnosis and case‑selection.

Before we talk technique or material, I want to know:
What is the pulpal status? Is this tooth actually restorable and worth preserving for this child, at this age, with this temperament? Can I achieve reliable isolation and a durable coronal seal? What do the symptoms and radiographs really show? And what is this child’s genuine capacity to cooperate?

For more than a decade, the evidence has pushed us away from routine aggressive caries removal and toward biologically based approaches that preserve pulpal vitality wherever possible.

The 2024 AAPD guideline, based on a systematic review of 299 studies, strongly recommends calcium silicate cement pulpotomy over formocresol, and supports indirect pulp treatment precisely because it reduces iatrogenic exposures in the first place (Coll et al., Pediatric Dentistry, 2024).

The IAPD Porto Declaration (November 2024) reinforces this. Sixteen international specialists produced 38 consensus recommendations, explicitly supporting conservative, biologically based pulp therapy and tissue preservation over escalation (Dhar et al., Int J Paediatr Dent, 2026).

Three things I keep in mind chairside:

- Deep caries management is not the same as complete caries removal.

- Selective caries removal reduces pulp exposures. The goal is to preserve vitality, not manage an exposure we create.

- The coronal seal is crucial to success

How are you currently deciding between IPT, pulpotomy and pulpectomy in your own primary molar cases?

22/04/2026

As clinicians who manage children, we’re all used to Tell–Show–Do.

A 2024 survey of American Academy of Pediatric Dentistry (AAPD) members found that 98.6% of respondents reported using TSD routinely.

We tell the child what will happen, we show them, and then we do it. It’s simple, structured, and it works.

Here’s another layer that works really well for me: Ask–Tell–Ask.

I use it to make sure kids leave knowing exactly what’s going to happen next time.

For example, when I’m planning to use the “nose” or “mask” (nitrous nasal hood) at the next visit, I’ll say:
“Can you tell me what we’re going to do next time you come to see me?”

The child gives me their version of the plan.
Then I tell them anything they’ve missed, in their language.

For example:
“Hey, that’s awesome. And remember, we’ll also use the strawberry mask on your nose to help fix your tooth.”

Then I ask again:
“Do you think you’ll be able to remind Mum and Dad what we’re doing when you get home?”

In some ways, Ask–Tell–Ask turns the child into the storyteller of their own treatment.

It confirms what they’ve understood, helps us fill in the gaps, and, more importantly, recruits them into the plan. It makes treatment part of normal conversation, not a mountain that needs to be climbed.

Tell–Show–Do helps with the immediate. Ask–Tell–Ask helps tomorrow feel a little less scary.

02/04/2026

Sharing a recent case that really highlights the risk of ‘just monitoring’ baby teeth.

This series of radiographs, kindly shared by a referrer, tracks a 6‑year‑old whose parents declined treatment for proximal lesions in teeth 64 and 74 for several reasons unrelated to cost.

The plan in May and August 2023 was to monitor under strict conditions: regular follow‑up, bitewing radiographs as indicated, and effective home care.

The child then failed to attend for over a year. By September 2024, bitewings show clear radiographic progression in teeth 64 and 74 and new or enlarged lesions in teeth 65 and 75, consistent with evidence that proximal lesions in primary molars can progress from enamel to dentine within roughly 12–24 months, particularly in higher‑risk children.

Current guidelines emphasise that every carious lesion in a primary tooth should be actively managed, whether with site‑specific prevention, sealing/infiltration, or selective caries removal and appropriate restoration.

“Not treating” is an important option, and one that we must sometimes employ as part of good clinical care, but it comes with caveats. Most importantly, that of reliable recall and demonstrable lesion arrest.

When attendance is sporadic, what was intended as a conservative plan can rapidly progress and ultimately require more extensive care.

Always keen to hear if any of you have had similar cases.

11/03/2026

This 6‑year‑old child was referred for dental treatment under general anaesthesia.

She was clearly nervous at her initial visit but willing to engage, and even managed bitewing radiographs at the end (often a good sign we may be able to avoid hospital).

With simple behaviour management (tell‑show‑do, modelling, clear signalling, short explanations) and a short course of nitrous oxide, we completed care in the chair and she accepted further visits for remaining treatment including extractions

Tooth 85 had a deep occlusal lesion, radiographically close to the pulp but asymptomatic. Given the high risk of pulp exposure, we removed caries peripherally under rubber dam, left affected dentine over the pulp, placed a glass ionomer core and cemented a stainless steel crown. Evidence in primary teeth supports incomplete caries removal in deep lesions, with lower iatrogenic pulp exposure and similar survival to complete caries removal.

Learning points:

- Some children do need a “short sleep”, but not every anxious child requires hospital‑based care.

- Use the first visit to build rapport and assess how far behaviour can be guided or shaped with pharmacological agents used as adjuncts.

- When possible, use rubber dam and preserve affected dentine over deep pulpal areas to avoid exposure.

- Aim for an excellent coronal seal; when it is safe and acceptable to the child, completing care in the chair can be more efficient than hospital‑based treatment.

05/03/2026

3 practical tips to help manage the child patient

I spend a lot of my week with worried little humans (and their even more worried parents).

These 3 simple habits have changed my practice:

1. I greet the child by name before the parent and get to their eye level. Sometimes I’ll even use the greeting to get them talking:
“Hi, my name is... What’s yours?”
If they answer, I use that to lead into questions about school or something else non‑dental. If they don’t, I quickly pivot to something on their T‑shirt, water bottle, shoes. Anything that’s theirs. Not their teeth.

2. Use humour and small talk on purpose
If you know me, you know my jokes are terrible. My co-workers constantly roll their eyes. But that’s ok. A rubbish joke is another chance to connect.
I start with school, pets, shows or games. Never teeth.

3. Be clear about what happens next using techniques like tell-show-do
I avoid “Don’t worry, it won’t hurt.”
Instead I give short, concrete steps:
“I’m going to lie you back and use my mirror to have a look.”
“You might feel my mirror touch your tooth" (model on a front tooth). "You can put your hand up if you need me to stop" (provides control to the child)

Tiny disclaimer at the end:

Beneath this all is developmental thinking. I don’t talk to a 3‑year‑old the same way I talk to a 12‑year‑old.

In practice, it looks like this: be child‑first, stay true to your personality, and keep your communication clear and honest.

Children are brutally honest. The are the best A/B‑testing subjects on the planet. They’ll tell you instantly which version works.

If there’s a hack you use in your chair. Or a horrendous joke that somehow works with your anxious tween patients; please let me know. I promise to shamelessly adopt and use it.

25/02/2026

The IAPD Porto Declaration has issued 38 consensus‑based recommendations on pulp therapies in primary and young permanent teeth. Here is a brief summary of the points most relevant to everyday paediatric practice.

Primary teeth

- Deep caries in vital primary teeth: selective caries removal is preferred. Complete caries removal is reserved for extremely deep lesions.

- For multi‑surface or large single‑surface deep lesions, Hall technique (no caries removal) or selective caries removal with a crown is recommended over complete excavation.

- Where deep caries in a vital primary tooth leads to pulp exposure, vital pulp therapy should be performed using calcium silicate cements (MTA, Biodentine).

- Pulpectomy is appropriate in primary teeth without pre‑operative root resorption that present with irreversible pulpitis or necrotic pulp, using rotary or manual instrumentation with NaOCl (1–5%), saline or 2% CHX as irrigants.

Immature / young permanent teeth

- Vital pulp therapy is the preferred approach where the pulp is still vital; calcium silicate cements are the material of choice and a high‑quality coronal seal is essential.

- Selective caries removal is advised for deep, but not extremely deep, carious lesions.

- Full pulpotomy is an acceptable alternative to non‑surgical root canal treatment in mature permanent teeth with pulp exposure and clinical signs of irreversible pulpitis, provided there is no evidence of pulp necrosis.

- In immature permanent teeth with extremely deep caries, irreversible pulpitis and no signs of necrosis, full pulpotomy with calcium silicate cement is recommended to allow continued root development.

Trauma – permanent teeth

- In complicated crown fractures, direct pulp capping shows lower success than pulpotomy, but may be used selectively or as a temporary measure in less cooperative children until pulpotomy can be performed.

- Non‑staining calcium silicate cements are recommended.

See the link to the open access article in the comments below

18/02/2026

When I left general practice for paediatric dentistry, I used to joke that I chose treating kids because I disliked communicating with adults.

The truth is that managing a child patient in the chair is actually a masterclass in communication. Every appointment is a triad: the child, their caregiver, and the clinician.

We’re speaking three “languages” at once. Our communication has to create playful safety for the child, calm and authoritative clarity for the parent, all on a foundation of evidence‑based clinical precision.

There is a study by Nalini Ambady and colleagues called “Surgeons’ tone of voice: A clue to malpractice history.” In it, surgeons were audio‑recorded during real consultations, and coders listened to just two brief 10‑second clips from each surgeon – with no content, only tone.

Those tiny slices of voice were enough to identify which surgeons had a history of malpractice claims: surgeons whose tone sounded more dominant and less concerned or anxious were significantly more likely to have been sued.

In other words, long before we ever need to think about indemnity insurance, patients are already picking up signals about our warmth, concern, and respect from the smallest fragments of how we sound.

Before anyone hears our treatment plan, they feel our presence.

In paediatric dentistry that might look like:

- Sitting at the child’s eye level and softening our voice when needed
- Turning to the parent with steady eye contact and slower, clearer explanations
- Allowing competence be driven by warmth

HOW we say things, not just WHAT we say, is one of the most powerful human tools we have.

I’ll link the Ambady paper for those who want to deep‑dive into the methodology and limitations. My disclaimer is that it was not designed for paediatric dentistry or even dentistry, and it has its own shortcomings. But it makes useful reading and is a powerful reminder of how important those first few moments with our patients and their carers really are.

(Nalini Ambady, Debi LaPlante, Thai Nguyen, Robert Rosenthal, Nigel Chaumeton, Wendy Levinson, Surgeons' tone of voice: A clue to malpractice history, Surgery, Volume 132, Issue 1, 2002, Pages 5-9)

11/02/2026

Bitewing radiographs in children – why and how we make them work

Bitewing radiographs in children are hard to get – but when we do manage to get them, they often provide valuable information that changes care.

Clinical/visual examination alone underestimates the presence of proximal caries in the primary and mixed dentitions; adding bitewing radiographs increases detection and can alter treatment planning.

Bitewings are also more useful than OPGs for caries diagnosis, particularly for proximal and occlusal surfaces.

There are well‑described paediatric behaviour‑guidance techniques to help obtain radiographs in children. Here are some that work in our practice:

- Eye‑level positioning
Aim to be at the child’s eye level (I am generally kneeling or have the chair elevated) to reduce perceived threat and support rapport. Pair this with a sensation‑based pre‑frame and tell–show–do using the film: let the child hold it, explore it, and describe it. Once they know what it is, it’s less of a threat.

- Use normalising language
Explain that “it will feel like a tickle / a bit funny” while gently rubbing a finger where the film will contact in the lingual sulcus, so the child knows what to expect without focusing on discomfort. This creates a brief desensitisation before the sensor goes in.

- Link to previous mastery + chunked instructions
“You’ve done this before; it’s the exact same thing” connects to past success. Then give simple, sequenced commands – “open big… now slowly bite down… hold it there between your teeth” – instead of a long string of instructions. Talk them through each step.

- Descriptive praise and positive reinforcement
Provide continuous, specific praise for micro‑moments of cooperation (“that’s it, hold still… perfect… you’re doing great”) to maintain engagement just long enough for the exposure.

- Clear endpoints and flexibility
Start with the most important side and accept a partial series if needed. Be comfortable saying “thank you for trying” when the behavioural cost outweighs the diagnostic gain.

As always if you want to read more here are some guidelines from the American Academy of Paediatric Dentistry:

1https://www.aapd.org/globalassets/media/policies_guidelines/bp_cariesriskassessment25.pdf
2https://www.aapd.org/globalassets/media/policies_guidelines/bp_radiographs25.pdf

Dr. Venkatesh Bhardwaj, Paediatric Dentist

02/07/2026

25/06/2026

30/04/2026

22/04/2026

02/04/2026

11/03/2026

05/03/2026

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