M|jor Topic Abnormrl teeth Behavior Management

& Conditions

Abbreviation

Major Topic

Abbreviation

Abn Tth

Primarv Dentin

Prim D€nt

Behav Mgmt

Pulp Treatment

Pulp Tx

& Cond

Restorative

Restorative

Drugs

Space Management

Space Mgmt

Fluoride

Fluoride

Tooth Development

Tth D€v

General Information

Gen Info

Tooth Trauma

Diseases

Drugs

Miscellaneous

Dis

Tth Trauma

Misc.

Abn Tth

PEDIATRIC DENTISTRY

The photograph shows an example

of

in a five-year-old girl.

. Amelogenesis imperfccta . Dentinogenesis

imperf-ecta

. Fluorosis

.

Enamel hypoplasia

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Copyright.C 201

I l0l2

Dentinogenesis imperfecta 1D1, is an autosomal dominant trait. its frequency of occurrcnce is about 1 in 8000. This inherited dentin defect originales during the histodilferentiation stage oftoolh dcvclopment. Thc predentin matrix is defective resulting in amorphic, diso.ganized, and atubular circumpulPal dentin. Teeih are blu€-gray or bro$n and abrtde rapidly. Occasionally, these teeth become abscessed as a result ofexposure ofpulp homs caused by wear. Full covcragc is the t.eatm€nt of choice. Both the primary and permanent denlitions are afTected in dentinogenesis imperfecta. lmportant: Radiogmphs ofa preschool child with dentinogenesis impefecta will show obliteration olth€ pulp chrmbers with secondary dentin, a chamcteristic finding. Roots of te€th usually are narrower tnd app€ar more fragile. Crowts gcnerally appear more bulbous than usual due to the smaller roots. Denlinogenesis imperfecta can be subdivided into three basic tlTres:

. shields Type I: occurs with osteogenesis imp€rf€cta. There is brittle boncs, bowing ofthc limbs. and blue sclera. Periapical radiolucencies, bulbous cro\rns, oblitcrated pulp chambers and root fraclures are common Teeth have amber translucent color Primary teeth affected more than permanent leeth. . Shields Type II: also kno\\'n as heredittry opalescent dentin, tends to occur as a selarate entify apart fiom osteogenesis imperticta. Same characteristics as T)?e l. Both primary and permanent teeth affected

equally. . Shields Type

III:

quite rare, demonsrates ieeth with

a

shell-like appearancc and muhiple pulp exposures.

Amelogenesis imperfect! is one ofthe major defects of enamel. It is a hcreditary disease characterized by faulty deve)opment ofthc enamel. There is normal pulpaland root morphology. Thcrc are four major catcgorics according to the stages oftooth development in wbich each is thought to occur . Hypopkstic Type: occur in the histodifferentiation stage oftooth development. There is an insullicient quantity ofenamel formed duc to areas ofthe enamel organ that are devoid ofinner enamel ePith€lium, causing a lack ofcell differentiation into ameloblasts. Affects both primary and permanen! dentitions The affected teeth appear small with open contacts, clinical crowns contain very thin or nonexislenl enamel. . Hypomaturation Type: det'ect in enamel matrix apposition and is characterized by teeth having normal enamcl thickness but a low value ofradiodensiry and mincral content. Hypoplastic or Hypomaturation Type with Taurodontism: is an examplc of inherited defecls in both apposition and histodifferentiation stages in enamel fomation. The enamcl appears motile with a ycl_ low-brown color and is pitted on the facial surfaces- Molar tceth demonstrate taurodontiim . Hypocalcification Typc: is an example ofinherited def'ect in the crlcification stage ofenamel formation. Quantitatively, lhe enamel is normal, but qualitatively, the matrix is poorly calcified. Thc cnamcl is soft and liagile and is easily fractured., exposing the underlying dcntin, which produccs an unesthetic appearance,

.PEDIATRIC DENTISTRY

Abn Tth

What condition is depicted in the radiograph below?

. Concrescence . Gemination . Fusion

. Dens-in-dente

2 Copyrighr

e 20ll-2012

Abn Tth

PEDIATRIC DENTISTRY

What condition is depict€d below?

. Enamel hypoplasia . Erythroblastosis fetalis . Nursing bottle caries

. Dentinal dysplasia

Cop)rrghl 1000 200:l Un Lve6tt]' ol Washrgton AU aghts reserved. Acce$ lo theAtlas ofPediafic Dentisrry is lovemed br a license. Un.urhorired accessor reprcduction is forbidden wirhout the prior*nuen pemissior ofthe Univelsity of Washingron. !'or irfomarion. conraci: licenseaau.washington.edu 3

Coplighr

a{i

20ll-2012

The tcrm Dens-in-dente (also called clens inNaginatus) means a "tooth within a toothri and results liom the invagination ofthe inner enamel epithelium. Most frequently involves the maxillary lateral incisors. The clinical significance ofthis anomaly results folm potential carious involvement through communicatjon ofthe invaginated portion ofthe lingual surface ofthc tooth with thc outside environment. The enamel and dentin in the invaginated portion can be both dcfective and abscnt, allowing dircct cxposure of thc pulp. Dens evaginatus is an extra cusp. usually in the central groove or ridge of a posterior tooth and in thc cingulum area of central and lateral incisors. In incisors, these cusps appear talon-shaped. It results from the evagination of inner enamel epithelial cells. This extra portion contains not only enamel but also dentin and pulp tissue, therfore, care must be taken with any operative procedure.

Gemination is a proccss in which

a singlc tooth gcrm splits or shows an attempt at splifting to form two completely or partially separated crowns. This process results in incomplete formation ofnvo teeth. Likc fusion, it is also more common in the primary dentition. It results in a bifid crown with a single pulp chamber. It most frequently occurs in the incisor region. Concrescence is a twinning anomaly invoJving the union of two teeth by ccmcnfllm only. Its etiology is thought to be hauma or adjacent tooth malposition.

Fusion ofteeth is

condition produced when t$,o tooth buds arejoined together during development and It is morc common in the primary dentition. It may involve $e entire length of two leeth (enamel, dentin, and cemenlum) ot jvst the rcot (dentin and cenenlum).This condition is usually seen in the incisor area. Although fused teeth can contain two separate pulp chambers. many appear as large bifid crowns with one chamber Note: A radiograph is needed to confirm rvhether thcre is fusion or gemination. a

appear as a macrodont (a single large crown).

. Not{dt

.a -

I . Taurodont teeth are chamcterized by a significantly elongated pulp chamber with short stuntedroots resulting from the failure ofthe proper Ievelofhorizontal invagjnation ofHert\r ie's cpithclial root sheath. l. dilace.ation refers ro an abnormal bend ofthe root during its developmcnt; it is thought to result from a traumatic episode, usually to the primary dentition. It is a consistcnt finding in children with congenital ichthyosis.

Enamcl hypoplasia lEIl) is a defect in tooth cnamcl that results in less quantity ofcnamelthan normal. The defect can be a small pit or dent in the tooth or can be so widespread that the entire tooth is small andlor mis-shaped. This type ofdcfcct may cause tooth sensitivity may bc unsightly or may be more susceptible to dental cavities. Some genetic disorders cause all the teeth to have enamel h)'poplasia. EH can occur on any tooth or on multiple teeth. It can appear whitc, yellow or brownish in color with a rough or pifted surface. In some cases. the quality ofthe enamel is affected as well as the quantity. Environmental and genetic factors that interfere with tooth formation are thought to be responsible for

LH.

. Environmental factors: . Severe infections such

as exanthemous diseases and fever-producing disorders particularly during the first year of life. Syphilis (caused 6t Treponeua pallidum) produces classic pattems ofhypoplasia including Hutchinson's incisors and mulberry molars. Rubella embryopathy has a high corelation with prenatal enamel hypoplasia in the primary dentition. . \eurologic defects as seen in children with cerebral palsy and Sturge-Weber syndrome . Fluorosisi excess ingestion ofsystemic fluoride . Nutritional deficiencies: particularly vitamins A. C, and D, along with calcium and phosphorus . Other: children bom premafurc and children who have received excess radiation cxposure as *ell as children rvith asthma *** Causes ofenamcl hypoplasia affecting individual tecth include local infection. localtrauma, iatrogenic surgcry as seen in cleft platc closure, and primary tooth overretention. Turner's hypoplasia is a classic example ofhypoplastic defects in pemanent teeth resulting from local infccIion or trauma to the primary precursor.

. Genetic factors: amelogenesis impcrfecta

(see

ca

#1)

Treatment options depend on the severity ofthe EH on a particular tooth and the symptoms associated 1\'ith it. The most conservative treatment consists ofbonding a tooth colored matcrial to the tooth to protect it t'rom further wear or sensitiviry [n some cases, the nature ofthe enamel prevents formation of an acceptable bond. Less conservative treatment options, but frequently necessary include use ofstainless steel crowns, pe(nanent cast crowns or extraction of affected tccth and replacement $ ith a bridge or implanr.

.

One part per

million

. Two parts per million . Three parts per million

. Four

parts per

million

1 Copynght O 2011-2012

. Tell-show-do (ZSD) . Positive reinforcement . Disfiaction . Non-verbal communication

5

Cop"ighi O

201 I -201 2

The role offluoride in caries prevention is a very important one. Indeed. one oflhe most significant contributions ofworld free enierprise systems to the health of people is to market fluoridated tooth paste. Huge reductions in caries prevalcnce have been made in the populations of numerous countries where fluoridated toothpastcs arc uscd rcgularly. One major reason for the decrease in decay rates is that low concentralions offluoride are prescnt in peoples' mouths and this is very etlective in the remineralization ofdemineralized teeth. For examplc, over ninety perceni ofihe toothpastes sold in thc United States contain fluoride. This amounts to a massive public health undertaking by rhe private sector Tle significant impact on decay rates demonstrates thc importancc offluoridc in caries prevention.

The mechanism ofaction for fluoride in caries abatement is sho*,n in the following list:

. . .

Increased resistance oflhe tooth structurc to demineralization. Enhanced remineralization ofearly carious lesions. Impaired cariogenic activity ofdental plaque, through disnrplion ofbacterial melabolism and function.

The studics and surveys link fluorosis to three factors:

. Fluorosis is more common in geographic areas where the endemic levels offluoridc in lhe drinking waler is higher than three parts per

million

. Fluorosis is associated *,ith fluoride supplementation at inappropriately high . Tle use offluoridated tooihpaste has been implicated in fluorosis

levels

Important: Excessive fluoride levels in drinking water are associated with fluorosis. Fluoride levels in elcess ofthree parts per million begin to pose a risk for fluorosis. This has been demonstrated in numerous sludies over decades ofresearch and in various geogmphic setiings around ihe world. Remember: Dentin Dysplasia is another group ofinherited dentin disorders resulting in characteristic inlol\ing the circumpulpal dentin and root moryhology. Two typ€s:

l_eatures

. Shields Type I: normalprimary and permanent crown morphology with an amb€r ffanslLrccncy. The roots tend to be short and sharply constricted. Primary and permanent dentitions demonslmte multiple radiolucencies and absenl pulp chrmbers. . Shields Type II: primary teclh are amb€r-colored closely resembling dentinogcnesis Tlpe I and II. Permanent teeth are normal in appearance but radiographically demonslrate thislle-tub€-shaped pulp chambers with multiple pulp stones. No periapical radiolucenci€s are s€en.

Child palients usually will not know what to expect during dental appoinhrents and many will be at an aqe $ hen thev have considcrablc fcars ofthe unknown. The TSD shategy is dcsigned to deal with those rssues.

- This approach is the backbone ofthe educational phase ofdcveloping an accepting, rclaxcd child dcnlal paricnt. - The effectiveness of the TSD approach depends on using language the child can understand. This mcans tha! r\c must use words or anecdotes that are age appropriate so the child can concepfualize the idea \r'e are trying to convey. -\Ian"- children are helped by watching procedures done on thcmsclves in the mirror during thc procedure. It is imponant to provide an explanation ofwhat is occurring as the proccdure continues. -\1an! children tcnd to be fearful ofthc unknorvn, especially in clinical situations. Being able to watch the procedure in the hand-held mirror seems to diffuse anxiety. - This approach $orks esp€cially well when trcating a child with a different cultural background. Important: The clinical cxamination ofthe infant and toddler should be accomplishcd with thc parents'assistance in a non-threatening environment. Most often. it is neither necessary nor recom_ mended that the dcntal chair be used. The parent and dentist sit facing cach other in a knee-to-knee position. supporting the child l'ith the head cradled on the dentist's lap.

Remember:

. Aggressive behavior in the dental office is usually a fear rcaction . Tle most realistic approach to managing a difticult child in the dental office is to aftempt to recondition the €hild through techniqucs ofapplied psychology Aversive conditioning: is a form ofbehavior training or modification jn whioh a noxious evcnt is uscd to punish or extinguish undesirablc behavior. Examples include HOME. voice control, etc. . Most pediatric dentistry graduate programs do not teach HOME (hdnd-over-moulh exc.tcIse) an ^s acceptable behavior management technique . Should always be followed by positive rcinforcement (i.e., patient pruise, use oftokens or "stick' ers, 'elc./ for improvcd bchaviors . Need parents consent ifusing HOME or any aversive conditioning technique

. Use restraint . Use the hand-over-mouth technique (HOME) . Permit the child to express his feax . Avoid all reference to the child's fear

6

Cop]'right O20ll-2012

. Tell-show-do . Voice conhol . Positive reinforcement

. Distraction . Nonverbal communication

7 CopFght O 201I -2012

All behavioral pattems afe motivated by anger and fear. The crying child is NOT an abnormal child. Anger is easier to treat than fear. Fear is most likely to be exhibited by a young child on his first visit to the dentist. This is related to the anxicty over being separated from a parent. The parent, not the dentist, has the greatest influence on the child's reaction at this inirial visit. . The angry child: - Separate the parent and thc child - Place the child in the chair abruptly and be firm - Use the "hand-over-mouth" excercise 11]OMtl - get the parent's permission lll - Display authoritv and command respect ofthe child by continuing with trcatment ifhe/she is uncooperative - Comfofl parenl at lhc cnd oflh. ! rsrt - Compliment child at the end ofthe visit . The fearful child: - Have the parent stand quietly behind the chair - Dentist must be consistent jn tonal quality - Permit the child to express his fears - identify the fear - Change the child's focus off fear - Lastly. sedation CIassifi cation of bchavior: . Cooperative: children with minimal apprchcnsion and respond well to behavior shaping . Lacking cooperative ability: children are deficient in comprehcnsion and/or communication skills (i-e., re^ roung children and children wilh ce ain disabililies). . Potentially cooperative: chid.en are capable ofbehaving but are disruptive in the dental setting. - Uncontrolled: characterized by temper tantrums. Typically 3-6 years ofage. - Defiant: characterized by "l don't want to" attitude or passive resistance. All ages. . Timid: typically preschool and younger grade school children. Hide bchind parent or put hands ovcr thcir mouth and face. . Tense-cooperative: coopentive but are very nervous. "White-knuckler" patients because they grip the dental chair arm rests so tightly. . Whining: they whinc throughout the \r'hole appointment.

obie.live! TcllShos-Do

Explanat(rns tarlored to

.

Allry fea$, slap€

cognitne lc\cl. folloscd by demonnral'on. iollowcd by

.

paxcrrs resporsc Giv€ expecrations of

.

avoidaco bchaviors Sstablish au$ority

comm!n'catc re8ard'es

Modulalion on vo'cc !olume, ronc or pace lo influcnce and

direcr pancnt

s

bch6vio.

Proccss of shapingpalicnf s

bchatior lhreugh appropriatcly

Di\cnin8 palrcnl

s

attcnnon liom

pcrc.i!cd !nplcasant p.occdurc Convcying reinforcem.nl and BUidinS bchavjor throush contact, posrurc. and facial cxprcsions

Dccrcalc likclihood of mp|easarr p€rc€prcn or

Enlare effectivdes lrv€ ma!.u8emert |e n-

B€havior shaping means providing the child with cues and reinforcements that dircct them toward desirable bchavior. Positive reinforcement al every stage ofthe treatment proccss is rccommended, to indicate to the child that he is making successful steps in the process ofreceiving treatment. The frequent use ofpraise dudng a child's appointment, when the child performs an appropriatc behavior is essential.

Note: Positive reinforcement may be verbal or nonverbal and should be immediate and spccific to thc desirablc bchavior.

.

Speak slowly and in very simple terms

. Listen carefirlly to the patient . Schedule long appointments . Ask the patient if there are any questions about anything you will be doing

E

Copyrighl O 201l-2012

. The age and maturity of the child

.

The past medical and dental experiences that might influence the behavior of the child

. The physical status ofthe child

. The length of time and amount of manipulation

necessary to accomplish the surgery

. All ofthe above

9 Coplright O 201l-2012

***

This is false; you should keep appointments short.

In addition

the following procedures are also helplul when treating mentally retarded

children:

. Cive

a tour to the patient before attempting to do any treatment. Introduce the patient to the office personnel. . Give only one instruction at a time, Reward the patient rvith compliments after the successful completion of the procedure. . Schedule the patient early in the day. The staff, the dentist, and the patient are less fatigued at this time.

In treating mentally retarded children, the following is usually found: . They can be controlled in the same ways as normal children. . They respond similarly to normal children ofthe same mental age. . They respond inconsistently, have short attention spans, and are restless and h1-peractive when undergoing dental care.

Important: The dentist should

assess the degree of mental retardation by

consulting the

patient's physician belore starting dental treatment.

The age and maturity ofthe child often determine the t)?e ofanesthesia best suited for the intended procedure. Childrcn bcloll the age ofrcason gcnerally are best managed undcr general anesthesia, since a sLght amount ofdiscomfort is always associated with the administration of a local anesthetic. It is very imponant to have total anesthesia before starting the procedurc. Usc both buccal and palatal infiltration on maxillary teeth and block anesthesia on mandibular teeth with infiltration, ifnecessary

The ven young patient is best managed under general anesthesia, usually ofthe inhalation type o. in combination with small doses of intravenous barbiturates. The most common premedication prior to general anesthesia is Versed. \ot€: Premedication wi!h a barbiturate may cause pandoxical excitement in a young child.

Remember: After extracting \ enrion oflip biting.

a

tooth on a child patient, the biggest post-operative concern is the pre-

Frankl behavioral rating scale: . Class l: . Class 2: siblc . Class 3: . Class 4:

child is completely uncooperative, crying, very difficult to make any progtess child is uncooperative. very reluctant to listen/respond to questions, some progress is poschild is cooperative. but somewhat reluctant/ shy

child is completely cooperative and even enjoys the experiencc

\hriables that influence the child's behaviot in the dental settingl . Age:

(

l)

less than 2 years old: usually are lacking in cooperativc ability. (2) 2 years old: Tell-Show-

Do technique works well and/or parent in operatory (3) 3-7 years old: generally cooperative; (4) 8 years old and older: usually cooperative. . Nloth€r's anxiety: there is a direct conelation bctween the mother's anxicty and a child's negative bchavior in the dental setting. . Past medical history: if a patient has had positive medical experiences in the past thcy are more apt to have positive dental experiences as far as behavior is concemed.

The grcat majority of children require minimal management efforts other than providing information on what is going to happcn (e.g, lell-show-do).

Import|nt:

. The presence of fxed orthodontic appliances . A patient with congested nasal pa.ssag€s or other nasal obsauction

. A very nervors or anxious patient

. A recently erupted tooth that will not retain

a clamp

lo @yriiht

O 201 l-2012

Cc''rittu

O 20tt:2o12

. Herpangrna

. Scarlet fever . Diphtheria . Mumps

11

One

ofthe main advadtages ofusing

a

rubbe. dam is that it can aid in the managemcnt ofthe chiid. It barier, both physically and

seems to quict and calm thc paticnt bccause the dam acts as a separation or

psychologically.

Other advantages include: l. Better access and visualization 2. Control ofsaliva and moisture in the operating field 3. Decreased operating time 4. Provides protection from aspiration or swallowing offoreign bodies 5. The child bccomes primarily a nasal breather when the rubber dam is in place. This then enhances the effects ofnitrous oxide ifapplicable. Nitrous oride sedation for children: for the production of conscious sedation, the inhalational route is limited to one agent. nihous oxide. Desirable characteristics ofnitrous oxider it is analgesic, anxiolytic, and amnestic. Note: Minimum oxygcn conccntration : 30o; or minimum oxygen flow rate: 3 L/min. Primarv advantages ofnitrous oxide for conscious sedation in pediatric dentistry:

. Rapid

onset and recovery: because nitrous oxide has a very low plasma solubility, it reaches a therapeutic level in the blood rapidly, and conversely, blood lcvcls decrease rapidly when it is discontinued. . Ease of dose control (Titration) . Lack ofserious adverse effects: nitrous oxide is considered to be ined and nontoxic when administered \r'ith adequate oxygen. The most common side effect is nausea/vomiting.

Xok{, ',: .-.,'l 'iii*,

l- Minimum alveolar concenhation 6rhich i.\ the concentratio required to ptoduce imnobilin* in 50%' ofpatients) of nitro.rs oxide is 105%. 2.The total flow rate is 4 to 6 L,'min for most childrcn. 3. The -aintenance dose during the dental appointment is usually around 30-3596. ,1. Upon termination ofnitrous oxide adminishation. inhalation of 10070 orygen for not less than 3-5 is recommended. This allows difnlsion ofnitrogen tiom thc venous blood into the alvcolus that is then exhaled as nitrous oxide through the respiratory tract- Note: This process

will prevent diffusion hypoxia.

Scarlet fever is an exotoxin-mediated disease arising from group A beta-hemol)4ic streptococcal infection. The peak incidencc olscarlet fever occurs in childrcn 4 to 8 years old. It is usually accompanicd by symptoms ol srcp throat. such as sudden onset of fever, sore throat, headachc, nausea, vomiting, abdominal pain, musclc pain. and fatigue. An enlargement ofthe fungiform papillae extending above the level ofthe white desquamating filiform papillae ei!es an appearance ofan unripe strawberry. During the course ofscarlet fevet lhe coating disappears and rhe enlargcd red papillae extend above a smooth denuded surface, giving the appearance ofa red strawberry or raspberr). Penicillin is the drug of choice, Early diagnosis and ffcatmcnt are important to prevcnt complications, \\hich include local abscess fomation. rheumatic iever, anhritis. and glomcrulonephritis.

H€rpangina is a viral infection, usually ofyoung childrcn, characterizedby mouth ulcers, but a high fever, sore throai. and headache may precede the appearance ofthe lcsions- The lesions are generally ulcers with a white to whitish-gmy base and a red border - usually on lhc roofofthc mouth and in the throat. The ulcers may be very painful. Generally, there are only a few lcsions. Thc disease usually runs its coursc in less than a week. Treatment is palliative. The cause is often an infection by a strain ofcoxsackie A virus. Diphtheria is an acute, contagious disease caused by rhe bacterium Corynebacterium diphrheria, characterized by the production of a systemic toxin. The toxin is panicularly damaging to the tissuc ofthe h€art and CNS.

Immunizrtion against diphtheria is available to all children in the U.S. Other conditions to know: . Puberty gingivitis: chamcterizcd by thc enlargement ofinterdental areas, spontancous or easily stimulated bleeding. Treatment includes profcssional cleaning and improved oral hygiene. . Herpes simplex infectio i - Primary herpetic gingivostomatitisi HSV-l infection, usually occurs in children under 3 years old. Vast majority are subclinical. -

Acute h€rp€ti€ gingivostomatitis:

.

I f diagnoscd with in 3 days of onsei, acyc Iovir suspcns ion should be prescribed. I 5 mg&g five tim es daily for ? days. . All patients, including those presenting more than 3 days after disease onset, may receive palliative care, including plaque removal, systemic NSAIDs, and topical anesthelics. . Recurrent herpetic simple\ (Herpes labialis): vesicles located at the mucocutaneousjunclion ofthe lips.

comers

ofthe mouth. and beneath the

nose. Associatcd

wilh cmotional

stress.

. R€current aphthous ulcer: painful ulcers on unattached mucous membranes.

. It is also called Vincent's infection, Vincent's angina or "trench mouth"

. It is a gingival

disease chaxacterized by painful hyperemic gingiv4 punched out erosions ofthe interproximal papill4 covered by a gray pseudomembrane with an accom-

panying fetid odor

. Risks include poor oral hygiene, poor nutrition, smoking, and emotional

stress

. It usually affects children . Fusiforms and spirochet€s, as well as Prevotella intermedia, have been implicated in the etiology ofANUG

12 Coplrighi O 20ll-2012

. Hard and soft palates

.

Soft palate only

. Alveolar process only

. Hard palate only

13 CopFighl O 20ll-2012

ANUG

is an acute fusospirochetal infection ofthc gingiva. It involves a progressive painful infection with ulceration, swelling and sloughing otrofdead tissue from the mouth and throat due to the sprcad ofinfection fiom the gums. It is usually associated with poor oral hygiene and is most common in conditions where there is crowding and malnutrition. It is rare in preschool children.

It

can be easily diagnosed because of the involvem€nt of the interproximal papillae and the prescnce of a pseudomembranous necrotic covering ofthe marginal tissues. The clinical manifestations of the disease include

inflamed, painful, bleeding gingival tissue: poor appetire; fever; general malaise; and a fetid odor. Treatmenr includes debridement. hydrcgen peroxide mouth rinses, and antibiotic therapy. Not€: Atrophic gingivitis is characrerized by gingival recession without a corresponding rate ofalveolar bone loss. Minor marginal and papillary gingival inflammation is found. The predominant clinical finding is the recession.

P€ odontal

dis€ase in adolescents: the clinical and histologic manifestations

ease in adolescents arc similar to those seen in adults. Bone loss from

ccntage ofteenagers, but the predominant condition noted in

ofgingival and periodontal dis-

pe odontitis

does occur in a small per-

thi! age group is gingivitis.

Pedodontal disease in children;

. A primary characteristic ofaggressiv€ periodontitis that differentiates it from chronic periodontitis is the rapid progression ofattachment and bone loss that is evident. Aggressive periodontitis may be localized or generalized. The classic form oflocalized aggressive periodontitis was initially refened to as 'periodontosis" and then as "localized juvenile periodontitis fl-lP/. Localized aggressive periodontitis 11,-rP) is the new classification designated to replace LJP. . LAP is defined by several distinguishing characteristics: onset around the time ofpuberty, aggressive periodontal destruction localized almost exclusively to the incisors and first mola6, and a familial pattem ofoccurrence. A. is the dominant bacteria in LAP, other microorganisms that have been associated with LAP include P gingivalis, E. coftodens, C. rectus, F. nucleatum, Bacillus capillus. Eubaclerium brachy, and Capnocytophaga species and spirochetes. Important: The one ouF slanding negative feature is the rclative absence of local factors (plaque) to explain the severe periodontal desfuction which is present. . Generalized aggressive pcriodontitis 1G.1P) is di{Tcrcntiatcd from thc localized form by the extent ofinvolvement around most ofthe permanent teeth, and it is considered to include rapidly progress-

ins neriodontitis.

Four Classes of Cleft Palate: . Class l: involves only the soft palate. . Class II: involves soft and hard palates but not the alveolar process. . Class III: same as Class Il but with alveolar process involvement on one side of the premaxilla.

. Class IV: involves the soft palate and continues through the alveolus on both sides of the premaxilla.

***

Females mor€ often affected

Four Classes of Cleft Lip:

. Class I: a unilateral notching ofthe vermillion not extending into the lip. . Class l[ same as Class I but the cleft extends into the lip but not to the floor of the nose_

. Class III: . Class

I!':

same as Class II but extending into the floor ofthe nose. any bilateral clefting ofthe lip whether incomplete notching or complete

clefting.

***

Males more often affected

Dis & Cond

Ectodermal dysplasia is chrracterized by a lack of sweat glands, sparse hair, dry skin, a concave nasal bridge, and:

. Oversized crowns . Elongated roots

. An enlarged mandible . The absence ofteeth

14 Copyright

aq

l0ll-2012

PEDIATRIC DENTISTRY

Dis & Cond

Thc child below is most likely suffering from what €ondition on the lower face?

. Chicken pox . Primary herpetic gingivostomatitis

. Scarlet fever

.

\4umps

Coplrighl 2000-2m4 Universily of [/a$ ington. All rights leseNed. Access to rle Ades ofPediatric Dentistry is govemed by a license. Undurhorized access orreproducrron s forbidden w'rhoul rhe pflor writteD pemission ofthe Unile6ity of washington. For infoma rion. conlacr: licensea.!u.washin8ton.edu

15 Coplright C 20ll-1012

Ectodermal dysplasir is a sex-linked recessive trait. Although both sexes arc affected, more males are affected than females. It is characterized by a lack of sweat glands, sparse hait dry skin, a concave nasal b dge, and the absence ofteeth. There may be complete failure ofthe teeth to develop (anodontia\ ot oligodontia (partial akodontia). Alveolar bone development is lacking because of the absence ofpermanent teeth. Note: Anhidrotic ectodermal dysplasia is characterized by the conical shape ofthe antedor teeth free photo belov,).lt is also characterized by lack of perspiration caused by the partial or complete absence ofsweat glands.

Copydghl 2000-2m4 Unive6ity ofwasbington. All n8his reseNed. Access lo lhe Ad6 of Pediatric D€nrisiry is govemed by a license. Unauthorized access or reproduclion is fo.bdden wirhout the prior lritien p€mission oflhe Univelsiry ofWashington. For infomation, conlact: license(4u.washinglon.edu

Cfeidocraniaf dysplasia (or d)'sostosis) is a ftre condition inherited as an autosomal dominant and chamcterized by partial or complete absence ofthe clavicles, defective ossification ofthe skull, and faulty occlusion due to missing. misplaced, or supernumeBry teeth. lt is equally common in males and females. Prolonged r€tention ofprimary teeth and delayed or complete failur€ oferuption ofpermanent teeth are characteristic features. The presence ofnumerous supemumenry and unerupted permanent teeth is very common.

Remember: Supemumerary teeth are most often found in the maxillary midline region and are called mesiodens. Supemumerary teeth are also frequently found distal to the maxillary molars and in the mandibularpremolar resion,

Gingivostomatitis is a disorder involving sores on the mouth and gingiva that result from a viral infection (HSV-|). k is characterized by inflammation ofthe gingiva and mucosa and multiple mucosal ulcerations. This is a very painful condition. The patient often does not want to eat or drink. The major concems are hydralion, secondary infection, and prevention ofconiagion. This disease is selfJimiting, and the acute phase generally lasts 7-10 days. Oral fluids are very important in childrcn so that they do not become dehy&ated.

lmportant: Pimary bcute) herpetic gingivostomatitis generally affects chil&en under the prodromal symptoms (ever, mqktise, irritobility, headache, dysphagid. \'omiting and lymphadenopathy) that occur l-2 days prior to the local lesions (ulcers) rn age ofthree. There are

the oral cavity. The treatment in children should be directed toward the reliefofthe acute symptoms so that fluid and nutritional intake can be maintained. Symptomatic treatrnent for pdmary herpes consists of rinsing with a 50:50 suspension of Benadryl Kaopectate and/or Viscous Lidocaine. The anti-viral drug used most frequently today to shoften the duration and severity ofth€ primary infection is acyclovi (Zovirax).It is prescribed (400 mg. q.i.d.) for I -2 weeks. Important: The main dillerential diagnosis for primary herpetic gingivostomatitis in patients with predominately gingival involvement without or with few discrete lesions is acute necrotizing ulcerativ€ gingivitis (ANUG). Patietts etith ANUG also present with a sudden onset ofa sore mouth. Howevel ANUG can be differentiated fiom primary herpes by the fact that in ANUG the interdental papillae are necrotic while in primary herpes, the interdental papillae are intact. In individuals with primary herpes manifesting multiple oral ulcerations, aphthous stomatitis must be considered in the diagnosis. However, primary herpes can be distinguished from aphthous stomatitis by lesion location and history. Aphthous ulcers occur only on mobile or unattached mucosa and there is a history of recurr€nce. In contrast, primary herpetic lesions occur on both mobile and attached mucosa and there is no history ofprevious episodes. Most patients with aphthous stomatitis do not have systemic symptoms such as feyer.

. The first statement

is true; the second statement is false

. The first statement is false; the

second statement is true

. Both statements are true

. Both

statements are false

16 Coplrighr O 20tl-2012

. Extremely high, extremely low

. Relatively the same

as the general population, extremely high

. Extremely low, relatively

the same as the general population

. Extremely low, extremely high

17

Coplnght

I

201 l -201 2

Cellulitis may be caused by a necrotic primary or permanent tooth. It often causes considerable swelling of the face or neck, and the tissue appears discolored. lt is a very serious infection and it can be life-threatening. The child will appear acutely ill and may have a very high temperature with malaise and lethargy. Note: The most common causative organisms are Group A Streptococci and Staphylococcus aureus.

Important: Cellulitis in a child is harder to treat because dehydration occurs more frequently, rapidly, zurd severely in children thim in adults.

If it involves the submandibular, sublingual, and submental space it is called "Ludwig's angina." In this condition, the tongue and floor ofthe mouth become elevated and the patient's airway is obstructed and swallowing is impossible. The treatment for cellulitis should include having the child go to the hospital if the signs and symptoms warrant il. In the case of Ludwig's angina, it is mandatory. 3 clinical stages of odontogenic infection:

l Periapical osteitis: occurs when the infection is localized within the alveolar bone. Although the tooth is sensitive to percussion and often slightly extruded, there is no soft tissue srvelling. 2. Cellulitis: develops as the infection spreads from the bone to the adjacent soft tissue. Subsequently, inflammation and edema occur, and the patient develops a poorly localized swelling. On palpation the area is often sensitive, but the sensitivity is not discrete. 3. Suppuration then occurs and the infection localizes into a discrete, fluctuant abSCCSS

Down syndrome is a congenital defect caused by a chromosomal abnormaliry (trisomr). The prrmary skeletal abnormality affecting the orofacial structures in Down syndrome is an underdevelopment or hypoplasia ofthe midfacial region. The bridge ofthe nose, bones of the midface and maxilla are relatively smaller in size. In many instances this causes a prognathic Class III occlusal relationship which contributes to an open 21

bite. The tongue may protrude and appear to be too large. With age, both the tongue and the Iips in people with Down syndrome tend to develop cracks and fissures. This is a result ofchronic mouth breathing. The eruption ofteeth in persons with Down syndrome is usuall,'" delayed and may occur in an unusual order. There is an extremely high rate of missing teeth in both the primary and permanent dentitions. The roots ofthe teeth in patients $ ith Down syndrome tend to be small and conical. The clinical features ofDown syndrome are fairly recognizable and include:

. Delayed physical and mental development . Short. stocky build . The face is broad and flat, with slanting eyes and a short nose . The ears are small and low set

. Heart defects

are common.

Important: SBE prophylaxis is required for dental treat-

ment The child with Down syndrome is said to be affectionate, fearful ofquick movements, but capable of leaming dental procedures. These children need a comprehensive preventive program. These patients often have difficulty accepting dental care but cooperation can be improved by using gradual exposure to the dental office.

. Type I

'

Type

II

.

TYPE

III

'

TYPe

IV

t8 Copyflght O 201l-2012

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is truei the second statement is false

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19 Coplright O 201I 2012

Type I, or insulin-d€pend€nt diabetes mellitus, is the most common form in children. Approximately 2 in 1000 children between the ages of5 and l5 years have the disease. The suspicion ofdiabetes usually arises by one or more ofthe following: . Family history . Symptoms; polydipsia, polyuria, weight loss with polyphagia, enuresis, recurrent infections, and candidiasis are common findings . Glycosuria may be present . Ketoacidosis and coma are possible Subjective findings include a history ofpolydipsia, polyuria, polyphagia' and weight loss. A fasting blood glucose level above 120 mg/dl is indicative of Type I diabetes mellitus.

Periodontal disease is the most consistent oral finding in patients with poorly controlled diabetes mellitus, These patients exhibit increased alveolar bone resorption and inflammatory gingival changes, which may mimic the clinical manifestations of localized aggressive periodontitis. Xerostomia and recurrent intraoral abscesses may be present. The goal oftreatment is to control blood glucose to as normal a level as possible, thereby reducing the potential complications ofhyperglycemia and ketoacidosis. This generally involves the administmtion ofan intermediate-acting insulin (NPH and Lente).

Dental management ofthe well-controlled diabetic consists ofthe follou'ing: . Advise the patient fo eat a normal meal before the appointment to avoid development of hypoglycemia . lf the dental procedure is anticipated to be stressful, consult the patient's physician regarding adjustment ofthe insulin dosage . Consider utilization ofprophylactic antibiotics for sr.rrgery, endodontics, and periodontal therapy to minimize risk of infechon . Have a glucose source available to treat the onset ofhypoglycemia

Hemangiomas are vascular birthmarks in which the proliferation of blood vessels leads to a mass that resembles a neoplasm. Hemangiomas differ from other vascular birthmarks in that they are biologically active; their growth is independent from the growth ofa child. Most hemangiomas appear within a week or two after birth. They are 5 times more common in girls than boys. They are common on lips, tongue and buccal mucosa. These lesions appear as flat or raised, usually deep red or bluish red and seldom well-circumscribed. They are removed surgically, others require no treatment.

rn

L Neuroblastoma is one ofthe most common solid tumors ofearly childhood found in babies or yor.urg children. The disease originates in the adreusually rL*t.)

..'i:; ';!tt:t;t:"'

';,,1r,

nal medulla or other sites of sympathetic nervous tissue. The most common site is the abdomen (near the atlrenal glaru)) but can also be found in the chest, neck, pelvis, or other sites. Most patients have widespread disease at diagnosis.

2. A lymphangioma is a fairly well-circumscribed nodule or mass of lymphatic vessels. They occur most frequently in the neck and axilla. These lesions appear as red to blue translucent enlargements that are cornpressible and spongy. They are treated by excisional biopsy. 3. A neurofibroma is a moderately fim, encapsulated tumor resulting from the

proliferation of Schwann cells. They occur on the tongue, buccal mucosa, vestibule and palate. These lesions appear as solitary or multiple submucosal enlargements. May become malignant (5-15%). Multlple lesions are associated with neurofibromatosis (von Recklinghausen's disease).

. Rampant caries . Periodontal disease

. Overcrowding of teeth . Supemumerary teeth

20 Copyright @ 201 1,2012

. Prominent mandible . High arched palate

. Bifrd uwla . Cleft palate . Severely crowded maxillary

teeth

. Class II malocclusion

.

Shovel-shaped incisors

.

Supemumerary t€eth 2'l Copyrighl O 201| -2012

Achondroplasia is the most common form of short-limb dwarfisrr. It occurs in all races and with equal frequency in males and females. An individual with achondroplasia has a disproportionate short stature -- the head is large and the arms and legs are short when compared to the trunk length. Other signs are a prominent forehead and a depressed bridge ofthe nose. Many ofthese children die during the first year of life. Deficient growth in the cranial base is evident in many children that survive.

Important: The maxilla may be small with the resultant crowding of the teeth. Note: A Class

lll

malocclusion is v€rv common.

Rememben The oral manifestations ofthe following disorders in children: . Gigantism: enlarged tongue, mandibular prognathism, teeth are usually tipped to the buccal or lingual side, owing to enlargement of the tongue. Roots may be longer than normal.

. Pituitary dwarf:

the eruption rate and the shedding of the teeth are delayed, clinical crorvns appear smaller as do the roots of the teeth, the dental arch as a whole is smaller causing malocclusion, and the mandible is underdeveloped.

***

This is falsel a Class

III

malocclusion is common.

Apert syndrome is a genetic defect and falls under the broad classification of cranial/limb anomalies. It is primarily characterized by specific malformations ofthe skull, midface, hands and feet. Note: The retrusion ofthe midface is often conected by performing a Lefort III sureical procedure. Remember: I . Crouzon syndrome is an uncomrnon, autosomal dominant craniofacial disorder characterized by cranios)'nostosis and dysmorphic facial features.

Clinical featur€s include: . Early childhood, no gender predilection . \laxi1lary hypoplasia, reduced width ofthe dental arch and crowded teeth

.

Shon upper lip . Short head, widely spaced eyes, shallow orbits . Calcified stylohyoid ligaments

.

and protruding eyeballs

Possible unilateral or bilateral posterior crossbite

2. Rieger's syndrome

is characterized by delayed sexual development and

hlpothyroidism.

This syndrome has important dental considerations, which include: hypodontia, an underdeveloped premaxillary area, cleft palate and a protmding lower lip. 3. Treacher Collins Syndrome, also called mandibulofacial dysostosis, is a rare autosomal dominant disorder ofcraniofacial development. The oral manifestations are characterized by cleft palate, shortened soft palate, malocclusion, ante or open bite, and enamel hypopoplasia.

. It is generally fatal

. It

is best treated by injecting insulin

. They generally recover ifrestrained from self-injury and oxygen . It can be prevented with antibiotics

22 Copyrighl O 20ll -2012

. Bifid tongue . Macroglossia . Cleft palate and cleft lip . Anodontia

23 Coplright O 201I "2012

is maintained

Of the multiple types of seizures, the tonic-clonic (grantl mal) type is the most lrightening and the one that most often requires treatment. Grand mal seizures are manifested in four phases: the prodromal phase, the aura, the conr.tlsive (icla1) phase, and the postictal phase.

The prodromal phase consists of subtle changes that may occur over minutes to hours. It is usually not clinically evident to the clinician or the patient. The aura is a neurologic experience that the patient goes through immediately prior to the seizure. It is specifically related to trigger areas of the brain in which seizure activity begins. lt may consist of a taste, a smell, a hallucination, motor activity, or other symptoms. As the CNS discharge becomes generalized, the ictal phase begins. The patient loses consciousness, falls to the floor, and tonic, rigid skeletal muscle contraction ensues. This usually lasts I to 3 minutes. As this phase ends, the muscles relax and movement stops. A significant degree of CNS depression is usually present dudng this postictal phase, and it may result in respiratory depression. Management of the seizure consists of gentle restraint and positioning of the patient in order to prevent self-injury ensuring adequate ventilation, and supportive care, as indicated, in the postictal phase, especially airway management. Single seizures do not require drug therapy because they are self-limiting.

Important: Should the ictal phase last longer than 5 minutes or ifseizures continue to develop with little time between them, a condition called status epilepticus has developed. This may be a life-threatening medical emergency. This condition is best treated with intravenous diazepam. and transport should be arranged to take the patient to the hospital.

***

Cleft palate and cleft lip account for halfofthe total number ofdefects. Of all cases, cleft palate alone and 7 5To are cleft lip with or without cleft palate.

259'o are

The lip and primary palate begin to develop at four to five weeks gestational age. The two medial nasal su'ellings and the maxillary swellings fuse to form the upper lip. Failure ol rhjs fusion results in cleft lip. Clefts of the lip are more frequent in males. Cleft lip inr olr ement is more frequent on the left side than the right.

The secondary palate develops at approximately nine weeks developmental age. The paired palatal shelves arise from the intraoral maxillary processes. These shelves, originallv in a venical position, reorient to a horizontal position as the tongue assumes a more inferior position. The palatal shelves fuse with one another and with the primary palate anteriorly, which, in tum arises lrom the fusion of maxillary and mandibular processes. Failure of fusion results in a cleft palate. Cleft palate is more frequent in females. The most severe handicap imposed by cleft palate is an impaired mechanism preventing nonnal speech and swallowing. The child will almost always need orthodontic treatment once the palate is surgically repaired. Also, speech therapy will be needed because these patients have problems related to the inability of the soft palate to close the air florv into the nasopharynx. Orthognathic surgery may be needed to correct the general concave appearance of the face. This concave appearance is generally due to deficient

maxillarv srowth.

. Acute myeloid leukemia

. Chronic myelocltic leukernia . Acute lymphocltic leukemia

. Cfuonic lymphocytic leukemia

u Copynghr O 20ll -2012

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is true; the second statement is false

. The first statement is false; the second statement is true

. Both

statements are true

. Both statements are false

25 Coplrighl O 201l-2012

Acute lymphocytic (lx-nphoblastic) leukemia is a life{hreatening disease in which thc cells that normally develop into lymphocytcs (h'mphoblasts) become cancerous and rapidly replace normal cells in the bone marrow The peak age is around four ycars old, and it is the form of acute leukemia that is most responsive to therapy. It can be successfully trcated, with a 60-80% 5-year survival ratc. The carly signs of acute leukemia in a child include fatiguc, palloq weight loss and easy bruising. This will progress to fever, hemorrhages, extreme weakness, bone and joint pain, and repeatcd infections.

Oral findings include: . Gingival oozing, petechiae, hematoma, or ecchymosis

. Oral ulceration, pharyngitis, and gingival infection which is unrcsponsive to conventional therapy . Submandibular lymphadcnopathy

\ote:

Candidiasis is common in children with leukernia because they are especially susccptiblc to this fungal infection. Nystatin rinses or popsiclcs are cffcctivc in clearing up this infection.

Hodgkin's Lymphoma or Hodgkin's Disease is a malignant growth ofcells in the lymph system. Hodgkin's Discasc is the better known fomr of lymphoma (the other lyuphomas are grouped into v,hat is called the Non-Hodgkin's L1'mphomas). Thc most common symptom ofHodgkin's disease is painless swclling of the lymph nodes in the neck, underarm, or groin. The common symptoms of N-on-Hodgkin's disease include: painless swelling in the lymph nodcs in thc ncck, undcrarm, or groin; persistent fever; feeling of fatigue; unexplained weight loss; itchy skin and rashes; small lumps in skin; bone pain; swelling in the abdomen; livcr or spleen enlargement.

Hereditary porphyria is a rare metabolic error resulting in fai)ure ofthe conversion ofporph)'rins. The urine is burgundy in color, and thcre is discoloration ofteeth and boncs. Thc tceth are reddish-brown and fluoresce undcr ultraviolet light. These features are characteristic oftissucs containing porphyrins. Idiosyncrasies in tooth color are important in diagnosing abnormalities in tecth. Horvevet, color is usualll not a reliable diagnostic criterion in itself. Clinical examination, patient history and radiographs are cssenrial in making a final diagnosis. The first diagnostic consideratjon relating to color is whether the color or stain in a particular case is intrinsic or extrinsjc. Prophylaxis utilizing pumice can be done to remorc lreen stains orycllow pigmentation caused by vitamin elixirs, tobacco, or other sources. Ifthe color is intrinsic. ir \\'illbc necessary to consider its distribution and thc paticnt's history, pJacc ofresidence,

earl] illnesses. and family background. Olien thc first evidence ofvariation from normal in the human dentition is an observable difference in the color ofthe teeth. Somc ofthcsc variations are apparent only to the trained eye, and others arc so ob\ ious rhat ihev are a cause ofgreat concem to the parents and/or children. Questions about the color of t.eth can bc the first signal ofan underlying problcm with thc dentition or of systemic discasc or an inherrled svndrome. Orher causes of

intrinsic tooth discolorationl

. Children $ith cystic fibrosis

have teeth that are dark in color, ranging from yellowish-gray to dark brown. This may be related io the usual high doscs oftetracycline given to children with cystic fibrosis. . Erythroblastosis fetalis is characterized by an excessive desfuction oferythrocytes. The primary teeth may have a characteristic blue-green color. . Tetrac!'.cline therapy oan cause the crowns of teeth to becomc discolored, ranging from yellow to brown and from gray to black. The drug will stain permanent teeth that have not completed enamel formation at the tjme the drug is given. For erample: Ifa five-year-old child receives tetracycline therapy. the teeth affected will bc thc canines, premolars, and second molars. Important: The incisors and first molars have already completed enamel formation. . Amelogenesis imperfectai teeth vary in color from white opaquc to yellow ao brown. . Dentinogenesis imperfecta: opalescent teeth. . Dental fluorotis: ycllou ro brown pigmenration. . Hyperbilirubinemia: jaundicc-likc ycllow-green tint on the tooth surfaces.

.

Maxillary posterior teeth, mandibular posterior teeth, maxillary anterior teeth, and mandibular anterior teeth

.

Maxillary anterior teeth, mandibular arterior teeth, maxillary posterior teeth, and mandibular posterior teeth

. Mandibular anterior

teeth,

mxillary posterior

teeth, mandibular posterior teeth, ard

maxillary anterior teeth

. Maxillary

anterior teeth, maxillary posterior teeth, mandibular posterior teeth, and mandibular anterior teeth

Copright

@

20l l -201 2

. They occur in women more than men

. They may occur at any age, but usually first appear between the ages of 10 and 40 . The cause is

a coxsackie

virus

. They appear to be associated

witl

stress

. They usually appear on nonkeratinized oral mucosa including the inner surface of the cheeks and lips, tongue, soft palate and the base of the gingiva

27 CoplriShl O 201I -2012

Inappropriate feeding ofchildren can lead to tlpical nursing pattem decay. The teeth typically are decayed in the following order: maxillary anterior teeth, maxillary poste or teeth, mandibular posterior teerh, and mandibular anterior teeth. The mandibular incisors are in general less affected since the tongue covers them. \ote: Nursing-boftfe caries is also called baby bollle tooth decay (BBTD), bottle-mouth s)'ndrome, eady childhood caries /ECC), nursing caries, botle caries and infantcaries. Nursi[g-bottle caries is a rampant decay that results llom sleep limc bottle-feeding combined with the activity ofStrcptococcus mutans. The stagnation of milk about the necks olanterior teeth and the fermentation ofthe disaccharide lactose. a susar found in milk. conlribute to this caries process

as

\r'ell.

Note: ECC definition by the Amcrican Acadcmy ofPcdiatric Dcntistry: the presence ofmore than one decayed (noncavitdted or caitecl). missing (due to decd)r, or filled tooth surface in any primary iooth in a child 7l months /6 rea,.t or younger. Sever€ ECC: . Younger than 3 years: any sign ofsmooth surface decay . Ages 3-5: one ormore cavitated, missing /drle 1() drcd_l'./ or filled smooth surtace in primary anterior teeth, or, a decayed, missing, or filled surface (dzf) score ofgreater than.l fdg€ J), greater than 5 (ag? 4),ot greater than 6 fdge J).

Pr€r'entive measur€s include: . lnlants should not be put to sleep with a bottle containing a liquid other than wat€r . Infanrs should be encouraged 1o drink fiom a cup prior to their first bifthday . Infants should bc weaned fiom the bottle at l2-14 months ofage . Infanls should start to supplemcnt their diet with nonliquids at 4-6 months ofagc . Jurces should only be offered from a cup . oral hygiene should be started with eruption of the first primary tooth . \\'rrhin six rnonths ofemption ofthe first toolh (no laterthan theJirst birthdqi) jt ts ttme for the first den-

tal \isit Remember: Natal tceth are teeth that are already present at the time ofbinh. They are diflerent fiom neonaral teeth, which grow in during the first 30 days after birth. Most develop in the mandibular incisor area. Frequentl). natal teeth are removed shortly after birth while the newbom infant is still ir the hospital, especially ifthe iooth is loose and the child runs a risk ofaspiration, or "breathing in" the tooth.

***

This is false; the cause is unknown, however evidence supports they are related to thc focal immune dysfunction where T lymphocytes play a major role. These lesions appear as painful white or yellow ulcers surrounded by a bright red area. Lay pcrsons refer to aphthous ulcers as rrcanker sores". Thcy can be triggercd by stress, dictary doficicncics te.specially ircn,./blic acid, or vitomin B l2), menstrual periods, hormonal changes, food allergies. and similar situations.

Thel

Lrsuail_v-

begin with a tingling or burning sensation, followed by a rcd spot or bump that ulto l0 days, with complctc healing in 1 to 3 weeks.

cerates. Pain spontaneously decreases in 7

lmportanti Recurrent aphthous ulcem and lesions ofintraoral herpes arc distinguished largely on thcir location. Rccurrent aphthous ulcers occur primarily on mobile (unaltaclredJ mucosa while lesions of jntraoral herpcs occur on tissue bound (aftached) to periosteum. Three Classifications: L Recurrent aphtho\s minor ((0.5

mm- 10 mnt in diameter.l are common, last over 2 weeks

L Recurrent aphtholus major (l0-20 mn in diamelet) arc much less corrmon, last over 2 weeks and heal with scarring :. Recurrent herpetiform: multiple, small, diffr.rse, painful, superficial ulcers *** Paticnts $,ith lrequent recurrences should be screened for diabetes mellitus or Behcet's svndrome-

Topical steroids have bccn suggcsted for the relief of symptoms as follows: Rx: Triamcinolone acetonide (Kenalog in Orabase) Disp: 5 g tube Sig: Dry lesion. Coat lesion with a thin film after each meal and at bedtime Nlechanism: Dccreases infl an'rmation. Side effects: Do not use on fungal ulcerations. Do not use for diabetics *lfsignificant improvemcnt has not occurr€d in 7 days, discontinue treatmcnt and reassess the diagnosis.

. Insulin . Thyroxine . Calcitonin

. Epinephrine

2A

Cop)right O 20ll-2012

. The first statement is true; the second statement is false . The first statement is false; the second statement is true . Both statements are true . Both statements are false

29 Coplrighl O 201l-2012

***

Thyroxine is a hormone secreted by the thyroid gland.

Cretinism is severe hlpothyroidism in a child and is characterized by defective mental and physical development. Cretins have dwarfed bodies, with curvature ol the spine and a pendulous abdomen. Their limbs are distorted, their features are coarse, and their hair is harsh and scanty. Severe mental retardation is caused by the improper development of the CNS. Note: Ifthis condition is recognized early, it can be markedly improved with the use of thyroid hormones.

Dental lindings in a child with cretinism (hypoth,vroidism) include an underdeveloped mandible with an overdeveloped maxilla, enlarged tongue which may lead to rnalocclusion, delayed eruption ofteeth, and deciduous teeth being retained longer. An anterior open bite is common and flaring ofthe anterior teeth often occurs. This may be related to the abnormal size ofthe tongue.

Additional intraoral findings include: thickened lips due to glycosaminoglycan deposits, unerupted yet fully developed permanent dentition.

Rememb€r: Severe hypothyroidism in adults is called myxedema.

Cystic fibrosis is an autosomal recessive condition. The gene responsible is on the long arm ofchromosome 7. lt occurs predominantly in individuals ofCaucasian origin. The disease is progressive and finally fatal, mostly as a consequence ofpulmonary complications and cor pulmonale. The glands most affected are those in the pancreas, the respiratory system, and sweat glands. Cr stic tibrosis is usually recognized in infancy or early childhood. Early signs are a chronic !'ough: frequent, foul-smelling stools (steatorrhea); and persistent upper respimtory inl'ecirons. The most reliable diagnostic tool is the sweat test, which shows elevations of both strdium and chloride. Note: In CF cells, salt does not move properly because the protein produ of the CF gene is defective and makes a faulty channel for the chloride to exit.

Oral tindings: . \asal polyps and recunent sinusitis are common . \losi patients have a high salivary sodium concentmtion . The major salivary glands may become enlarged, with associated xerostomia . Halitosis is common

. . . . .

The lorver lip may become dry, enlarged, and everted Enamel h$oplasia may be seen Both dental development and eruption are delayed Tetlacycline staining ofthe teeth was common, but should rarely be seen norv Pancrcatic enzymes may cause oral ulceration ifheld in the mouth

Dental management for CF patients:

. Shon appointments are recommended . Early moming appointments are not recommended . Patients with CF are best treated in the upright position . Avoid seneral anesthesia

. Smdlpox (Variola) .

German rneasles (Rubella)

. Mumps . Measles (Rubeola)

30 CopyriSnt O 201 l-2012

. Inattention . Mental retardation

. Hyperactivity . Impulsivity

31 Copyrigbt O 20ll-2012

Mersles (also called Rubeola) is

a highly contagious viral illness characterized by a fever, cough, and a spreading rash. It is caused by a paramyxovirus. The incubation period is I to 2 weeks before symptoms generally appear The oral lesions are pathognomonic of this disease. These characteristic "Koplik's spots" usually occur on the buccal mucosa. They are 1-2 mm, yellow-white necrotic ulcers that are surrounded by a bright red mar-

gin.

Rubella (or Cerman measles) is a fairly benign viral disease. The symptoms usually include a red, bumpy rash, swollen lymph nodes fno.!/ ofien arcund the ear.s and neck), and a mild fever. Sorne people will feel a little achy. The virus can manifest in the oral cavity as small petechiae-like spots of the soft palate. The defects of congenital infection from an infected mother are more severe defects, hypoplasia, pitting and ab-

nonnal tooth morphology.

-enamel

Sm

lpox (Variola) is an acute viral disease, it manifests itselfclinically by the occunence of a high fever, nausea, vomiting, chills, and headache. The skin lesions begin as small macules and papules which first appear on the face, but rapidly spread to cover much of the body. Oral manifestations include ulceration of the oral mucosa and pharynx. ln some cases, the tongue is swollen and painful, making swallowing difficult. NIumps is an acute contagious viral infection characterized chiefly by unilateral or bilateral swelling ofthe salivary glands, usually the parottd (pat'cttitis). Although it is usually a disease ofchildhood, mumps may also affect adults. The papilla of the opening of the parotid duct on the buccal mucosa is often puffy and reddened.

Attention Deficit Hyperactivity Disorder (ADHD) is

a condition that becomes apparent in some children in the preschool and early school years (6e1rreen the ages of 3 dnd 5 but varies v'idely). lt rs hard for these children to control their behavior and/or pay attention. lt is estimated that between 3 and 5 percent ofchildren have ADHD, or approximately 2 million children in the United States. This means that in a classroorn of25 to 30 children. it is likely that at least one

will

have ADHD.

The cause is unknown. The disorder is l0 times more common in males than f'emales. Typically affected children, whether intellectually handicapped or not, perform poorly in school because ofthe inability to attend to tasks at hand or to sit still during the school day. Note: lfthere are any questions conceming the ability of the child to handle dental treatment, contact the childs'physician. ln most cases, th€ child doesn't need any special treatment.

Common Medications used to treat ADHD: The medications that seem to be the most effective are a class ofdrugs known as stimulants.

. Riralin

.

( Met

hlp

h en

id ate )

Concena lMethl'lphenidate extended releqse) . Adderall (Amphetanirte and dext"oamphetamine)

Among the more serious adve$e reactions ofthese medications are nervousness, insomnia, and anorexla.

. Escherichia coli . Viridans group Streptococci

. Staphylococci . Bacteroides

Coplnghr O 20ll-2012

. Oral . Inhalation

.IM

Cop''right O 201l-2012

50 mglkg (rnax. 2 g) 20 mg/kg (max 600 mg)

50 mgAg (max 2g)

Penicillin allergy

I5

mg/kg (rnax 500 mg)

Remember: I lb = .453 kg Endocarditis prophylaxis recommended: dental procedures known to induce gingival or mucosal bleeding, including professional cleaning.

Endocarditis prophylaxis not recommended: dental procedures not likelv to induce gingival bleeding, such as simple adjustment of onhodontic appliances or fillings above the gingiVal margin. injection oflocal anesthetic (except.fbr intrctligamentary injections), and exfoliation of primary teeth. Important: Because ofthe diversity of circumstances with each patient, it is recommended that the clinician consult with the patient's physician if the complete medical status of the patient is not fully known or th€re is any doubt.

Ninous oxide is a slightlv sll eet smelling, colorless, inen gas. It must alu ays bc coupled with no less than 2070 ox] gen. Nitrous oridc is quickly absorbcd from thc lungs and is physically dissolved in thc blood. There is no blotransformation, and thc gas is raprdly excreted by the lungs \\,hen the concentration gradient is reverscd. It is recommended that lhe paricnt be m|intained on 1007o oxygen for 3 to 5 minutes after the sedation pcriod.

\irrous oxide basicallv

creates an altered state of awareness with impaircd rnolor function. It is a ccnral nen!us svslem depressant. h produces litlle analgesia. The combined vol me ofgases being delivered /o].r .L., .rr,? nir?r/r/ should be at least 3 to 5 liters/minute, The operator should encourage the patien! to breathc

tlrourh lhe nose \\'ith

Ihe mouth closed.

Local Anesthesia tbr children: An important factor is mrximum dosage.

. Deremine

the patient s lveight in pounds and convert to kilograms by dtyidingby 2.2 (2 2 lb = L0 k:<) e\ariple, 66-lb child '2.2 lbs,&g = 30 kg . \lulripl) \\eight in kilograms by rhe mrrimuIn r€commended dose oflocal an€sthetic to obtain the

-

r-or

nnirnum rnilligram dosage. - lor e\ample, 30 kg x 4.4 mg/kg lidocaine - 132 mg . Calculete rhe nunrber of milligrams per caftridge of anesthetic by multiplying :herrc times 10, then multiply this by the size ofthe cartridge. tlpically L8 ml.

,ibr

exanplc.29:o

. Dir

r

l0 x

1.8

ml:36

the percent of local ancs-

mg/cartridge

ide the maximurn rnilligram dosage by the numbcr of milligrams pcr canridgc to obtain the maximum a1lo\\'able cartridges of anesthetic. - fbr example. 132 mg maxi'num dose / 36 mg/cartridge: 3.66 rartridges

Important: The maximum recommended

dose oflocal anesthetic with/without vasoconstriclors, whcthcr it be lidocaine or mepivacaine is 4.4 mg/kg and the absolut€ maximum dosage is 300 mg.

:

.. , L For restorative dentistrv, nitrous oxidc ,,f{oteni: of thc dentisr fubng v,ith local dne.rlhesia).

'---

2

| he leelrng

ol floating or !rddrne.s

is usually all vou need to treat a child who is

$ rlh trnglrng

ol

rhc dr! its is rhe

fearful

proper response lo nirrous

o\tde 3. Nitrous oxide is stored as a liquid under pressure. and is not flammable bllt will supporl combustion. 4. Nitrous oxide is much less soluble in blood than alveolar air, thus allowing for rapid changes in alveolar gas concentration.

. Pentobaxbital

. Secobarbital . Paraldehyde

. Chloral hydrate

34 Coplright e 201I,2012

.

50olo

reduction in dental caries

. Moderate dental fluorosis . An increase in the amount offluoride stored in her bones

. Gastrointestinal problems

CopFight O 201l-2012

Chloral hydrate acts on the CNS to induce sleep. At nonnal doses, the sleep induction does not allect breathing, blood pressure or reflexes. It may be used before some surgeries or procedures to help relieve anxiety and to induce sleep. When used in combination with analgesics, it can help n.ranage pain after surgery. It has an onset ofaction of 15 to 30 minutes when given by mouth. Important: Children often enter a period ofexcitement and irritability before becoming sedated. As with barbiturates, pain may cause paradoxical reactions.

Chloral hydrate is bitter tasting, rvhich can produce management problems during administration. A final disadvantage is that chloral hydrate can induce nausea and vomiting secondary to gastric initability.

The short acting barbiturates secobarbital (Seconal) and pentobarbital (Nentbutal) are sedative drugs. They are sometimes considered for pediatric conscious sedation by oral administration. They are of very limited value. They are nonanalgesic. They may cause hyper-excitability rather than sedation in some children.

Note: Chloral hydrate and the barbiturates are classified as sedative-hypnotics whose prrncrpal effect is

"edation

or sleepiness.

Nlodcrate tluorosis *ill not occur since by agc 15 all ofhcr dentirion has undcrgone complete enamel calcificalion /r ir, rrc porrlble exception of the third nohrs). r\ 500; reduclion in dental caries is not probable for the reason listed above as \lell. l. water 1'luoridation is onc of history's most cffeciive public hcalth stories. It is perhaps thc mosl successful public health measure in history. L II is eflective. safe, inexpensive. and nondiscriminatory. It is the classic public health measure that u'orks. Survevs havc shown that community witer fluoridation results iD a reductiorr in deca) ol abou! fofy b fifty percenr in the primary dentition and about lifry io sixty pcrcenr in thc pcrmanenr dentition. L Of rhe 50 largesr cities in the United States, 43 have community watcr fluoridation. Fluoridarion reaches 629/0 ofthe population through public r'"ater supplies. morc than 1,14 nlillion

\otes

leoplc. -1. \later fluoridation rnd diet supplernentation mry affect tooth morphology, while sclfand professionally applied topical treatments r,r,ill not. 5. The typcs of lluoride added to different watcr systcms include lluorosilicic acid. sodium fluorosilicare. and sodiunr fl uoride. 6 Up to a levcl of I ppm fluoride. thcrc is an inveNc relation bct['ecn dental decav and fluorrde concentration. As fluoride concentration increases beyond I ppm. ihere is an incrcased prevalcnce offluorosis and no increase in the reduction oldental decay.

Pit and fissure sealrnts ' Indications:(1) deep. retentive pits and fissures: (2) stained pits and fissures with minimal appearancc of decalciilcalion or opacification; (3) no radiographic or clinical evidence ofinterproximal caries in nccd of resloration on iccth to be sealed . Contrlindicetions: (l) rampant carics; (2) intcrproximal carics; (3) wcll-coalcsccd groovesl (4) iDability to maintain a dry field . Technique: (l) clean tceth: (2) isolatc leeth with colton rolls or rubber danl; (3) acid etch tooth surfaces apply l5% to 409n phosphoric acid for l5 to 60 seconds /air? r,aries Jt>r prinart or pa manent), rinse for l0 seconds, dry with comprcsscd air for l5 scconds. apply scalant, chcck occlusion . Resin-based sealanls arc most common and have supcrior rctcntion as compared to glass iolomer-based seilants. The tag formation in the enamel is about .10 Fn1. Any saliva contamination follo*,ing isolation requires repeafing the *hole proccdure

Fluoride

Fluoridation has several mechanisms for caries inhibition. are enhancement of r€mineralization of enamel, inhibition of and the incorporation of fluoride into the enamel bydroxyapatite crystal.

. The first statement is true; the second statement is false

. The first statement

is false; the second statement is true

. Both statements are true . Both statements are false

36 Copy.ighr O 20ll'2012

PEDIATRIC DENTISTRY

Fluoride

Which of the following fluoride therapies should be recommended to a thirteen-year-old child who is prone to decay and lives in a community where the water is fluoridated at an appropriate level?

. Professionally applied fluoride every six months

. Fluoride toothpaste . Dietary fluoride supplements . A low concentration fluoride mouth rinse . A high concentration fluoride mouth rinse

37 CopynShr O 20ll'?012

Fluorides exert their anticaries e{Iect by three different mechanisms:

l.

The presence

offluoride ion greatly enhances

the precipitation into tooth structure

afflu-

orapatite from calcium and phosphate ions present in saliva. This insoluble precipitate replaces the soluble salts containing manganese and carbonate which were lost due to bacterial-mediated demineralization. This exchanse orocess results in the enamel becoming more acid resistant. 2. Incipient, noncavitated, carious lesions are remineralized by the same process. 3. Fluoride has antimicrobial activity. In low concentrations fluoride ion inhibits the enzymatic production of glucosyltransferase. Glucosyltransfemse prevents glucose from forming extracellular polysaccharides, and this reduces bacterial adhesion and slows ecological succession. Intracellular polysaccharide formation is also inhibited, preventing storage ofcarbohydrates by limiting microbial metabolism between the host's meals. Thus the duration ofcaries attack is limited to periods during and immediately after eating.

Important: Fluoride mouth rinses have been shown to have the greatest eft'ect on newly erupted teeth, making it essential to have rinsing continued into the teen years to protect both the second and third permanent molaru. It seems that fluoride rinses are most beneficial to smooth tooth surfaces, although there are some benefits to pits and fissures as well. :

NoteJ,

:ti*::il

***

l. Fluorine. from which fluoride is derived. is the l3th most abundant element and is released into the environment naturally in both water and air 2. Fluoride is naturally present in all water Community water fluoridation is the addition offluoride to adjust the natural fluoride concentmtion ofa community's water supply to the level recommended for optimal dental health, approximately L0 ppm (parts per million). For warmer or colder climates. the amount can be adjusted ftom 0.7 to 1.2 ppm.

Fluoride supplements would be contraindicated since the community water is fluori-

of6s"

dated at an appropriate level. Remember: "Rules iffluoride level is greaterthan 0.6 ppm. ifpatient is Iess than 6 months old, and ifpatient is older than 16, no supplemental sys-

temic fluoride is indicated. Supplemental fluoride should be administered only from the age of six months, and only if the tbllo$ ing conditions prevail: . The concentration offluoride in drinking water is less than 0.3 ppm . The child does not brush his or her teeth (or haw them brushed b1' o parent or guardian) at least i\ ice a day; and if, in the judgment of a dentist or other health professional, the child is susceptible to high caries activity (ani[' histo4,, caries treuds and patterns in cotltn ntities or geogrqphic areas) . Supplemental fluoride should be given in preparations that maximize the topical effect, such as mouthwashes.The most common fluoride comoound used in mouth rinse is sodium

flvortde

/0.050,4 sodium

fiuoride).

Toothpaste is available with or without fluoride. Toothpaste tubes containing fluoride are now labeled and contain approximately 0.1% fluoride. Some tubes suggest covedng the bristles with toothpaste. A'pea-siz€d' portion weighs approximately 0.75 g and contains about 0.4 mg of fluoride; a 'full cover' portion weighs approximately 2.25 g and contains about 1.0 mg of fluoride. Thus, brushing twice a day would deliver 0.8 to 2.0 mg of fluoride, depending on which regimen is used. lf swallowed. the amount of fluoride could be excessive and could cont bute to the development offluorosis. Important: Children should use only a'pea-sized' amount oftoothpaste, and be encouraged not to swallow the excess.

Note: The most common forms of fluoride found in toothpastes are sodium fluoride and sodium monofluorophosphate. Amine

fluo

de and stannous fluoride. are less common.

. One minute . Two minutes

. Three minutes . Four minutes

38 Coplright O 201l-2012

. Vasoline is applied to protect ary teeth with sealants . The teeth should be dry to prevent dilution ofthe fluoride concentration . All bacterial plaque must be removed to prevent interference with fluoride uptake by the enamel surface

. Patients should be placed in a semi-supine position

39 Cop)righl O 20l l -201 2

Prof'essionally applied topical fluo de agents are applied in the dental offlce or in other settings by health care providers. Cunently there are four types oftopical fluoride agents that are used on the teeth by health care providers.

. Acidulated phosphate fluoride 1,4PFl - in

geJ. foam, or solution fonn .2olo neutral sodium fluoride - in gel, foam, or solution form . 87o stannous fluoride - in porvder fbrm supplied in bulk containers or powder preweighted capsule fonn; mixed with water immediately before use . Fluoride-containing vamishes

Each agent has advantages and disadvantages and all are used in various settings. Several of the professionally applied topical agents carry the ADA Seal ofAcceptance. All the agents are effective and can be used in different situations to meet the range ofrequirements for topical fluoride agent$ in pediatric practice.

\ote: Acidulated

phosphate fluoride /,4PF) is the most populaf topical fluoride used in pedi-

atric of'fices.

Important: APF solutions and stannous fluoride fSNF2,/ should not be used on patients with porcelain. glass ionomer, and composite restorations. They have been shown to remove the glaze liom the sud'ace of these restomtions. Neutral sodium lluoride (Na-Fi is best to use if these restorations are present. Also, APF should be avoided on implant patients. it may corrode the of titanium implents. 'urface Topical fltroride (abng v'ith occlusal sealants) is the pdmary prcventive agent during adolescence (pa.\t the age o/72l because the entire dentition except for the third melars normally erupts by age 13. Theretbre, fluoride tablets may not be as beneficial. Remember: Caries activity is directly proportional to the consistency offermentable carbohydrates ingested, the frequency ofingesting fermentable carbohydrates and the oral retention of f'ermentable carbohydmtes ingested.

It is best to thoroughly dry the teeth before applying the fluoride to maximize the effectiveness of the fluoride application and prevent dilution of the agent. The teeth can be dried rvith comnressed air or cotton rolls.

Agent

Form

Concentration

Mode of Applicrtion

Special Not€s

Sodium fluoride

Solution

9.040 ppm 0.90% F ion

Painr on

Cotton roll isolation absorbs

Paint on or tray

zvo

9,040 ppm 0.90% F ion

Take care not to overfill tray Request Patient not to swallow

9,040 ppm 0.90% F ion

Tray

2%

Less amount needed to fill tray Less risk ofswallowing because

OiaF) pH = 9.2

2%

Gcl

excess solution

ofconsistency Vamrsh 5ro

22,600 ppm 2.36/oF ion

Paint on

Sets promptly

Acidulated

Solution

12,300 ppm

Paint on

Cotton roll isolation absorbs

phosphate

|.23./.

fluoride (APF) pH= 3.0 to 3.5

excess solutton

Avoid cemmic and composite resm rcslorutrons Gel

12,300 ppm

Paint on or tray

Take care not to overfill tray Avoid ceramic and composite resin restontions

12,300 ppm

Tray

Smaller amount needed to

\.23% Foam |.230/.

fill

trayl less F

Avoid ceramic and composite restn teslomhons

Fluoride

PEDIATRIC DENTISTRY

You examine a ten-year-old boy in your practice and det€rmine that he has multiple carious lesions. The family resides in a rural area and drinks well wrter. What is your advice regarding lluoride supplementation?

. Prescribe fluoride tablets for the patient immediately . Arrange for a sample of the patient's well water to be sent to a laboratory to assess the amount ofnaturally occurring fluoride in the water. Then prescribe the appropriate dose of fluoride supplementation in lieu ofthe fluoride that is occurring in the water, if any. . The child is too old for fluoride supplementation to be ofbenefit, so you do not recommend rt

. None ofthe above

Copyright

40 aq 20ll-2012

Fluoride

PEDIATRIC DENTISTRY

Clinical studies demonstrate that acidulated phosphate lluoride is most effective at what pH?

.

1.0

.2.5 . 3.5

.

5.5

41 Copyright

(]

201

I

2012

Children who are not receiving fluoride in their water should receive dietary fluoride supplements. However, you want to avoid having the children receive too much fluoride, so you should make sure their water is tested for any naturally occurring fluoride content ifyou have any doubts about the amount of fluoride already in the water You want to avoid fluorosis. Fluoride supplementation is generally recommended at least until age sixteen years. Note: Fluoride is particularly efficacious as long as teeth are still forming.

Note: Sodium fluoride is approximately twice the weight of fluoride. So L I mg of NaF delivers approximately 0.5 mgs of flr.roride.

6 years up to at leasr 16 yeals

Important: Prenatal fluoride supplements are not approved by

the FDA and are not recommended. However, prenatal fluoride does not cross the placental barrier. No studies to date support the administration of prenatal fluo des to protect the primary dentition against caries.

is L23 percent fluoride ion, which is over 12,300 ppm. It is acidic. with of3.5. Clinical studies demonstrate that it is most effective at that pH. The APF agent

a

pH

APF is formulated in solution, foam, and gel preparations. Foams and gels are the most useful. since the mate al stays in a fluoride delivery tray while in the child's mouth. They are also easier to apply than a watery solution. All ofthe APF products should be applied for four minutes in order to achieve the best results. Note: An APF gel has been developed which is adr enised as effective with a one-minute application. However, the four-minute products have nruch greater professional acceptance and, presently, only four-minute products carry the ADA Seal.

Important: You

are going to encounter children who gag and vomit and have problems holdthe trays in their mouths for four minutes. All experienced care providers realize ing fluoride that 1ou are asking for lots ofclean-up jobs and some unhappy children with spoiled clothes if l ou insist on the four-minute rule lbr all applications. Parents also are not pleased with these L)urcomes. The first fallback position is a two-minute application, and a one-minute applicatioll \\ ould be next. \ote: Eighty percent ofthe absorption offluoride into the enamel occurs dudng the first two rninutes ofa four-minute application. Consequently, you should strive fbr at least a two-minute application. However, you should terminate the procedure immediately ifthe patient is showing signs ofbeginning to vomit. A one-minute application will result in some absorption, but not as much as a two-minute application and certainly not as much as a four-minute application. Nevertheless, a one-minute application is better than nothing.

Remember:

*** *** ***

The pH ofAPF is approximately 3.5 /acidrc) The pH ofNaF is approximately 9.2 lbasly' The pH of SnF2 is approximately 2 .1 to 2.3 (acidit')

.

100 mg

. 200 mg . 350 mg . 500 mg

a2

coprridt

.

O 201l-2012

School water fluoridation

. Fluoridation ofthe communal water supply . Fluoride rinses at home . Frequent dental visits

/t3 Coplright O20ll-2012

The studies and surveys link fluorosis to three factors:

. Fluorosis is more common in geographic areas where the endemic levels offluoride in the

drinking water is higher than three parts per million . Fluorosis is associated with fluoride supplementation at inappropdately high levels . The use offluoridated toothpaste has been implicated in fluorosis In acute fluoride toxicity, the goal is to minimize the amount of fluoride absorbed. Therefore, syrup of ipecac is administered to induce vomiting. Calcium-binding products, such as milk or milk of magnesia, decrease the acidity of the stomach, forming insoluble complexes with the fluoride and thereby decrease its absorption. Note: EMS s,fioald be qctivated /91I ).

In acute fluoride toxicity, symptoms may appear within 30 minutes of ingestion and persist for up to 24 hours. Patients may experience some nausea, vomiting, diarrhea, and abdominal cramping. This may be due to the fact that 90-95% of ingested fluoride is absorbed through the stomach and small intestines. Fluorides are primarily eliminated from the body by way of the kidneys. However, the fluoride that does remain in the body is found mostly in skeletal tissue. ln acute fluodde poisoning fu,liclr is rqre), the most common causes ofdeath are cardiac failure and respiratory pamlysis. Fluoride toxicity shor-rs up in Ihe bones as o.teosclerosis.

Important: The lethal dose of fluoride for a typical 3-year-old child is approximately 500 mg and would be proportionately less for a younger child and smaller child. To avoid the possibility of ingestion of large amounts of fluoride it is recommended that no more than 120 mg of sr"rpplemental fluoride be prescribed at any one time. Not€: If a six-y€ar old child were receiving fluoridated water in thc amount of 3 ppm, the result would most likely be fluorosis but not systemic toxicity. On the other hand, if a child in thc samc age range (6-7) werc receiving 8 ppm of fluoridated water, thcrc would be a good chancc of systemic toxicity and moderate to severe fluorosis occurring.

The optimal concentration in the communal water supply varies with mean arurual temperature. In most states, it is I ppm. Fluoride suppl€ments are recommended if the water fluoride content is less than 0.7 ppm.

The school water fluoridation optimal concentration is 4.5 times that plies because of less water consumption at school.

ofcity water sup-

The US Public Health Seruice (PHS) has, since 1962, recommended that public water supplies contain between 0.7 and 1.2 milligrams of fluoride per liter of drinking water ,r-q Z/ to lrelp prevent tooth decay fsome naturql bater sources havefluoride levels vithin Illis ra ge. or even higher).

Fluoridation is now used in the public drinking water supplied to about two thirds of Americans. The types ol fluoride added to different water systems include fluorosilicic acid. sodium fluorosilicate. and sodium fluoride.

Other facts concerning fluoride: . It is deposited in calcified tissues

/.r,te

letal).It normally accumulates slowly in bones

as a person ages.

. Proximal tooth surfaces derive the greatest benefit from fluoridation

. It is excret€d by the kidney . Dental fluorosis can occur in permanent . The U.S. Public Heatth Depanment

and deciduous teeth

sets the optimal fluoride level at 0.7

to 1.2 ppm

for public water . The cariostatic effect of fluoride is produced during the calcification stage of tooth develoDment

. Primary mandibular canine . Primary maxillary lateral incisor . Primary maxillary canine . Primary rnandibular first molar

u Coplrigbt O 201l-20| 2

o

Primary lateral incisors and canines

. Primary canines and first molars . Primary canines and

second molars

. Primary cenhal and lateral incisors . Primary first and second molars

a5 CopriShl

@

201l -2012

The most common cong€nitally missing permanent teeth with the exc€ption of the maxillary and mandibular third molars, are the mandibular second premolars. followed by the maxillary lateral incisors, and the maxillary second premolars.

L The naxillary lateral incisor is most often atypic al in size (peg-shaped, etc.). , ,,f{otea.2.Apatientrvhohaspennanentcentralincisors,permanentcanines.andprimaryca'.!;;;]1i nines anterior to the premolars most likely has congenitally missing pemanent lateral incisors.

Heredity is most frequently responsible for the congenital absence ofteeth. 'Ihe roots ofthe primary tooth wiJl resorb slower than normal without the presence ofthe permanent tooth. As a general rule, if only one tooth is or a f!u, teeth are missing, the absent tooth will be the most distal tooth ofany given type. Ifa molar tootb is congenitally nissing, it is almost always ihe third molar [f an incisor is missing, it is nearly always the lateral. If a pretrolar is missing. it almost always is the second mther than the first. Rarely is a canine the only missing tooth.

Important: ln the case of a congenitally missing second premolar, you want to hold onto the primary second molar as long as possible. If it is still present it may be ankylosed. \ote: Cessation oferuption (tooth is out ofocclusion) is most diagnostic ofan ankvlosed pri-

mar] molar, Remember: Space maintenance is of utmost importance u'henever primary or perrnanent reelh are congenitally missing or lost prematurely witch results in the loss ofarch integrity. The loss of space. arch length, perimeter, or circumference may result. Migration ofprimary and/or permanent teeth can occur and the available space may be reduced by an amount sufl'icient to cause some degree of crowding in the pennanent dentition.

Replacement resorption, also known as ankylosis. results after ineversible injury to the periodontal ligament. Ankylosed primary teeth should be extmcted ifthey cause a delay in or ectopic eruption ofa developing permanent tooth.

Rule of four: This simplifred rule will enable you to determine the number of teeth of four teeth every four months

present at any given time. It implies the eruption beginning with four teeth at age seven months.

4: mandibular and maxillary cenkal incisors 8: mandibular and maxillary central and lateral incisors 12: mandibular and maxillary central and lateral incisoN, four first molars 16: mandibular and maxillary central and lateral incisors, four first molars and four canines

20: mandibular and maxillary central and lateBl incisors, four first molars- four canines. and four second molars

Example from question on front of card: At age l5 months. l2 teeth are erupted four centrals, four laterals, and four first molars.

-

. There is greater blood and lymph supply . The alveolar crest is flatter

. The cementum is thicker . Gingival pocket

and more dense than that

depths are larger

. Attached gingiva is not as wide

46 Cop)right O 201 I -201 2

. 5-6 years old . 8-9 years old

.ll-12yeanold .

l3-14 years old

t7 Copynghl O 201I -2012

ofthe adult

***

This is false; the cementum is thinner and less dense than that ofthe adult. Cementum

tends to increase with age.

The components ofthe gingival and periodontal structures are the same in childhood, adolescence, and adulthood. However, the clinical and radiographic images ofthe gingiva and periodontium ofchildren and adolescents differ fiom those seen in adults, owing to the significant changes that take place during growth and development.

More comparisons of the child periodontium to the adult periodontium: . Gingiyal tissues are more red. This is so because in the child the gingir l is more r ascular, thinner and less keratinized. . Lack of stippling: the connective tissue ofthe lamina propria is shorter and flatter. . Flabbier tissue: this is due to a decreased density ofconnective tissue. . Rounded and rolled gingival margins: this is probably due to normal eruption pattems. . The PDL fibers run parallel to the teeth. In adults, the PDLs are more horizontal against the tooth. The PDL is also wider in the child. This is why you may see mobility in the child's teeth as well as a decreased resistance to forces. The fiber bundles ofthe PDL increase with ag€.

. Alveolar bone has fewer trabeculae, larger marrow spaces, is less calcified, has a thinner

lamina dura and wider periodontal membranes.

. The width ofthe attached gingiva: (1) changes concomitantly to changes in the sulcus and crevice depth dudng eruption and shedding (2) increases with age in the primary dentition (3) is signiticantly narrower in newly erupted permanent teeth than in their deciduous predecessors (4) is nonnally minimal to none in newly erupted permanent teeth.

Note: A labial eruption path is the most common cause of inadequate attached gingiva in children.

8-9

l

l,ll

t0.l r

tvt2 I2-ll

?,8

t2 l6

2510

It

***

l6

As a general guideline. a permanent tooth should erupt when approximately three-fourths is completed. Aper is fully deveJopcd two to threc years after cruption.

ofits root

.

1.5 to 2 months in utero

.

3.5 to 6 months in utero

.

7

.5 to 9 months in utero

. l0 to 12 months

in utero

1A

Cop),ridt O 201l-2012

. The permarent maxillary

and mandibular premolars

. The permanent maxillary

and rnandibular first molars

. The permanent maxillary

and mandibular second molars

. The permanent maxillary and mandibular third molars

49 Copyrighl O 201l-2012

***

On the average thcy takc l0 months for completion ofcalcification.

First Evidence of Crlcillcstion

Cmwtr Completed

(we€ks in Utero)

Birth)

Root Completed (Ye3rs)

(Monlhs Aft€r

Mrtill.ry cenaal

t4 /t3-t6)

Late€l

t6 04 2/3

Canine

17

First molar

t5|2(t4

I/2-t

seco.d (i|olar

t9 (t6 23

1r)

(15

16 I/2)

5

9

18) 7)

6

l0-12

Mrndibrltr Centml

t4

(

Lareral

t6

(14

Canine

t7l5-t8)

Fi$i moler

t5v2(14

Second inolar

ta

(

13-16)

2/3 I6 t/2)

4.5

9 1/2-

17- 19 1D)

t7)

6 l0-12

L The largest primary tooth is the mandibular second molar.

lNor.tl

2. The mandibular lateral incisor is the smallest

primary tooth.

permanent tooth is thc maxillary first molar 4. Thc mandibular central incisor is the smallest permanent tooth. 3. The largest

A permanent tooth that moves into a position formerly occupied by a primary tooth is called a succedaneous tooth. In each quadrant, five permanent teeth, the incisors, canine. and premolars. succeed or take the place ofthe five primary teeth. \onsuccedaneous teeth includ€: . The pennanent maxillary and mandibular first molars . The permanent maxillary and mandibular second molars . The permanent maxillary and mandibular third molars

*** ***

These leeth do not move into a position formerly occupied by a primary tooth These teeth do not succe€d deciduous teeth

f\lote: The last primary tooth to be replaced by a permanent tooth is usually the maxillary canine (the permanent maxillary canine usuall!- erupts betueen the age oJ I 1- 1 2). The permanent mandibular canine usually erupts between the age of 9- | 0.

Remember: Permarent molars do not replace primary teeth

(see above).

. Crouzon's disease . Gardner's syndrome . Down's syndrome . Hallerman-Streiff syndrome

50 Coprighr O 20l l,20l2

.I

]clnlv!

:

.I

?"tt3

=

10

.I

3"i*tr

:

12x2=24

.I

]clnlnl :

16x2=32

l0x2=20

x2:20

51 Cop)'right @ 20ll-2012

Syndromes Marifestirg Bolh

SyDdrom€s Demonstratirg

H,?erdordr rnd Hypodontir

Ilypodontia Ectodermal dysplasia (bypohidroiic type) Chondroeclodermal dysplasia

Oral-facial-digital s).ndrome I Hallermann-Streiff slndrome

Ri€ger's syndrome Incontinentia pigmenti

Syndromes Demorstrating

Seckel slndrome

SuperDum€rary Teeth Cleidocranial dysplasia

Conditions Demonstrsting

Taurodontism

Cardneis syndrome

Klinefeller's syndrome Crouzon disease

Tricbodento osseus syndrome

Srurge-Weber s)ndrcme

Ectodermal dysplasia (hypohidrotic t)pe)

oral-facialdigital syndrome

I

Hallermann-Sreiff syndrome

Amelogenesis imperfect, Tr?€

lV

Oral-facial-digital slndrome I Down's syndrome

Syrdromes Demotrstr.titrg

Microdontia Ectodermal dysplasia (hypohidrotic type)

Syndromes l)emonstrating

Mrcrodontia

Chondroectod€rmal dysplasia

Facial hemihypertrophy

Hemifacialmicrosomia

Otodental slndrom€

Down syndrome

,:- 1.,2 = 5 ner ouadrant - l0 oerarch 'l'T"l=5*r""".ttr"=10*r".h - 20 total teeth I = Incisors C : Canines

\I :

Molars

Note: There are no premolars (bicuspids) in the deciduous dentition.

rlc\nlv'I =16x2=32 r!c{n}uf =14x2:28 rzrc trszrul.. :16x2=32

126-ly3

213

=12x2:24

52 Copyright O 201 1"2012

. At

bith

. One month . Four months

.

One year

53 Copyright O 20ll-2012

, 2 t-

'; |

:

|

2 _, 3

-

8 Der ouadranr

i o^ ; nt ; - ffi

=

16

neurch

-ii*o",u,J - 32 total teeth

Incisors

C

:

Canines

B

:

Bicuspids (premolars)

1I = Molars

First Evidence of Calci{ication (Weeks in Utero)

lltaxillary Cerrtral incisor

Lateral incisor Canine

Fint molar Second molar

l4 ( l3- l6) t6 (t4 213-16 | /2) l7 (r5-18) t5 v2 (r4 t/2-t7) t9 (t6-23 V2)

Mandibulsr Cenual incisor Lateral incisor Canine

First molar Second molar

14

(13-16)

t6 (t4 2/3-16 | 12) l7 (ls-18) ls t/2 (14 r/2-r7) t8 (r7-19 t/2)

Maxillary Cenkal incisor Lateral incisor Canine First premolar Second premolar First molar Second molar Third molar

3-4 months l0 months 4-5 months 1.5-1.75 ).rs 2-2.25 yrs

Ar birth 2.5-3.0 ),rs 7-9 yrs

Mrndibular Central incisor Lateral incisor Canine First premolar Second premolar First molar

3-4 months 3-4 months 4-5 months 1.75-2.0 yrs 2.25-2.5 y,rs

Second molar

2.5-3.0 ),rs 8-10 yrs

Third molar

Ar birrh

Note: Typically it takes 4 to 5 years for most permanent crowns to complete formation, except for the first molars (J.l,earrl and canines (6-r€drs). It takes approximately l0 years from the start ofcalcification to root completion, except for the canines ( l3 vears).

. 6-8 years old . 7-9 years old

.

9-12 years old

.

14- 16 years

old

54 Copyright O 20ll-2012

. The primary teeth are lighter in color than the permanent teeth . For primary teeth the interproximal contacts are broader and flatter than permanent teeth

. The pulp cavities are proportionately smaller in the primary teeth . In general, the crowns ofprimary teeth are more bulbous and constricted than their permanenl counterpart

. The pulp homs of primary teeth are closer to the surface ofthe tooth .The crown surfaces ofall primary teeth other words, there is less evidence

are much smoother than the permanentreeth (in

ofpix

and grooves)

Coplriehr

@

. Primary teeth have thinner enamel 201l -2012

Primary teeth ate exfolialed bv thc phcnomcnon called resorption of the primarv roo!- The permanent rooth in its folliclc attempts to forcc its way in 1o the position hcld by its prcdecessor. Thc prcssurc brought to bear against the primary rool evidentlv causes resorption of the root, which continucs until thc priman/ crown has lost its anchoragc. bccomcs loose, and is finally erfoliated.

Ifduring a routinc cxam. you notc that a pcrnanent tooth is rrying to erupt while the primary tooth is still lirmly in place. thc bcst treatment is to €xlract the primary tooth and allow the pcmanent both to erupl.

5

t0-12

4.5

lGt

***

2

This i:i fals€; the pulp cavitics arc proportionatcly larger in the prinlary leelh.

\lore

comparisons ofprimary and permanent teeth:

.Thccro$nsoftheprimar]anteriorteetbarewidermesiodistallyandshortcrincisocervicallythan thcir pcrmanent coun{crparts .l hc aro\\'ns of the primar-"- molars are shoner and morc narrow mcsiodistally at the cen ical third rhan th(' pcnnancnt molars . The roots ofthe primary ant€rior teeth taper more rapidly than do thosc ofthc pemranent antcri. The roors oithc primary molars are Ionger and more slender than ihosc ofthe permanent molars . I hc cnamcl rods in thc gingival third slopc occlusally instcad ofccn'ically as in pcrmancnt tccth. . Thc buccal and lingual surt'aces of primarl'. molals are flafter above the crest ofcontour than on pcr-

m!nenl molars . Primar] molar roots arc nrorc dive.gent (rclat^,e to lheit crofrl r irlt/y' compared to their pcrmanent couDlerparts to allorv room for the developing permanent dentition

ridg€

Fixtractcd tccth showirg thc ditlcrcnccs bct*ccn llrc primary and pcrmancDl tc€th.

Primary\'l!rill,rl C.ntral Incisor

Permancnll\raxill.t Certrrl Inchor

. 6 months old . 9 months old

. 1l .

months old

14 months

old

56

Copright O 20ll-2012

. 5-10 mm greater . 2-5 mm

than the permanent teeth that succeed them

less than the permanent teeth that succeed them

-

-

premolars

premolars

. 2-5 mm greater than the permanent teeth that succeed them - premolars

.

5-

l0 mm

less than the permanent teeth that succeed them

57 coplright O 20ll-2012

-

premolars

Maxillary Central incisor Lateral incisor

7.5 o

1.5-2.0 1.5-2.0

Canine

16-20

2.5-3.0

First molar Second molar

t2-t6

2.0-2.5

20-30

3

Central incisor Lateral incisor

6.5

1.5-2.5 1.5-2.5

Canine

t6-20

2.5-3.O

Filst molar

t2-t6

2.0-2.5

Second molar

20-30

3

Mandibular '7

***

Eruplron datcs arc variablc. Some infants get them early, othcrs do so late. A 6-month variarion in time of eruption is considered normal.

\otes

l. Whcn a prirnary tooth clinically crupts in thc mouth, one-half to two-thirds ofthc root structure has usually developed. 2. A primary tooth usually takes L5 to 2 months frorn thc beginning ofclinical eruption until il reaches the occlusal planc. Canincs take the longest to crupt. l. Calcification ofthe roots is normally con'rpleted by thc age 01 3 or 4. 4. Calcification of the primary teeth begins in the second trimester ofpregnancy.

***

Also, the cnamcl on the ocolusal surfaces ofprimary molars is ofuniform thickness and is approximately I mm thick, as opposed to that ofpermanent molars. which is 2.5 mm thick.

Charaoteristics

. Crowns

ofprimary molars

are

/ds (on?pared to permanent nolars): shorter with pronounced buccal and lingual cervical ridges and a constricted

cervical area. . The occlusal table is narrower faciolingually. . Anatomy is shallower (i.e.. lhe cusps are short, the ridges are nol as protlou ced and the.fbssae dre nol us aleep.). . A prominent mesial cervical ridge lrrdfes it easr to dislinguish rights lion lefrs). . Roots are longer and morc sl€nder than the ruots ofthe pemianent molars. The roots are ertrem€l!'

narrow mesiodistally and very broad lingually. . Roots are very div€rg€nt and l€ss curved. There is little or no root trunk.

Primar.r_Marillary l'irst

Molar

PermanentMaxillary First )Iolar

Remember: Leerray space is the size differential befiveen the primary postc.ior teeth /. anine, jirst and secottl rnolar.s), andlhe permanent canine and first and sccond prcmolar- Usually the sum oflhc primary tooth widths is greater than that of their permanent successors. So when these primary teeth fall out, thcrc is usually a slight amount ofspace fdbout 3.I mm per side in the nnndibular arch and |.3nm per side i the ma\illan, orc,/r.This space is often used to help relievc crowding. Ifnothing is done to prescrvc this spacc, thc permanent first 1nolars almost always

drift fonvard to close it-

. Molar bitewing radiographs . Mandibular molar periapical radiographs . Mandibular anterior periapical radiographs . Maxillary molar periapical radiographs

@yrigbt

58 O 20ll-2012

. Maxillary second molars

. Maxillary first molars . Mandibular

second molars

. Mandibular first molars

59 Copyrighi O 201 l-2012

Molar bitewing radiographs are the most frequently taken views in pediatric dentistry They especially are used to detect interproximal caries between molars. The film is placed in the bitewing tab and the patient bites on the tab to secure the film. The cone is positioned ten percent above the horizontal plane and is directed toward the contact areas ofthe molars. One film is used on each side in the pdmary and mixed dentitions. When second permanent molars are present, two films are necessary on each side. The distal surface ofthe cuspid should be included in the radiograph and together with all posterior teeth, as well as the distal surface of the most posterior molar in the mouth. Note: A size 0 film is used with small children. A size 2 film is used as soon as the patient can tolerate the larger film.

A child should have his / her first pediatric visit by their first birthday. Following that, if the child's teeth are spaced far apart and there is no clinical evidence ofdecay, bite-wings are not needed until the establishm€nt of contacts on the posterior teeth. At age six a child should have their first panoramic x-ray in order to get all vital information on developing teeth, roots and any possible malocclusion. X-rays for growth and development depend on the patient's stage of tooth eruption. The frequency of radiographs should depend on the child's risk for decay. Situations that make a child at higher risk for decay include lack of fluoride in the drinling watel high sugar diet, history ofcavities, poor oral hygiene, and many others.

L

The nice thing about panoramic x-rays is that they are taken

without placem€nt

ofthe film in the mouth so it does not alarm the nervous child. 2. Children are often "entertained" by the panoramic unit. 3. The drawback of a panorex is that there is a loss of image detail (it is hqrd to diagnose early carious lesions). Bite-wing x-rays are required for the diagnosis ofcarious lesions.

Primary mandibular first molar that needs sectioning for removal.

Ov€r-retained primary teeth in the mix€d d€ntition: . May prcvent the nomal eruption of the permanent teeth . May be caused by the abnormal root resorption ofthe primary teeth

. Are ot'ien treated by extraction Be car€ful in extracting th€se teeth. The

succedaneous tooth bud may be in close proximiry. This is especially true when placing the beaks of forceps into bifurcations ofprimary molars in older children.

Important: The most frequent cause of fiacture ofroot tips in extracting a primary molar

is

root resomtion between the aDex and the bifurcation. 1. lfa permanent tooth bud is accidentally extracted while removing a primary molar, the best treatment is to imm€diately orient th€ tooth bud, replant the bud

using digital pressure, and suture. 2. The best way to extract a primary molar that has the permanent tooth bud close to (a,s in the photo above) it i.s to section the iooth and remove the pans in-

dividuallv.

.30% .50% .80% .90%

60 Coplrigbt O 201l-20| 2

. Mandibular central incisor . Mandibular first molar . Maxillary central incisor . Maxillary first molar

6t Coplrighl O 201| -2012

Miscellaneous facts that you may need to know for boards: . At birth, thejaw is large enough to accommodate all primary teeth ifthey were to erupt simultaneously. . At birth, the width of the face has reached the greatest percentage of its adult size (as opposed to height and depth). . At birth, the palat€ is prett"v flat, in adults, it is vault-shaped (this occurs b1'deposi-

tion ol alveolar ctestal bone). . At birth, a newbom cannot differentiate between sour, salt, or a bitter taste. . At birth, the cranial vault is very near the size it will eventually attain in adulthood (as compared to the cranial bqse, mandible, mid-face, etc.). The brain and the cranial fully developed by age six. . In early life, tonsils function to filter bacteria and program the production of antibodies. . From age 6-12, the body's lymph tissue is 2007o of its normal adult mass. Because of this, enlarged tonsils in a six-year-old are, at age twelve, most likely to be srraller. This is because lymphoid tissue in the nasopharynx decreases at puberty. At the same base are

time, genital tissue is developing, . Dentists are mandated by law to report suspected child abuse or neglect. Proof of abuse or neglect is not necessary. . Failure to report suspected child abuse may result in significant legal ramifications for the dentist, including a fine, jail sentence, and civil liability. . Neglect: Definition from the American Academy of Pediatric Dentistry is the "willful failure ofparent or guardian to seek and follow through with treatment necessary to ensure a level oforal health essential for adequate function and lreedom from pain and

infection."

.

LThe first perman€nt tooth to erupt is the manditrular first molar, followed ,'Notcqr. shortly thereafter by the maxillary first molar kAr: 2. The lirst permanent tooth to begin calcifying is the mandibular first molar

kt

bifth).

3. The

first succedaneous tooth to erupt

is the mandibular central incisor.

Remember: The n.randibular first molar and the maxillary first molar are not succedaneous teeth.

PEDIATRIC DENTISTRY

Ordinarily, a 6-year-old child would have what teeth clinicallv visible in the mouth?

. AII (20) primary teeth and 4 permanent first molars

. l8 pdmary

teeth and 2 permanent mandibular central incisors

.18 primary teeth, 2 permanent mandibular central incisors,

and 4 permanent first

molars

PEDIATRIC DENTISTRY

When attempting a MO Class II amalgam preparation and filling on a primary tooth, you encounter a very large mesial marginal ridge that resembles r cusp. You also notice a transverse ridge from mesiolingual to mesiobuccal cusp that is rather large. This tooth proves difficult to restore, which tooth is it?

. Mandibular first molar . Maxillary first molar . Mandibular second molar . Maxrllary second molar

63 Cop)rr8lrt (] 201l'l0l:

Remember:

. The permanent mandibular centrals erupt between the ages of 6-7 . The permanent maxillary centrals erupt between the ages of 7-8 Note: A 7-year-old child would have the following teeth present clinically:

. l8 primary and

6 permanent teeth

--

the 6 p€rmanent teeth include:

- Mandibular first molars (2) - right and left - Maxillary first molars (2./ - right and left - Mandibular central incisors (2) - right and left

*** All ofthe

primary teeth except the two mandibular central incisors (20 - 2 = 18).

This transverse ridge separates the mesial portion from the remainder ofthe occlusal surface.

Other characteristics of the primary mandibular first molar: . It does not resemble any other primary or permanent tooth . The mesiobuccal cusp is always the larg€st and longest cusp, occupying nearly hvothirds of the buccal surface . The mesiolingual cr.rsp is larger, longer, and sharper than the distolingual cusp . Croun js wider mesiodistally than high cervico-occlusally . The mesial marginal ridge is very well developed and rcsembles a cusp

. . .

It

has a

Class

It

ll

prominent mesiobuccal cervical ridge cavity preparations are diflicult due to morphology

has no central fossa

Primary Mandibular Right First Molar

Buccal Rcpnnrcd

iion Aalh'Baloah. M.ry

Lingual and

Occlusal

ltlara.rcl J Fchnnb..h Dp,r,/

trraoloJ.'r I ti!!.|o{,.

Mesial and

.4nk,nt. S?ctnd atui,n O 2006.

Distal tr idr

pcmission fsm

PEDIATRIC DENTISTRY

Prim Dent

Match the primary molar tooth on the left with the appropriate occlusal picture on the right.

m

. Primary mandibular right first molar

. Primary mandibular right second molar . Primary maxillary right first molar

@

. Primary rnaxillary right second molar

ffi 64 Copynghr

a.lr

201

I

l0ll

PADIATRIC DENTISTRY

2006.

with

w Prim Dent

A neophl.te dental student, only about two w€eks into the program, gets scared when her l0-year-old cousin g€ts hit in the face and looses a tooth. She calls you up and says that her cousin lost his permanent mandibular first molar. Once she tells you more about the root morphology of the tooth, you realize it is a primary tooth and the child simply lost his:

. Primary mandibular canine . Primary mandibular first molar

. Primary mandibular second molar . Primary maxillary first molar

55 Copyrighl aO:0ll-1012

t',1

ml ffi_l ffil ffi I tJ [,q

Primary mandibular right first molar

[=-]

I

ffi ru mu m] MI W ff_l M M

Primary mandibular right second molar

^

Primary maxillary right first molar

Primar] marillary

Iii w L]ru lL FIII

right second molar

Occlusal

Lingual

I

Mesial

r

*{

|

rl

Distal

***

The permanent mandibular first molar has a morphology that closely resembles the pdmary mandibular second molar Note: Amalgam prep outlines on these two teeth also resemble one another.

Differences include: . Relative size ofthe distal cusp. The primary molar has its mesiobuccal, distobuccal, and distal cusp almost equal in size. The distal cusp ofthe permanent molar, however, is smaller than the other tu,o cusps. . From the buccal aspect, the primary mandibular second molar has a narrow mesiodistal dimension at the cervical portion ofthe crown when compared with the dimension mesiodistally on the crorvn at the contact level. The mandibular first permanent molar, accordingly, is $ ider at the cervical portion. . Groove patterns are different on the occlusal surface. . The primarv molar has more divergent roots to allow for the emption of the second premolar. . The orimarv molar has a more orominent facial crest ofcontour.

Permanent mandibular risht first molar ; Not

{4.'

11!;le*,

m

Primary mandibular right second molar

l. The primary teeth that present the most noticeable morphologic deyiations from the permanent teeth are the first molars. 2. The primary second molar has the greatest faciolingual diameter ofall primary teeth.

. The primary mandibular central incsor

. The primary mandibular lateral incisor .

The primary maxillary lateral incisor

. The primary marillary central incisor

66 CopFight O20ll-2012

. Permanent maxillary third molar . Permanent maxillary second molar . Permanent maxillary first molar . Permanent mardibular second molar

67 CopyriShl O 20ll-2012

Thc primary maxillarv central incisor rcsemblcs the permanent maxillarv central in shapc. It is rnuch smaller in size than thc permancnt maxillary central and has a morc pronounccd ccn,ical linc. The crown is the only antcrior tooth in cilhcr dcntition to have a shortcr inciso-ccr1ical hcight than thc mcsio-distal width. This tooth crupts rvith no mamelons, and the labial surface is convex anci smoolh.

Primar) marillart. right central

Primary maxillary right lateral

incisor

incisor

T-=:--'l

t/ \l

le"l

BB

KK

7\ lY./l

Labial Lingual Labial Lingual Incisal Thc primary maxillarv lateral incisor is similar to thc central incisor e\cept i! is smallcr Anothcr Incisal

dif--

ference is that it is longer than it is wide- The incisal cdgc ofthc primary maxillary latcral incisor is more roundcd on the mesial and distal sides than thc straight incisal cdgc olthc ccntral incisor.

Thc prirnaa_v mandibular central incisor more closel)' resemblcs thc permanont mandibular Iateral incisor than its centml incisor counterpart. The crown ofthe tooth is slightly wider than the pernanent Iatr'ral incisor lhc shape and foml of thc incisal edge is a lmost cxactl-v thc samc as that of the pcnnancnt laleral. The root is slender and rather Iong. Mesial and distal surfaces of the root are flat. while linSual and Iabial surfaccs arc convcx.

primsrl -= l:l , .rl". ;" :..' m ' m ltll lvl i1j l\i I llJl ;;,';r".'r#, :,, , i

@

i H] N] o

,1,

nrandihurar

b] lxl

lncisal Labial Lingual

primar) mandiburar

rir*"i-.

Labial Lingual Incisal

The primary mandibular lateral incisor rcscmblcs thc primary mandibular central incisor except that it is slightly longcr and wider The cingulum and the mesial and disral marginal ridgcs are more pronounced and the fossa is nol as shallow. The root cuNes toward the distal at thc aDcx.

In general. the primar-r- second molars are larger than the prinrary first molars and resemble the form ofthc pcrmancn{ firsl lnolatsL)ther characteristics ofthc primary maxillary second molar:

.Thc faciolingual measurement oflhe crown is grealer than the mesiodistal measurement . \1a\ hclc a fifth cusp (ol Carobelli)

. Has a prominent mesiobuccal cenical ridgc . Has an oblique ridge . \18 cusp is almost equal in sizc or slightly larger than . Th(- largcst and longesl pulp ho.n

is thc

lhe ML cusp

MB

jry* ,hJ Primar! \Ia\illary Right Second Molar

Primarv Dentition (facial view)

Permanent N{axillary Right f'irst Nlolar

Primary Dentition (lingual rien)

DENTISTRY

Prim Dent

A 10-1/2-year-old patient comes into your oflice. You are not sure whether his maxillary canines are permanent or primary. Which of the following statements will help you determine whether or not they are permanent or primary canines?

. The cusp of the primary maxillary canine is much shorter than the cusp of the permanent maxillary canine

. The mesial cusp ridge on the primary maxillary ridgel this is opposite ofall other canlnes

canine is shofier than the distal cusp

. The cusp on the primary maxillary canine is much longer and sharper than the cusp on the permanent maxillary canine . The primary maxillary canine is much narrower and longer than the permanent maxillary canine

PEDIATRIC DENTISTRY

varies from

The occlusal form of the

that ofany tooth in the permanent dentition,

.

The primary mandibular first molar

. The primary maxillary first molar . The primary mandibular second molar

. The primary maxillary

second molar

69 Copynght

a9

20ll-2012

The most significant dilferences between the p mary maxillary canine and the permanent maxlllary canrnes are: l. The cusp on the primary canine is much longer and sharper. 2. The mesial cusp ridge is longer than the distal cusp ri
***

Obr,iously they difler in otber rvays. but these tuo diUbrences are the most significant. r-ote: Thc primary rnaxillary canine also appears especially wide and short. The Primart-' Nlarillary Right Canine

[f [r tt l,tl I

L_l

Labial

Lingual

Incisal

BE Nlcsi.l

Distal

Th€ Primar! i\Iandibular Right Caninc

--r'--1

t()l

I{ Itullf I

Labial

I I

td

I fY

tl;l

I

tul I ingual

Incisal

t-ll t--f l \v| \/l tti|ul llesial

Distal

Chanrctcristics of the primary maxillar]' first molar:

. In all dimcnsions ercept labiolingual diamctcr, it is the smallest molar Basically the .ro\\ n ot ihis tooth is bicuspicl (tfo (usped) . There are i\\o main crLsps: a wide mesiobuccal and a narrot mesiolingual. Indistinct .usf\

are the distobuccal and distolingLral The \18 cusp is alu'ays the longest. The ML clrsp is the second longest. but sharpcst -l he cerr ical line is higher mesially than dislall), Thc cer\ ical ridge stands out very clistinctly on thc rnesiobuccal ponion of this tooth The ecclusal pit-groove pattcrn is most frequently H-shaped . ThL- nLlmber ofroots (3) and the lbrm ofthe roots closcly rcscmbles the pennanent ma)i-

. . . .

il.a1 iirst molar . On the cron n, the mcsial surface nonnally is )arger than the distal surfacc The Primary Nlaxillary Right First NIolar

MF!]]m l( ill(, ,| Buccal

Lingual

Occlusal

M€sial M€sial

Distal

. Pulpotomy . Extraction

. Pulpectomy . Observation

70 Copyrighl

@

201l -2012

. A necrotic pulp . A deep carious lesion adjacent to the pulp

. A periapical radiolucency

. Pulp tissue that is irreversibly infected

due to caries or trauma

71

Cop)'rightO20ll-2012

This is treated the same way as you would treat the adult patient. At age eleven the root of a maxillary central incisor should be completely formed, therefore an apexification procedure is not indicated. If the root were not fully formed, then an apexification process should be started. This involves the placement of calcium hydroxide pastes into the canal to stimulate continued apical closure. The fact that the tooth is painful and there is swelling is a contraindication to a pulpotomy. You need healthy pulp tissue in the root for success of a pulpotomy. Il the tooth were non-restorable, then a pulpectomy procedure would be contraindicated and the only altemative would be to extract the tooth.

Note: Apexogenesis is a vital pulp therapy procedure performed to encourage continued physiological development and fomation ofthe root end. This term is frequently used to describe vital pulp therapy perfotmed to encourage the continuation of this process. \lTA (Mineral Trioxide Aggregate)is frequently used for this procedure.

Important: The best sign for

success ofapexogenesis is continuous completion ofapex.

\ote:

Pulp therapy is generally contraindicated in children who have serious illnesses (i.e., Ieukemia, cancer pdtients, etc.).

Indirect pulp caps arc those procedures whcre, at the first appointmcnt, all of the superficial oarious dcntin is excavated. Thc caries that is estimatcd to be approximating a potential pulp exposure is left in the !oo!h ifit js still sufficiently healthy (i.e. , affected - not i fected dentin) Alt!1p &essing is placcd in rh. rlrorh tbr a predetermined period of time (usually 6- 12 months). At thc second appointmenl (afler 6' /-' ,rdrdt. all the carious material is excavatcd, and the floor ofthe cavity is examined for pulp exposurcs If no c\posures arc seen and the tooth has been asymptomatic, the treatment is considered :rrccessful and a pemranent rcstoration is placed. However, the single appointrnent procedure has also appointment Sarned in popularily and is probably the most common approach in curent use ln the singlc monitoring of the placed with is at the first appointnlellt, approach. a permancnt restoration Periodic 1.r6th

Calcir:m hrdroxide, hybrid ionomcr matcrials, or glass ionorncr maierials are often the dressings of chorce for indirect pulp therapy- The ftlling material is placed over the pulp dressing on the first appornrment /.,.g, conposile, glass iononel h!-brid ionomer, or amalgatt). Important: The preoperative x-ray ofthe tooth to be treated by indirect pulp therapy must not indicate a carious exposure ofthe pulp. In addition, the tooth should be asymptomalic and no periapical change should bc obsen'able on the x-ray.

Indircct pulp capping in the primary dentition: . Absence ofprolonged or repcatcd cpisodes of pait (att rnprot'oked toolhache) . \o x-ray evidence ofcarious penetration ofthe pulp chamber . Absencc offurcal orperiapical pathology fa lways ask ,-ourselfif the root ends at? conpletelt' closed' or are xe obseming pothological change in lhe case ofanterior leeth?) . No pcrcussive symptoms Evaluarion and restoration ofa tooth treated with indirect pulp therapy: . Absence of subjective con.,pl:dints (toolhaches) . After 6- l2 months, periapical and bitcwing x-ray reveal deposition ofnew secondary dentin . Place a pcrmanent restoration if no exposure r.rf thc pulp chamber is present after rcmoval ofthe temporary restoration and remaining soft dcntin. For the primary dcntition, a glass ionomer, hybrid ionomer, compositc, compomer, amalgam, or stainless steel crown may be uscd For the permanent dentition. composite, amalgam, stainless steel crown, or cast crown restorations may be selected.

A four-year-old child presents with acute pain associated with a primary mandibular second molar that has a large carious lesion with pulpal involvement. Radiographically, there is periapical pathology on the distal root. The child is very cooperative and is able to tolerate long appointments, What is the preferred choice of therapy for the primary mandibular second molar?

. Incision and drainage

. Pulpotomy . Primary tooth endodontics

(pulpectomy")

. Extraction

72 Copyright

c

20lr -20t2

Pulp Tx

Which treatment is the proper one for a Cl&ss II fracture ofa permanent tooth with an immature apex?

. Pulpectomy

. Apply calcium hydroxide to exposed dentin and restore tooth with a restoration

. Pulpotomy . Obsene

73 Copynghr O

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permanent

The first and probably most important indication for primary tooth endodontics (pulpectomy) is space maintenance- Ofcourse, the best space maintainer is the natural primary tooth. Saving the tooth is very important so that a space maintainer will not be necessary Constructing a space maintainer in cases where second primary mola6 are lost before eruption offirst permanent molars is extremely difficult. Since there is periapical pathology and the child is four years old, the treatment ofchoice is pulpectomy. If there wasn't any periapical pathology, a formocresol pulpotomy would be indicated. If the child were older and there was a periapical radiolucency but successful pulpectomy could not be acoomplished, the treatment of choice would be extraction with placemetrt of a space maintainer. This should be done to prevent damage to the surrounding bone and the developing permanent tooth. Endodontics for the primary d€ntition is a rclatively quick and easy procedure for treating teeth with necrotic tissue, which cannot be treated with a pulpotomy. A high-spccd bur is used to gain access into the pulp chamber and Hcdstrom files arc thcn used for filing thc canals. The canals are irrigated with hypochlorite to wash out any remaining tissue and loose dentin. Thc canals and chamber are then filled rvith zinc oxide er.rgcnol. A post-operative x-my is taken to evaluate the condensation procedure. The tooth is then restored using a stainless stccl cro\r,n. Indications for primary tooth endodontics (pulpectom!'). . A tooth that is restorable with a stainless steel crown . No pathological root resorption . Layer of ovcrlying bone between pernanent tooth bud and area of pathological bone resorption. The radiograph should demonstrate that a layer ofhealthy bone exists between the lesion and the permancnt tooth bud. This allows thc lcsion to fill in with normal bone once the endodontic therapy is conlpleted. . Suppuration . Parhological periapical radiolucency Contraindications for primary tooth endodontics (ptlpectomv), . Floor ofthe pulp opening into thc bifurcation . Radiographio indication ofextensive intem al resorption (tooth has beenweakenetl lo the exlenl dt it cannol support a stainless sleel crci,n) . More than 2/3 ofthe roots have been resorbed

. Teeth without accessible canals /corrnoa l7' jirst primary nolars)

Smooth enamel edges, restore tooth

Apply calcium hydro\ide to e\posed dentin and rcstore tooth with

a

pemanent rcstoration

Imm€diately after injury, apply calcium hydroxide over exposure and place a temporary restoration. Ifcxposurc is large or the injury was several hou$ or days ago, perfbrm a calcium hydroxidc pulpotomy. Oncc apex closes, do pulpectomy. CalciLrm hydroxide pulpotomy. Once apex closes, do pulpectomy

In an older child with a fully forrned apex: Ifthere is a pinpoint exposure and it's been while (da-y) since tl're lracture, the treatment ofchoice would be conventional root canal therapy using gutta-percha. If it is seen immediately, then a direct pulp cap with calcium hydroxide is indicated, lollowed by a permanent restoration. a

PADIATRIC DENTISTRY

Pulp Tx

The lirst indication for a pulpotomy is carious invasion deep enough to cause mechanical exposure of the pulp or inflammation of the coronal pulp.

Infl*nmation or infection ofpulp

tissue beyond the coronal pulp

contraindicates a pulpotomy.

. The first statement is true; the second statement is false

. The first statement is false; the second statement is true . Both statements are true

. Both

statements are false

74 Copyrighl O 20ll-2012

PEDIATRIC DENTISTRY

Direct pulp caps (DPQ involve direct placement of the capping material is the agent that is most trequently used. on the pulp.

. Cavity varnish . Glass ionomer

.ZOE . Calcium hydroxide

Copyright

75 e 20ll-2012

There are sev€ral specific indications and contraindications when you are considering a pulpotomy. The first indication for a pulpotomy is carious invasion deep enough to cause mechanical exposurc of the pulp or inflammation ofthe coronal pulp. However. it is vcry important that thc inflammation and/or infection not have extended beyond the coronal pulp tissuc. Important: The success ofa formocresol p lpotomy for a primary tooth depends primarily on a vital root tip. Contraindications for thc pulpotomy procedure in the primary dentition include the following. All of these symptoms indicate that inflammation and/or infection extend beyond the coronal pulp. History ofspontaneous pain . Pain from percussjon . Furcal radiolucency . Periapical radiolucency . Intemal resorption . Calcification ofthe pulp The Formocresol pulpotomy is the preferred technique at this time:

. The pharmacotherapcutic agent in the formocresol pulpotomy consists of 19% formaldehyde, 35% cresol, l5o% glycerin, and water. . Local anesthesia and rubber dam isolation are used for almost all pulp therapy procedures. including the formocresol pulpotomy . Cotton pellet(s) are placed in formocresol solution (Bucklets solution is olien used) Important: It is necessary to dry the pellet(s) using a cotton roll. . Cofton pcllets are pressed gently against the pulp tissue at the orifices ofthe canals . Conon pellets are left in position for five minutes . \ote: Formocresol is a tissue fixative. T]?ically, the tissue is a brownish-purple color when fixation rs complcte. . Once the formocrcsol pellcts are rcmoved (after live inutes), ZOE is used to obturate the pulp chamber It is placed directly on the exposed pulp tissue. . Tooth is rcstorcd r-ote: Formocresol willcause suface fixation ofthe pulpaltissue accompanied by dcgencration ofthe odontoblasts.

Direct pulp caps fDPCi usually are not done in the primary dentition. In fact, most dental schools teach that the DPC is a contraindicated procedure in pdmary teeth. Howevet although seldom used in the primary dentition, it occasionally is used for primary teeth if rormal exfoliation will occur in the near future (up to six months). Wten the tooth will erlbliare normally in less than six months, treatment with a DPC sometimes is selected ro eliminate the time, complexity, and expense associated with a pulpotomy procedure.

Direct pulp capping is primarily used on permanent teeth. The reason it is not widely used on primary teeth is because ofthe alkaline pH ofCaOH. CaOH can affect (irritate) rhe pulp either mildly or most often severely. With a mild irritation, there is a mild inflammatory reaction which will resolve itself and regroup as reparative dentin. With se\ ere irritation, there is a probability ofinternal resorption. ln pdmary teeth this severe irritation resulting in intemal resorption happens more often than not. In permanent teeth rhis rarelt.' occurs, because the severe inflammatory response will cause reparative dentin to form.

Ke) point: Primary teeth do not respond well to direct pulp capping procedures. Poor long-term prognosis is the reason most clinicians avoid DPC's on primary teeth and move directly to the pulpotomy procedure when primary tooth pulps are exposed during cavity preparation.

Note: A situation where it might be appropriate to perform a direct pulp cap instead ofa pulpotomy: Occasionally you will have a small surgical exposur€ of the pulp on a primary tooth, and the tooth is not going to be in the child's mouth for an extended period of time - perhaps six months at the most you could consider the direct pulp cap in such a situation.

. One-third . One-quarter . One-fifth . Three-fifths

76 Coplrighr O 2011-2012

following strtements are true llXC.lgP? one,

Which one is the.EXCfPtlOi2

. The occlusal anatomy of primary teeth is not as defined

as that

of permanent teeth

therefore amalgam preps can be more conservative

.

Enamel and dentin are thicker in primary teeth, therefore amalgam preps are deeper

. The pulpal homs of primary teeth are longer

and pointed, therefore amalgam preps must be conservative to avoid a pulpal exposure

. Primary molars have an exaggerated cervical bulge that makes matrix adaptation much more difficult . The occlusal table is narrower on orimaw molars

Coplridl

77 @ 20ll-2012

The procedure for the diluted formocresol pulpotomy is the same as that ofthe traditional pulpotomy: apply nonsaturated fbrmocresol cotton pellets moistened with diluted formocresol for five minutes to the pulp stumps and check for acceptable fixation before proceeding with obturation. You may experiencc greatcr dilTiculty in obtaining initial fixation with the diluted formocresol compared with the full-strength formocresol. Your options arc to repeat the topical application ofthe fomrocresol or to proceed with primarl endodontics rpalpc, rolrvl or crtraction. Various altemative pulpotomy proccdures that have been developed as potential replacemcnt proccdures for the traditional formocresol pulpotomy technique:

. Glutaraldehyde Pulpotomyi glutaraldchydc

is a tissuc fixativc. Howcver. it is more miid and potentially less toxic than formocresol. These properties have favored its use by some as a pulpotomy agent. [t does not invade systemically to the same degree as fomocresol fM.v?rJ/. This factor, along with its potentialJy less toxic form, has favored its use in some areas. A two percent solution ofglutaraldehydc is used on cotton pellcts to fixate the pulp. Thc moistcncd cotton pellets are placed on the pulp stumps for four minutes. The pulp stumps will be pinkish in color when the tissue is fixed. . Ferric Sulfat€ Pulpotomy: onc ofthc main attractions offcrri. sulfate is that the material is not associated with toxicity and mutageniciry Thereforc, a milder agent is being placed on vital pulp tissue in children. A 15.5 pcrccnt fcnic sulfatc solution is uscd. Suitablc solutions are available commercially. The material most often used is the Ultradent astringent solution. A slringe with 2-3 ccs offerric sulfatc solution is dispcnsed into the tooth pulp chamber. Only a small amount is neccssaryJust cnough to achieve hemorrhage control. Typically the color ofpulp tissue treated with ferric sulfate is red or slightly darkish red. Thc fcrric sulfatc is lcft in placc for approximatcly l5-20 seconds and then the pulpolomy preparation can bc rinsed to remove excess medication. This is a very rapid procedure, es-

pecially in comparison with othcr pharmacothcrapcutic approachcs to pulpotornies.

. ]lineral trioxide aggr€gate (MTA):

has shown clinical and radiographic success as a dressing material following pulpotomy in primary teeth after a shofi term evaluation pcriod and has a prornising potential to become a replacement for fomocresol in primary teeth. Furthcr long term clinical evaluation of MTA as a pulpotomy agent needs to be carried out.

*** This is falsei

the enamel and dentin are thinner in primary teeth, therefore amalgam preps are shaflower (0.5 mm into dentin, 1.5 mm overall). The thickness ofcoronal dentin in pnman rceth is abuul one-halflhat ofFermanenl leelh. The morphological characteristics of primary teeth affect the way restorative procedures are approached. ln particular, the morphology of primary teeth necessitates modifications in re\rorations compared to the same type ofprocedure in permanent teeth. Some ofthese moditications are subtle, but they still are important. For example, the depth of Class I cavity preparations in primary teeth is shallower than occlusal restomtions in permanent teeth. This is due to the relatively larger pulp chamber in primary teeth. Ifthe primary teeth were prepared :o a depth that is common for pernanent teeth, the dentist would be much more apt to expose rhe pulp. In addition, the enamel cap is thinner in primary teeth than in permanent teeth. Consequenlly. the occlusal depth for a preparation on a primary tooth can be much less than the depth of a preparation for a permanent tooth.

Other important morphologic considerations of primary t€eth include:

. Primary molaIS have an exaggerated ceryical constriction which requires special care in the formation ofthe giogival floor in Class ll preps . Enamel rods in the gingival third ofpdmary teeth extend occlusally ftom the DEJ, eliminating the need in Class ll preps for the gingival bevel which is always required when preparing Class lI preps on permanent teeth

Important: When preparing a Class ll amalgam prep on a primary tooth, there are several other recommendations for the proximal box preparation: . The proximal box should be broader at the cervical than at the occlusal aspect . The buccal, lingual, and gingival walls should all break contact with the adjacent tooth, just enough to allow the tip ofan explorer to pass . The buccal and lingual walls should create a 90-degree angle with the enamel

PEDIATRIC DENTISTRY

Restorative

The success rates for rnandibular nerve blocks are lower in children than in adults because of the lnatomy ofless developed mandibles. The anterioposterior position of the mandibular foramen is about the same or slightly more mesial in children than in adults.

. The first statement is true; the second statement is false

. The first statement is false; the

second statement is true

. Both statements are true . Both statements are false

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PEDIATRIC DENTISTRY

Restorative

The trulbous, conically shaped primary teeth also affect the amount ofextension ofthe occlusal outline of the preparation. The general rule is that the occlusal outline is about of the intercuspal dhtance, betw€en the buccal and lingual cusps, on the occlusal surface of primary molars.

. One-half . Onerhird

. Trvo-thirds . Three-quarters

79 CopyriSht O 201

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2012

The success rates for mandibular newe blocks are higher in children than in adults because ofthe analomy of less developed mandibles. The anterioposterior position ofthe mandibular foramen is about the same or slightly more distal in childrcn than in adults. However, the vertical position ofthe mandibular foramen jn young children is closer to the occlusal plane when compared with that in adulls. In adults, it is located roughly ten millimeters above the occlusal pLane. In young children, it is located somewhere belween scvcn millimelers above lhe occlusal plane and slightly below the occlusal plane. Therefore, local anesthctic solution can more easjly diftusc inferiorly liom the site ofdeposition olthe solution to thc target area. For a child, the slringe barrel should bisecl lhe primary molan on the opposite side ofthe injection. Note: An imperfcct irjection techniquc is the most common cause ofproblems with getting a child palient numb. In the mandibul'r arch, the only guaranteed way lo accomplish prolound pulpal anesthesia is 10 perform an inferior alveolar ncn'e block. Primary incisors. however. can be anesthetizcd using suprapcriostial injections - which ancsthetizes branches olthc incisive ncrvc. Not€: Local infiltration can be uscd fbr anesthetizing m.xillary primary teeth. Adequate diffusion of thc local ancsthetic readily occurs in childrcn because their bones are less dense than those ofadults. Remcmbcr: Young children don't always understand what "numb lip" means when you ask them this follo\r'ing a mandibular block. The best indicator ofa profound block would be to probc the labial-attachcd gingiva between rhe latcral incisor and caninc with an explorer Ifthis js done without a reaction from the child. hetshe is "numb."

lmportart:

Overdosage of local anesthesia may cause CNS complications, such as dizziness. blurred vi-

jion. seizures, CNS depression. and death. Cardiac complications may includc myocardial dcpression.

No&3

1. The two most commonly used injectable local anesthetics in pediatric denlistry are lidocaine 27o wilh/without epinephrine (X.y/orairel and mepivacaine 3o/" (Carbocaifle). 2. Do not excced the maximum rccommended dose (2 300 nrg max. 3. Long-acting local anesthetics, such as bupivacaine (Marcaine), mrely are used in pediatric dentistry. .1. The lwo most commonly used topical anesthetic agenls in pediatric dentistry are: . 20 70 Benzocaine gel or liquid . 2 -107o Lidocaine gel or liquid

ng/lb)

5. Remember to wam the child not 10 bite lhe "numb" cheek or lips. Cive the waming during the dental appointment as *ell al lhe end ofthe appointment.

*** Important:

Class II amalgam rcstorations for primary tceth are prone to isthmus fractures. Some textbooks even go so far as to recommend removing tooth sffucture at the axio-pulpa) line angle. so that more bulk ofamalgam can bc obtajned to strengthen the isthmus.

Other basic principles in the preparation ofcavities in primarv teeth include: . Occlusal outline forms also are aflected by other anatomical characteristics ofprimary teeth. For example. because ofthe shallowness ofthe preparations and the relatively large sizc ofthe interproximal boxes. dovetails usually are constructed to give more retention and more bulk to the restoration.

. The Class I and Il preparations should include those areas that have ca es and thosc areas that retain plaque and are potential carious areas /pits and fssures). Note: This "extension for prevention" rs onl) \}hen restoring with amalgam. It is not necessary to "extend for prevention" when restorrng \1irh composite resin or resin modified glass ionomer, it is possible to seal thc remaining pit and tliiurcs. . Fl.t pulpal floor . Be\eled iotoded)

line angle. This will hcip reduce stress in the amalgam and provide ^xio-pulpal Sreatcr bulk ofmaterial in lhis area. . Rounded angles throughout thc preparation. This will result in less concentation ofshesses and \4ill allo\\ more complete condensation ofthe amalgam material into the extremities ofthe preparation. . hl Class Il prcparations, the facial and lingual walls ofthc proximal box should bc carried to selfcleansing areas and should be parallel to the extemal surfaces and convergc slightly. . The gingival margin need not be beveled in Class II preps. The enamel rods in this area incline occlusally.

. In Class II

prcparations, thc gingiva] floor is not ideal in most cases as the preparation gets deeper in this area. This is due to the cenical colstriction found in this arca on p mary molars. . Problcms with open contacts duc to interproximal restorations can be avoided with good matrix and wedge placement. It is important to avoid open contacts. . The critical clcmcnt in filling all intcrproximal resto.ations in terms of achieving good contacts, $hether you are restoring one or two adjacent teeth, is to push the wedgc t'ar enough into the interproximal space to achicve slight separation ofthe teeth. Finally, a good visual check ofthc matrix adaptation before the tooth is restored will yield consistently excellent results.

IEDIATRIC DENTISTRY

Depth cuts can be used as a gauge to help establish the depth of the occlusal reduction when preparing a primary tooth for a stainless steel crown,

Approximately

.

I to

.3

ofthe occlusal surface should be removed.

1.5 millimeters

to 3.5 millimeters

. 4 to 4.5 millimeters

. 5 to 5.5 millimeters

80 Copynghr

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PEDIATRIC DENTISTRY

Restorative

Alf of the folfowing statements are true EXCEPT one. Which one is the EXCCPZOM

. Dental decay in primary teeth is an infectious process that can be very painful, spread, and affect the development

ofthe adult teeth

. Dental decay in primary teeth most often means there will be dental decay in the adult teeth

. Primary teeth are slightly more opaque on x-ray film than permanent teeth because ofa Iower inorganic content

. Dental

decay in primary teeth tends to progress more rapidly from initial surface de-

mineralization to involvement ofthe dentin

. The enamel layer ofprimary teeth is thinner in all dimensions nent teeth 81

copyright (c

20lI :ol2

as compared to perma-

Posterio. stainless steelcrowns on primary teeth are a fast, predictable, durable. and relatively inexpensive restorative technique. Primary teeth have a limited lifespan compared to the permanent dentition; as a rcsult, a restoration nceds to last only until exfoliation. Bccausc primary tecth arc smaller lhan permanent tecth, a given amount ofdecay causes the tooth structure to become thinner and lcss stable than it would be in a larger permanent tooth. The larger pulp space ofprimary teeth limits the depth of amalgam preparations; these factors result in less stable Class II amalgam rcstorations among primary molars. Premature loss of a Class II amalgam can lead to the mesial migration of posterior teeth with a corresponding loss ofarch length. Two commonly used types ofstainless steel crowns:

l.

Prctrimmed crowns

2. Precontoured crowns Once the rubber dam is placed, tooth prcparation can begin. There are three basic steps to tooth preparation for stainless stccl crou'ns: ocolusal reduction, buccal and lingual reduction/beveling. and proximal reductron.

. Depth cuts can be uscd as a gauge to help establish the depth ofthe occlusal rcduction. Approximately 1-1.5 millimeters ofthe occlusal surface should be removed. . The next step involves the buccal and lingual reduction/beveling part ofthe preparation. It is bcst to slightly reduce the cewical bulges of some tccth (rsua\'by approximate\, l- 1.5 nillimeters) jnst abovc rhe gingival tissue. Note: In the case offirst primary molars, the buccal bulges often are very promineat. [t is so]netimes necessary to remove them in order to get thc preformed crown to fit over the buccal promincnce. . Rounding all line angles and point angles is rccommended . Fitting the stainless steel crorvn. Stainless stcel crown margins should be placed rjght at or slightly belo$ thc height ofthe ftee gingiva. Fortunately, the advent ofnew preformed crowns has made most

tlrmmlng unncccssary. is ao leave an intcrproximal Iedge. This has been a popular question on national board examinations for decades. A prcparation 1lith a ledge wil) not allow the stainless steel crown to scat complctely because it often will get caught on the ledgc.

Importantr The most common eror in preparing teeth for stainlcss crowns

**r

This is false; primary teeth are slightly less opaquc on x-ray film than pemancnt teeth because of hrsher inorganic content. Remember: Ttere must be 30-6070 loss in mineralization before caries is .adio!:raphically cvidcnt with standard D-and E-speed intraoral films. Thereforc, the clinical progress of a carious lesion is advanced, sometimes significantly, compared with its radiographic progress. a

.{malgam has been uscd as a restorative material sincc early in the nineteenth ccntury In the past, as nou'. anialgam periodically has been the object of confoversy. The cause ofthe confoversy often has been ::s mercury content. Currently, amalgam also is bcing challenged by the introduction of other re storative Tha ncw mate als have many feafures that are more desirable than those of amalgam. 'raterials. KeJ Point: Thc usc ofamalgam is declining rapidly in pediatric dentistl-1". Thc rnator force behind the decrcasing use ofamalgam in pediatric dcntistry is the devclopment ofale materials rvith supcrio. features. Some ofthe newer materials have the following excellent feafdr('s: lhev are casy to nse, they release fluoridc, they are tooth oolored, they adhcrc to enamel and dentin, and their durability is satisfactory

limati\

Gla5s ionomers arc among the most notablc ofthe newer materials being uscd as altematives to amalgam. Ionomen aftach to both dentin and enamel as well as telease fluoridc- They are composed offluLrroalumino silicate powdcr and polyacrylic acid. They are used for small Class I and very conservative Class II preparations fthq,are nol rery stro g).

The hfbrid ionomer materials truly revolutionized pcdiatic rcstorative dentistry \lhen they were introduced in the 1980's. Thcy have the advantages ofboth glass ionomers and resins. . Ttey can be light c|ied (manv h|brid ionomer produ.ls . They adhere to enamel and dentin . They release fluoride also self-cure) . They are morc durablc than the glass ionomers . They are reasonably user friendly Compomer materials contain resin and ionomcr matcrial. They are more likc composite materials than they are like ionomer matcrials.The most important advantage ofcompomers over hybrid ionomers is the strength ofthe material. Note: The hybrid ionomers rclcasc morc fluoride to the adjacent tooth structure and are better caries inhibitors than the compomers.

. Two . Three

. Four . Five

a2 CopFiglt O 201l-2012

Listed bclow are the usual events in the histogenesis of N tooth. Pkce them in their correct seq[ence + from .wbet hsppens lirst to what happens lart.

. Deposition ofthe first layer ofdentin

. Differentiation of odontoblasts . Deposition ofthe first layer ofenamel . Elongation ofthe inner enamel epithelial cells of the enamel organ

83

Copyndi O 20ll-2012

Tooth development begins with incrcased cell activiry in gowth centers ir the tooth germ. A groMh center f/ole) is an area ofthc tooth germ where the cells are particularly active. These lobes are primary centers of calcification and are primary sections of fomation in the development ofthe crown of a tooth. They arc represented by a cusp on postedor teeth and mamelons and cingula on ante or te€th. They are always sepamted by developmentrl grooves, which are very prcminent in the posterior t€eth and form sp€cific pattems. With anterior teeth, their presence is much less noticeable and these lobes are separated by what are known as developmentel depressions.

Summrry ofnumber of lobes: . Alf anterior teeth: three labial and one lingu^l (cingulum) . Premolrrs: three buccal and one lingual. Exceptioni The mandibular second premolar has three buccal and two lingual lobes.

. First mofars /rraxil/dry and mandibular), frve lobes, represented by five cusps . Second molars frrar-illary arul mandifular) l four lobes, one for each cusp . Third molars: at least four lobes, one for each cusp *** va alions are seen

one lobe for each cusp

Usually mamelons are wom olf afler the tooth comes into functional position. The presence ofmamelons in a teenager or an adult is evidence of malocclusion. Most likely there is an anterior open bite relationship $here ihe incisors do not Iottch (see pholo below).

An eight-year-old with erupting maxillary incisors is shown. Note the prominent mamelons on th€ incisal edges of the tecth as well as the anterior open bite relationship.

Coprriehr 2000 2004 Unrvcsity of WashinElon ALI nehh.eseryed Acce* ro rheAdrs ofPodiatic Dentislry is govemed by a licens. Untuthonzcda.ccsror rel)(xlucion is forbidden {ilhou $epnorwtten pcmlns.n ol thc Uni!.rsdy of

\hshinston.

r_or

infom,ton,

contacr: lic.nsc{dlu washingron cdu

Tooth development is dependent on a series ofsequential cellular interactions between epithelial and mesenchymal components ofthe tooth germ. Once the ectomesenchlme influences the oral epithelium to grow down into the ectomesenchyme and become a tooth germ, the above events occur. , --,..

.

.,lNot{l

'*;i

l. Some texts include the deposition ofroot dentin and cementum as #5 in the histogenesis ola tooth. 2. Korffs fibers is a name given to the ropelike grouping of fibers in the periphery ofthe pulp that seem to have something to do with the formation ofthe dentin matrix.

Rem€mber: Histogenesis means the formation and d€velopment of the tissues of the body. in this case the tooth.

.Initiation . Bud

.

stage

Cap stage

. Bell

stage

. Apposition

. Calcification . Eruption . Attrition

8a Coplrighl O 201I '2012

functions to shNpe the rcot (or rcots) rnd induce dentin in the root area so that it is continuous wi h the coronal dentln?

. Dental papilla . Dental lamina . Dental

sac

. Henwig's sheath

85 Cop''right O 201 I -201 2

l. Initiation

(sixth to seventh weekr): ectoderm lining the stomodeum gives rise to oral

epithelium and to the dental lamina, adjacent to deeper ectomesenchlme, which is influenced by the neural crest cells. Induction is the main process involved. Congenital absence ofteeth (anodontia) and supernumerary teeth result from an interruption in this phase.

2. Bud stage (eighthweek): growth ofthe dental lamina into bud that penetrates growing ectomesenchyme. Proliferation is the main process involved. 3. Cap stage (ninth to tenth weeky': enamel organ forms into a cap, surrounding the mass of the dental papilla from the ectomesenchyme, thus forming the tooth germ. Proliferation, differentiation, and morphogenesis are the main processes involved. Dens in dente, gemination, lusion, and tubercle lormation occur during this phase. 4. Bell stage (eleventh to n'elfth u,eeks): final shaping ol tooth, cells differentiate into specific tissue forming cells (ameloblasts, o(lontoblasts, cementoblasts, andfhroblasts) in the enamel organ. Histodifferentiation and morphodifferentiation are the main processes involved. Macrodontia and microdontta (i.e., peg lateral incisors),as well as dentinogenesis imperfecta and amelogenesis imperlecta occur during this stage. 5. Apposition (varies per tooth): cells that were differentiated into specific tissue-forming cells begin to deposit the specific dental tissu€s (enomel, dentin, cementum, and pulp1. Enanel dysplasia, enamal hypoplasia, concrescence, and the formation ofenamel pearls occur during this stage. 6. Cafcification (varies per tooth)i mineralization. Begins at cusp tips and incisal edges and proceeds cervically. Trauma or excessive systemic fluoride ingestion may cause

hypocalcification. 7. Eruption (varies per tooth) 8. Attrition (varies per tooth)

The slnrclure responsiblc for root dcvclopmcnt is the cervical loop. The cervical loop is the most cenical ponion ofthe enarnel organ, a bilayerrim that consists ofonly IEE 1funer etld el epithe liunt) and OEE (outer enamel epithelium). The cerrical loop begins to grow deeper into the surrounding mesenchyme ofthc dental sac, elongating and moving au,ay lrom the newly completed crown arca to enclose more ofthe dentalpapilla tissue and form Hertwig's epithelial root sheath lHtRt. After crown fomlation, thc root shcath grows down and shapes the root of the tooth and induces formation ofroot dentin. Unilonrr growth of this sheath will result in thc formation of a singlerooted tooth, while medial outgrowths or evaginations of this sheath will producc multi-rootcd tecth. Remember: Cementum, which develops from the dental sac, forms on the root after the disintegration of Hertwig's epithelial root sheath. This disintegration allows the undiflcrentiatcd cclls of thc dcntal sac to cornc in contact with the newly formed surface ofroot dcntin, inducing these cells to bccome cemcntoblasts. The cementoblasts then disperse to cover thc root dcntin area and undergo

cementog€nesis, laying down cementoid. Whcn a tooth clinicaliy erupts in the mouth, one-halfto two-thirds ofthc root has usually developed. For primary leeth, the roots are complcted between I 1/2 and 3 years ofagc, 6 to 18 months afler eruption. The intact root ofthe primary tooth is short livcd. Thc roots remain fully fomred only for aboul three years. Thc roots ofthc pennanent teeth arc completed between l0 and l6 years of agc. 2 to 3 ycars aftcr eruption.

l. Accessory root canals are formed by a break or perforation in thc root shealh bcfore the root dentin is deposited. Noted' .: ':&*'ia:,: 2. Tooth development is initiated by the mcsenchymc's induclive influencc on the overlying ectodcnn. 3. The enamcl of a tooth is derived from the ectoderm of lhe oral cavity. All othcr tissuesofthe looth differentiate from the associatcd mcscnchyrne (mesoderm). 4. Ectodermal cells are responsible lor determining crown root and shape.

PEDIATRIC DENTISTRY

Tth Trauma

A three-year-old patient reports to your oflice with an intrusion injury on teeth #E and #F (see photograph). You inform the child's parents about the current standard ofcare regarding intruded teeth, Which of the following statements best describes the current understanding regarding intruded primary teeth?

. The intruded tccth should be extracted

. The intruded teeth should bc left to reerupt . The therapeutic approach to intrusron injuries in primary tceth is controversial. Some authors in the field advocate extraction and some advocate leaving the tooth to reerupt

.

The intrudcd tccth should bc gcntly moved

into position with gauze and stabilizcd by splinting

Copynghr 2000-200,1 Unryc^ry .1 \\'rsh,ngiJn Allrieihrc\.ned Acc$s ro rhcArlasofPcd,ati. D.nristry is gor.m.d hy a lircnsc unalthonrcd scccss or rcprodu.rion lbrb'ddcn *lrhout thc tnor *rnlen p.mn*,on orrhc Univcr

^ nryof\\rshrngbn Fo nfom,arion.cdnra.t lic.ns.'iru$r{h,ngloncdu Copyrighr ,il 201 l '201 2

PEDIATRIC DENTISTRY

Tth Trauma

Discolored primary teeth thal are symptom-free and show no radiographic changes are best treated by:

. No treatment

.

Extiryation of the pulp tissue follorved by the placement of ZOE paste in the root canal space

. Extraction . Pulpotomy

87 Copyright C 20ll-2012

Informed opinion is divided whethcr it is best to extract intruded teeih or to leave them alonc to reerupt. h is always best to inform parents when the choice oftreatment approach is disputcd by thc expefts. It certainly is appropriate fbr you to indicate a preference over which slralegy !o selcct in cach case, and to provide reasons why. Bur parents need to be part ofthe process whcn the choice oftherapy is morc scientifically unsettlcd. Parentbetically, researchers and authon do nor advocate repositioning and splinting intruded primary tecth\ote: For ),,hlional Board purposes, the conect treatment is to administer no treatment and lct the tooth reeiupt.

Immediate attention should be given to sofl{issue damage. Howevet as in the case ofall luxation injurics an x-ray

oflhe

area should be taken. Re-eruption usually occurs in 2 - 4 months.

Ifthe inhuded incisor

is con-

tacting the permanent footh bud, the primary iooth should be extracted. Noto: Damagc to the succedaneous permanent tooth, including hlpoplastic defects, dilaceration ofthe root, or arrest oftooth development, has been reported.

For luxation injuries: It is important to take a radiograph to rule out any fractures and for comparison purposes during later examinations. And it is important \,vith all luxation injuries to evaluate them to make sure that the luxaled tooth is not intcrfcring \lith thc paticnt's occlusion. This is most apt to occur $ iih Iingually luxated maxillary teeth. Consequently, taking a radiograph and checking the palienfs occlusion arc both necessary. Primary endodont;cs (pu[pectom)l o( exrqction would only be necessary if the tooth became necrotic later \ote: The primftry objective oftreatmeDt in these injuries is to maintrin periodonlal ligrm€nt vitality. During thc first six months after the injury you may obsenr'e that there is pulpal necrosis which usually manrtisrs as a gra,v or gray-black color change in the crowr of the involved primary tooth at any time alter the inIu4 The roodl can rhen be endodontically treated, ifn€c€ssary, as long as lhe tooth is sound in the socket and ro pathologic root resorption is evident. Note: lfthe tooth is asymptomatic, leave it alone.

Important: Repositioning displaced primary teeth that

are mobile is not recommended. ExFaction is recom-

mended due to the potential ofaspiration in young children.

L Concussion is defined as an injury to the rooth w ith ou1 displ acem cn! or mobjlity. Te€tb are tender to pcrcussion. Prognosis for concussed primary and permanent teeth is good. l. Subluxrtion is dcfincd as an injury to the tooth without displacemeni but €xhibits mobilily. Pulpal necrosis is far morc common in permanent teeth than in primary teeth.Teeth should be monitored closely with x-rays for at least I year, il pathologic changes are scen root canal is treatment.

\ot€sr

. I -rtt';'-'

**" Thel Primary

should be examined periodically by taking a radiograph. will olten d^rken (hecome grat) after injury. This is due to pulp bleeding and the ditfusion into the dentinal tubules.

!ee1h

bili!.rdin

of

Facts about darkened teelhi . S0n" ofprimary incisors that are darkened due to injury are asympfomatic. . Occasionally thcse teelh $ill lighten.

.l5"ooftheseteethwillnecdloberemovedinoneyea/stime.Thisisduetorepeatedtrauma. . \5n , oflhese teeth will remain until normal exfoliation.

\i

i r.sLrh ofrrauma to the primarJ" dertition, you should not expect to have problems with thc succcssors u:less rhe cro*n is not calcified. In this casc. you will scc hypocalcification in lhe tooth. This is Inost common $ rrh rhe mandibular incisors. Enamel ht pocalcification refers to quality deficiencies of enamel. These delects can be directly related to faults in the mineralization ofthe organic matrix in enarnel fomration. The same factors that cause enamel hlT'oplasia also cause hypocalcification. Thc majority of localized defccts occur subsequcnt to localized inle.:ion and rauma. Excess exposure to citric acid resulting from habitual sucking on cilrus li1rils can produce ce.erdlized erosi\e hypocalcified lesions thal mimic the hlpocalcification type ofanlelogcnesis impqrfccla. Pirsiiblc reactions ofa tooth to trauma: . Pulpal hlperemia: it is the pulp's initial response to trauma. Due to capillary congcstion. May lead to necrosis.

. Pufpsl bleeding /irternal hemoffhage):

as a resull ofhyperemia, the capillarics in thc pulp occasionally hcmo.rhage. lcaving blood pigmenrs deposited in th€ dentinal hrbules. Teeth will often discolor (rlarken). ho\\ever. a color change does not mean that the tooth is nonvital. pafiicularly when the discolomtion occurs $ ithin 1 to 2 days after the injury Color changes that occur wecks or months after lhe injury are more prone indicarilc ofa nccrotic pulp. . Pulp canal obfiteration (calciJic metarflorplrosrr: thc pulp chambers are gradually obliterated by progressive deposition ofdentin. 90% ofprimary teeth resorb nomally. Frequcntly appear yellowish in color . Pulpal necrosis: may occut immedialely or after several months. . Inflammrtory resorption: can occur either on thc extemal root surfacc or intemally in the pulp chamber or canal. It can progress very rapidly, destroying a rooth within months. . Replacem€nt resorption (dzblosit: results after ineversible injury to the PDL. Akylosed primary teeth should be extracted ilthey cause a delay in or ectopic eruption ofa developing permarcnt tooth-

PEDIATRIC DENTISTRY

Tth Trauma

An eight-year-old patient pres€nts to your o{fice with a small pulp exposure on the permanent maxillary left central incisor, resulting from a fracture ofthe tooth. The injury is about one hour old. Your clinical and radiographic examinations show there are no other injuries. What is the indicated course of therapy at the time of the emergency?

. Place a direct pulp cap and proceed with a glass ionomer band-aid restoration . Begin partial pulpoton.ry therapy immediately

. Begin endodontic therapy immediately . Schedule the patient for endodontic therapy

as soon as possible, once the

initial anx-

iety from the traumatic episode has abated 88

Coptright.e20ll20l2

PEDIATRIC DENTISTRY

Tth Trauma

A nine-year-old patielt has fractured th€ root of the permanent maxillary right lateral incisor. There is no other identifiable injury. The fracture occurred around the middle of the root What is the indicated course of therapy at this time?

. Begin endodontic therapy immediately

. Extract the tooth, and

the root remnant ifpossible

. Do nothing ifthe tooth seems fairly stable

. Splint

the tooth to the adjacent two or three teeth

89 Copyrignr

!l20ll-2012

Fmctures ofpermanenlt teeth resulting in small pulp exposures, and where the cxposurc is ofrccenl durallon (usuoll)' less lhan t\,to hours), are lreatcd with direct pulp caps and a glass ionomer band-aid build-up at the time oflhc emergcncy appointmcnt. It is not necessary, however, to build-up the hybrid ionomer or glass ionomer band-aid to thc original morphology ofthe tooth, which might result in unnecessary manipulation ofthc tooth. Partial pulpotomy thcrapy is indicated in cases r\here the exposure is ol-longerduralion (e.9.. longer than t\o hours). It generally is not used incases where the injury is ofrecent duration. Endodontic therapy usually is not appropriate at the emergency visit for small pulp exposures ofrecent duIation. And, hopefully, the direct pulp cap will result in rnaintaininS the vilality ofthe tooth, making cn dodontic therapy unnccessary over the longcr term.

. - .. .. L Permanent tecth with largc, open apices. which have been fraclurcd wilh rcsulting large pulp :Notoi'r exposures. and where the fraclure injury is ofrecent duration. are trealed by coronrl calcium hy-

-.{n'

droxrdc pLrlpotomies. Thc hopc is that pulpal vitality lvill be maintained in the root canal pulp lrssuc and the aprces e\ entually will closc normally. Formocrcsol and ferric sullale pulpotomies generally are not recommended as pulpotomy agents in permanenl teclh. Conventional endodontic therapy is appropriate llor fraclured permanent teelh wilh large pulp exposures when the apices are already closed. l. Traumatic injurics: a loolh with an open apex is more likely to ha\e a good prognosis. This concept is one ofthe mosl importart in the assessmenl ofpolential outcomes in traumatic inj uries to lceth. An open apex allows a better blood supply to the pulp ofthe toolh nnd helps 1be pulp injury. of lhe tooth ro .un i\ e 3. Traumatic injurics: most iliuries to the primary teeth occur al I 112-2 l/2 ycars ofage. lhe toddler strge. The teeth mosl frequcntly injured in thc primary dcntition are the maxillary cenlral incisors. Children with protruding incisors, as in children with Class Il. Division I malocclusion arc more connnoniy atlected. ,+. Avulsed primary tceth ar€ not replantcd. The prognosis lor replanted primary leeth is poor and. worse, ankylosis also can rcsult. Rcplanting an avulscd primary toolh involves forcing a child 1() go through a lotally unnecessary and inappropriale proccdure5. Underdeveloped motor coordination is thc most common cause of denlal lraunla irl very young children. 6. Remember: Recently traumatized leeth may givc false negativ€ rcsponses to pulp vitality tests. This impaired nene conduction may be temporary or permancnt, only time willtell.

a

Splinting is fhe appropriatc immcdiatc choicc ofthcrapy lbr most root fracture injuries ofpermanent recth. Endodontic therapy may be needed later if{hc tooth becomes necrotic. Doing nothing mat be tempting ifthe tooth sccms quitc stablc. Howcvcr, splinting thc tooth u,illprovide additional stabilitt \\ hile eating; and it rvill reduce the chance for additional injury to an already compromised tooth. lmportant: Fracturcs in the middle third ofthe root have the poorest prognosis. Howevet splintrng still is thc trcatmenl ofchoice

\otes

1. Fixed splinting, as opposed to flexible splinting, is the preferred approach lbr root fractures. Note: 0.032 to 0.036 SS wire and bonded compositc is comn'tonly used. 2. Currently thc standard monitoring pcdod for fixed splinting for root fracturcs is three

months. 3. Approximalely 75 percent ofpermanent teeth with root fractures maintain their vila lrty. .1. Trcatmcnt ofroot fractures ofthe apical third ofthe root has by lir the best prognosis, You have a better chance of stabilizing and maintaining thc vitality of the tooth ifyou are conlionted with a frachrre in this area. The reason is that more surface area of lhe root is in an approximatc position with thc alvcolus with this type ofinjury

5.Thcse teeth should be monitored aggressively, with follow-up clinical and radiographic evaluations every three to six months lbr the firsl year. Any sign ofnecrosis or resorption waEants initiation ofroot canal therapy immediatell 6. Root fractures involving primary teeth arc relatively uncommon because the morc pliable alveolar bone allows displacemcnt ofthe tooth. 7. Splinting is not rccommcnded in the primary dentition. 8. Fractured maxillary anterior leeth occur most often in children with Class II, Division I nralocclusion i/max i I I a D' a nte ri o rs a rc I ared). 9. For an avulsed permanent tooth, the composile rcsin rctaincd arch wirc splint has been advocated as the best system to use. To allo$, for flexibilitl, a light orthodontic wire or a 30 - to 60-pound test monofilamcnt fishing linc can be used. lt should be left in place for l-2 weeks nraximum to prevent akylosis.

PEDIATRIC DENTISTRY

Tth Trauma

What is the most reliabl€ method to determine the pulp vitalify in the case ofa recently traumatized primary tooth?

. Radiograph . Electric pulp test

. Thorough intraoral exam . There is no reliable method

90 Copynghl a.l:01I

l0l2

Space Mgmt

PEDIATRIC DENTISTRY

The patient below is a five-y€ar-old child with acute pain associated with tooth #K. If tooth #K were extraeted, what type of space maintainer would be needed?

. Band

and loop space maintainer

. Distal shoe space maintainer (fixed) . Distal sboe space maintainer (removable)

. Crou n rnd loop

space maintainer Copyrighr 200G2004 Univenit! ofWadlingron. All righrs reseNed Access to thc Arlas ofPediaric Dcntisr) is go\enred by a liccnse. UDaudronzed access or reproduclion 6 tbrbiddcn wrthoul rhe prior wrilren pemNsion oi rhe UnNersny of\}hsbinSton. For infomarion. conract: I'cense(au {asfi ington edu

91

Copyright C

20ll-:0ll

Often, traumatized teeth will not respond to vitality testing. Pulp vitality testing is not routinely performed in the primary dentition. This is because primary teeth do not respond to such tests reliably and because the test requires a relaxed and cooperative patient objectively reporting a reaction.

Congestion ofblood within the pulp chamber a short time after injury can often be detected in the exam. Shining a bright light on the facial surface and holding the mirror to view the lingual will usually show a reddish hue which is indicative of pulpal hyp€r€mia. Ifthis color change is evident after several weeks, it is often indicative ofa poor prognosis. Electric pulp tests are seldom reliable to determine pulp vitality iftaken immediately aft€r the injury The thermal test is the most reliabl€ t€st, especially in primary incisors. Failure ofa tooth to respond to heat is indicative ofpulpal necrosis,

ofavulsed and replanted permanent teeth with open apices, the blood supply is usually regained within the first 20 days after replantation but nerve sup-

Note: In young children, in

cases

ply lags behind. Remember from Endodontics section: The chiefcause of failure of replantation of permanent teeth is external root resorption.

A fixed distal shoe space maintainer is used. In this way, the space maintainer can be constructed so that the first permanent molar can erupt against the distal shoe and space will be maintained for the developing bicuspid. Removable appliances are not chosen since they are easily lost and damaged.

Copyrighl 2000-2004 Unilcnny of washinSlon. All nghrs 6.tucd Ac.ess ro ft. Atlas of Pediadc Ddtisrry's gormedby r lice.* U.au$onzcd &cess or rt'odution is rbrbiddd vithour the prior pcmission ofrhe UnileF sn, oawlshi.eton For inlbma lio.conractliccnsc(@u wasningron

*itn

This appliance is called a distal shoe space maintainer ora distal extension space maintainer. It is used to prevent unerupted first pemanentmola$ from moving mesially with the premature loss ofsecond primary molars. Tle example shown is a crown with a distal extension segment soldered to the crown. The distal segm€nt is extended into the tissue against the unerupted first pemanent molar. The distal extension. also called a distal shoe, is used when the second primary molarc are lost prior to the eruption of the first permanent molars (i.e., very premature loss).

Ectopic eruption reflects the eruption ofa tooth in an abnormal position. The most frequently found ectopic teeth are the ma,xillary first perman€nt mola6 and canines, follow€d by the mandibular canine, mandibular second premolar, and the maxillary lateral incisors. Ectopic eruption and impaction should be differentiated. In the latte. case, the tooth cannot eruptbecause something impedes it and not because

of its ectopic position.

Notei In the absence ofrecession, the reatment ofa heavy maxillary fienum with a diastema is delayed until the permanent canines have erupted. Ifthe midline diastema has not closed after the canines have erupted, orthodontic closure is accomplished fimt and a frenectomy is performed afterwards.

Space Mgmt

What cement is the best choice for cem€nting a lower fixed bilateral holding arch in place?

. Zinc phosphate cement . Zinc oxide eugenol cement

.IRM . Glass ionomer cement

92 Copyrighl er 20ll -2012

Space Mgmt

PEDIATRJC DENTISTRY

A mother ofa six-year-old female reports that her daughter has complained of a severe spontaneous pain on the upper right side ofher mouth. Your indicates a large lesion on the distal aspect of the primary maxillary right first molar which extends to the pulp. All other maxillary teeth are present and are noncarious. You decide that extraction of the tooth is warranted. What type of space maintainer will you advise for the patient?

. Maxillary right removable unilateral appliance . Maxillary removable bilateral appliance . Maxillary right band and loop appliance . Distal shoe space maintainer

Copynghr

ao

201l-2012

Glass ionom€r cement is the best choice, and it is especially helpfirl to choose among the newest generation glass ionomer cements. The glass ionomer cements are very user friendly since they mix easily and clean-up easily in the mouth. Once in the mouth, they also set-up rapidly. They have low solubility and therefore do not dissolve and leave voids between the tooth and the band. The ionomercements also adhere well, especially since they form attachments to both the tooth and the band. Zinc phosphate cement is still used by many practitioners, and it provides acceptable cementation. However, it is not the best choice, pafiicularly since it is more soluble than glass ionomer cement. ZOE and IRM are not lutins cements and should not be used for band cementation

Coplrigh 2000-2004 Univ*siiy of Washing' lon.All.ights GseNed.A.cess lo lh.Atlas of Pedi.tnc De.lisry is sovmed by a license. Unauthorized acce$ or ieproduction is forbidden wiihour the prior wins pcmission of rhe Unilesily ofWashington. For infomstion. conrdd: licns€r0u.washingion.€du

photograph shows an example of a fixed bilateral space maintainer The patient is four years of Tte appliance is cemented on the two-second primary molan. Fixed bilateral space maintainen on the mandibular arch often are called lingual arch spac€ maintainers. Mandibular fixed bilateral space

Tlis age.

appliances generally are prefened by clinicians overremovable space maintainers. Fixed appliances are easier to maintain and they are less likely to be removed, damaged, or lost by the child.

The mandibular lingual arch space maintainer is used very commonly in the primary dentition and the mixed dentition, where bands can be cemented to primary or permanent mola6 respectively. This is one ofthe most ubiquitously used space maintainers. It prevents posterior teeth from tipping mesially and can also be used to prevent lingual movement ofincisors following the premature loss ofa primary canine. It is even used on occasion in the permanent dentition whe.n bicuspids are missing and maintaining space is necessarv Drior to orthodontic and/or Drosthetic theraDy.

A space maintainer is indicated to prevent mesial movement ofthe second primary molar. A band and loop space maintainer is the best choice. It is especially important to start space maintenance therapy prior to rhe eruption phase ofthe first permanent molar, since the force oferuption ofthe permanent molar will exefi a lot of prcsswe to push the second primary molar forward. The eruption phase ofthe pemanent molar is the time ofgreatest force exerted against the primary molar

Coplrighi 2000-2004 Univ*siiy of \'6hing1or All ngh$ reseaed Access ro tie Atld ot Pediaric Dntisiry is govemed by a licensc. Unauihorted acce$ or reproduction is forbidde. vnnout th. prior Mitton

pmission of rhe Uiiveuity of Washinglon. For infomalion, con-

l&l:

license(au.washingion.edu

This photograph shows two band and loop space maintainers, an example ofthe bilateral use offixed uniJateral band and loop space maintainers. These arc very common q?es ofunilateml space maintainers, and rhev ofien are used bilaterallv.

l. Loss ofa primary incisor in the primary dentition does not genemlly cause loss ofoverall arch l€ngth, however, it may result in localized space loss, especially ifthere was no interdental primary spacing prior to the loss. 2. Space loss can occur very quickly after the loss of a permanent incisor, an appliance should be constructed ASAP after the tooth loss. 3. Lingual eruption of permanent incisors is a very common problem in the early mixed dentition. These incisors almost always move labially until they contact another tooth. 4. The fateral ectopic eruption of pemanent central incisors (maxillary or mandibular) often causes early exfoliation of p mary lateral incisors (maxillary or mandibulor). Thls often results in a midline deviation.

The photograph shows a maxillary fixed bilateral space maintainer. This type of space maintainer also is known as a:

. Frankel appliance . Nance appliance . Herbst appliance . Ricketts appliance

Copyashl 2000 2004 Univ$sily ol lashington. A1l rights reseNed. Access to lhe Atlas ofPediatric Dentisrry is govemed by a license. Uiaufiorized acces or reproduction ; forbidden n rrhoDr tlie prior wilren pemision ofrhe Uni ve6ity of \rrashinglon. For infom.tion. .onrdcr: licensca4,u.washington.edu

94 Copynghl O 20ll-2012

Note the small acrylic button that will rest against the palatal tissue with this appliance. Some clinicians object to the button since it can create tissue iritation. Therefore, it is important that patients and parents be instructed to make sule thatthe patient meticulously flosses underthe acrylic button. The Nance appliarce (Nance

Holding Arch) is wed in situations where premature bilateral loss of maxillary primary teeth has occurred. Space management is an important responsibility ofthe general dentist and the pediatric dentist. Inadequate space management can cause problems that are long lasting and severe. The prcmature loss ofprimary teeth may cause loss ofarch lcngth, resulting in crowding of the permanent dentition, impaction ofpernanent teeth, esthetic difficulties, malocclusion, and other problems. Note: The best spac€ maintainer is a primary tooth, When nature's best space maintainer is lost prematurely, space management is needed to maintain the space for normal development ofthe dental arches.

Remember: 1. A ricketts retainer is a rctainer often uscd ifthc top of the mouth is supposedly taller than average. 2. A herbst appliance is a splint with tubcs and hinges to hold the mandible forward so il will grow and push the maxilla back so it won't grow. It's for kids that won't wear their headgears or lo help headgears work

better 3- Frankel appliances are used to correctjaw imbalances and crowding problems.

.

.

.. ,

,'NotcJl

'i-..,-l'l ,,w

l. The loss ofa primary canine can cause the lingual collapse ofthe permanent incisors, loss of arch length, increased overbite, increased ov€det and midline deviation to the side ofthe canine loss. Note: Bilateral loss ofthe primary canines causcs the same things. 2- Factofi to consider in planning space maintenance: . Amount of resorption ofprimary roots: ifmore than one-founh ofthe rcot rcmains, space maintenance is likely necessary; ifless than one-fourth ofthe root remains and ifno bone is l€ft between lhe primary tooth and permanent tooth, space maintenance is likely unnecessary . Amount of bone covering the permanent toothi Ifthcro is no bone, no space maintenance is oecessary; if there is bonc, space maintenance is usually indicated. Note: If therc is any doubt, us€ a space maintainer to prevent space loss. .Amount of root d€velopment: the average tooth erupts through ihe gingival tissue with onehalfto two-thirds root formation . Time elapsed since tooth loss: Most space loss occurs within lhe first 6 months