M|jor Topic Abbreviation Major Topic AbbreviationAbnormrl teeth Abn Tth Primarv Dentin Prim DntBehavior Management Behav Mgmt Pulp Treatment Pulp TxDiseases & Conditions Dis & Cond Restorative RestorativeDrugs Drugs Space Management Space MgmtFluoride Fluoride Tooth Development Tth DvGeneral Information Gen Info Tooth Trauma Tth TraumaMiscellaneous Misc.

PEDIATRIC DENTISTRY Abn Tth

The photograph shows an example ofin 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 in8000. This inherited dentin defect originales during the histodilferentiation stage oftoolh dcvclopment. Thcpredentin matrix is defective resulting in amorphic, diso.ganized, and atubular circumpulPal dentin. Teeih areblu-gray or bro$n and abrtde rapidly. Occasionally, these teeth become abscessed as a result ofexposureofpulp homs caused by wear. Full covcragc is the t.eatmnt of choice. Both the primary and permanentdenlitions are afTected in dentinogenesis imperfecta. lmportant: Radiogmphs ofa preschool child with dentino-genesis impefecta will show obliteration olth pulp chrmbers with secondary dentin, a chamcteristic find-ing. Roots of teth usually are narrower tnd appar more fragile. Crowts gcnerally appear more bulbousthan usual due to the smaller roots. Denlinogenesis imperfecta can be subdivided into three basic tlTres:

. shields Type I: occurs with osteogenesis imprfcta. There is brittle boncs, bowing ofthc limbs. and bluesclera. Periapical radiolucencies, bulbous cro\rns, oblitcrated pulp chambers and root fraclures are commonTeeth 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 apartfiom osteogenesis imperticta. Same characteristics as T)?e l. Both primary and permanent teeth affectedequally.. 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 byfaulty deve)opment ofthc enamel. There is normal pulpaland root morphology. Thcrc are four major catcgoricsaccording to the stages oftooth development in wbich each is thought to occur

. Hypopkstic Type: occur in the histodifferentiation stage oftooth development. There is an insullicientquantity ofenamel formed duc to areas ofthe enamel organ that are devoid ofinner enamel ePithlium, caus-ing a lack ofcell differentiation into ameloblasts. Affects both primary and permanen! dentitions The af-fected 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 normalenamcl thickness but a low value ofradiodensiry and mincral content-. Hypoplastic or Hypomaturation Type with Taurodontism: is an examplc of inherited defecls in bothapposition 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 softand liagile and is easily fractured., exposing the underlying dcntin, which produccs an unesthetic appear-ance,

Abn Tth.PEDIATRIC DENTISTRY

What condition is depicted in the radiograph below?

. Concrescence

. Gemination

. Fusion

. Dens-in-dente

2Copyrighr e 20ll-2012

PEDIATRIC DENTISTRY Abn Tth

What condition is depictd below?

. Enamel hypoplasia

. Erythroblastosis fetalis

. Nursing bottle caries

. Dentinal dysplasia

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

3Coplighr a{i 20ll-2012

The tcrm Dens-in-dente (also called clens inNaginatus) means a "tooth within a toothri and resultsliom the invagination ofthe inner enamel epithelium. Most frequently involves the maxillary lateral in-cisors. The clinical significance ofthis anomaly results folm potential carious involvement through com-municatjon 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 cx-posure of thc pulp.

Dens evaginatus is an extra cusp. usually in the central groove or ridge of a posterior tooth and in thccingulum area of central and lateral incisors. In incisors, these cusps appear talon-shaped. It resultsfrom the evagination of inner enamel epithelial cells. This extra portion contains not only enamel butalso 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 twocompletely or partially separated crowns. This process results in incomplete formation ofnvo teeth. Likcfusion, it is also more common in the primary dentition. It results in a bifid crown with a single pulpchamber. It most frequently occurs in the incisor region. Concrescence is a twinning anomaly invoJv-ing the union of two teeth by ccmcnfllm only. Its etiology is thought to be hauma or adjacent tooth mal-position.Fusion ofteeth is a condition produced when t$,o tooth buds arejoined together during development andappear as a macrodont (a single large crown). It is morc common in the primary dentition. It may involve$e entire length of two leeth (enamel, dentin, and cemenlum) ot jvst the rcot (dentin and cenenlum).Thiscondition is usually seen in the incisor area. Although fused teeth can contain two separate pulp cham-bers. many appear as large bifid crowns with one chamber Note: A radiograph is needed to confirmrvhether thcre is fusion or gemination.

. I . Taurodont teeth are chamcterized by a significantly elongated pulp chamber with short

Not{dt stuntedroots resulting from the failure ofthe proper Ievelofhorizontal invagjnation ofHer-t\r ie's cpithclial root sheath.

.a - 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 findingin 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 smallandlor mis-shaped. This type ofdcfcct may cause tooth sensitivity may bc unsightly or may be more sus-ceptible to dental cavities. Some genetic disorders cause all the teeth to have enamel h)'poplasia. EH canoccur on any tooth or on multiple teeth. It can appear whitc, yellow or brownish in color with a roughor 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 forLH.

. Environmental factors:. Severe infections such as exanthemous diseases and fever-producing disorders particularly dur-ing the first year of life. Syphilis (caused 6t Treponeua pallidum) produces classic pattems ofhy-poplasia including Hutchinson's incisors and mulberry molars. Rubella embryopathy has a highcorelation 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 hy-poplasia is a classic example ofhypoplastic defects in pemanent teeth resulting from local infcc-Iion 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 associated1\'ith it. The most conservative treatment consists ofbonding a tooth colored matcrial to the tooth to pro-tect it t'rom further wear or sensitiviry [n some cases, the nature ofthe enamel prevents formation of anacceptable bond. Less conservative treatment options, but frequently necessary include use ofstainlesssteel crowns, pe(nanent cast crowns or extraction of affected tccth and replacement $ ith a bridge or im-planr.

. One part per million

. Two parts per million

. Three parts per million

. Four parts per million

. Tell-show-do (ZSD)

. Positive reinforcement

. Disfiaction

. Non-verbal communication

1Copynght O 2011-2012

5Cop"ighi O 201 I -201 2

The role offluoride in caries prevention is a very important one. Indeed. one oflhe most significant contribu-tions ofworld free enierprise systems to the health of people is to market fluoridated tooth paste. Huge re-ductions in caries prevalcnce have been made in the populations of numerous countries where fluoridatedtoothpastcs 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 per-ceni ofihe toothpastes sold in thc United States contain fluoride. This amounts to a massive public health un-dertaking by rhe private sector Tle significant impact on decay rates demonstrates thc importancc offluoridcin 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 waleris higher than three parts per million. Fluorosis is associated *,ith fluoride supplementation at inappropriately high levels. Tle use offluoridated tooihpaste has been implicated in fluorosis

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

. Shields Type I: normalprimary and permanent crown morphology with an ambr ffanslLrccncy. The rootstend to be short and sharply constricted. Primary and permanent dentitions demonslmte multiple radi-olucencies and absenl pulp chrmbers.. Shields Type II: primary teclh are ambr-colored closely resembling dentinogcnesis Tlpe I and II. Per-manent teeth are normal in appearance but radiographically demonslrate thislle-tub-shaped pulp cham-bers with multiple pulp stones. No periapical radiolucencis are sen.

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

- This approach is the backbone ofthe educational phase ofdcveloping an accepting, rclaxcd childdcnlal paricnt.- The effectiveness of the TSD approach depends on using language the child can understand. Thismcans tha! r\c must use words or anecdotes that are age appropriate so the child can concepfualize theidea \r'e are trying to convey.-\Ian"- children are helped by watching procedures done on thcmsclves in the mirror during thc pro-cedure. 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 watchthe procedure in the hand-held mirror seems to diffuse anxiety.- This approach $orks espcially well when trcating a child with a different cultural background.

Important: The clinical cxamination ofthe infant and toddler should be accomplishcd with thc par-ents'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-kneeposition. 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 re-condition the hild through techniqucs ofapplied psychology

Aversive conditioning: is a form ofbehavior training or modification jn whioh a noxious evcnt is uscdto 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) ^s

an

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

. Tell-show-do

. Voice conhol

. Positive reinforcement

. Distraction

. Nonverbal communication

6Cop]'right O20ll-2012

7CopFght 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 tothe 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 handsovcr thcir mouth and face.. Tense-cooperative: coopentive but are very nervous. "White-knuckler" patients because theygrip the dental chair arm rests so tightly.. Whining: they whinc throughout the \r'hole appointment.

Bhavior shaping means providing the child with cues and reinforcements that dircct them toward de-sirable bchavior. Positive reinforcement al every stage ofthe treatment proccss is rccommended, to in-dicate to the child that he is making successful steps in the process ofreceiving treatment. The frequentuse 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 thcdesirablc bchavior.

obie.live!

TcllShos-Do Explanat(rns tarlored tocognitne lc\cl. folloscd bydemonnral'on. iollowcd by

. Allry fea$, slappaxcrrs resporsc

. Giv expecrations ofcomm!n'catc re8ard'es

Modulalion on vo'cc !olume,ronc or pace lo influcnce anddirecr pancnt s bch6vio.

avoidaco bchaviors. Sstablish au$ority

Proccss of shapingpalicnf sbchatior lhreugh appropriatcly

Di\cnin8 palrcnl s attcnnon liompcrc.i!cd !nplcasant p.occdurc

Dccrcalc likclihood ofmp|easarr prcprcn or

Convcying reinforcem.nl andBUidinS bchavjor throush contact,posrurc. and facial cxprcsions

Enlare effectivdes

lrv ma!.u8emert |e n-

. 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 thechild

. The physical status ofthe child

. The length of time and amount of manipulation necessary to accomplish the surgery

. All ofthe above

9Coplright O 201l-2012

*** This is false; you should keep appointments short.

In addition the following procedures are also helplul when treating mentally retardedchildren:

. Cive a tour to the patient before attempting to do any treatment. Introduce thepatient to the office personnel.. Give only one instruction at a time, Reward the patient rvith compliments after thesuccessful completion of the procedure.. Schedule the patient early in the day. The staff, the dentist, and the patient are lessfatigued 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 andh1-peractive when undergoing dental care.

Important: The dentist should assess the degree of mental retardation by consulting thepatient's physician belore starting dental treatment.

The age and maturity ofthe child often determine the t)?e ofanesthesia best suited for the intended pro-cedure. Childrcn bcloll the age ofrcason gcnerally are best managed undcr general anesthesia, since asLght amount ofdiscomfort is always associated with the administration of a local anesthetic. It is veryimponant to have total anesthesia before starting the procedurc. Usc both buccal and palatal infiltrationon maxillary teeth and block anesthesia on mandibular teeth with infiltration, ifnecessaryThe ven young patient is best managed under general anesthesia, usually ofthe inhalation type o. incombination with small doses of intravenous barbiturates. The most common premedication prior togeneral anesthesia is Versed.\ot: Premedication wi!h a barbiturate may cause pandoxical excitement in a young child.Remember: After extracting a tooth on a child patient, the biggest post-operative concern is the pre-\ enrion oflip biting.Frankl behavioral rating scale:

. Class l: child is completely uncooperative, crying, very difficult to make any progtess

. Class 2: child is uncooperative. very reluctant to listen/respond to questions, some progress is pos-siblc. Class 3: child is cooperative. but somewhat reluctant/ shy. Class 4: 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) 8years old and older: usually cooperative.. Nlothr's anxiety: there is a direct conelation bctween the mother's anxicty and a child's negativebchavior in the dental setting.. Past medical history: if a patient has had positive medical experiences in the past thcy are moreapt to have positive dental experiences as far as behavior is concemed.

Import|nt: The grcat majority of children require minimal management efforts other than providinginformation on what is going to happcn (e.g, lell-show-do).

. The presence of fxed orthodontic appliances

. A patient with congested nasal pa.ssags 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

. Herpangrna

. Scarlet fever

. Diphtheria

. Mumps

11

Cc''rittu O 20tt:2o12

One ofthe main advadtages ofusing a rubbe. dam is that it can aid in the managemcnt ofthe chiid. Itseems to quict and calm thc paticnt bccause the dam acts as a separation or barier, both physically andpsychologically.Other advantages include:

l. Better access and visualization2. Control ofsaliva and moisture in the operating field3. Decreased operating time4. Provides protection from aspiration or swallowing offoreign bodies5. The child bccomes primarily a nasal breather when the rubber dam is in place. This then enhancesthe effects ofnitrous oxide ifapplicable.

Nitrous oride sedation for children: for the production of conscious sedation, the inhalational route islimited 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 atherapeutic level in the blood rapidly, and conversely, blood lcvcls decrease rapidly when it is dis-continued.. Ease of dose control (Titration). Lack ofserious adverse effects: nitrous oxide is considered to be ined and nontoxic when admin-istered \r'ith adequate oxygen. The most common side effect is nausea/vomiting.

l- Minimum alveolar concenhation 6rhich i.\ the concentratio required to ptoduce imno-Xok{, bilin* in 50%' ofpatients) of nitro.rs oxide is 105%.

',: .-.,'l 2.The total flow rate is 4 to 6 L,'min for most childrcn.'iii*, 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 lessthan 3-5 is recommended. This allows difnlsion ofnitrogen tiom thc venous blood into thealvcolus that is then exhaled as nitrous oxide through the respiratory tract- Note: This processwill prevent diffusion hypoxia.

Scarlet fever is an exotoxin-mediated disease arising from group A beta-hemol)4ic streptococcal infection. Thepeak incidencc olscarlet fever occurs in childrcn 4 to 8 years old. It is usually accompanicd by symptoms olsrcp throat. such as sudden onset of fever, sore throat, headachc, nausea, vomiting, abdominal pain, musclcpain. and fatigue.An enlargement ofthe fungiform papillae extending above the level ofthe white desquamating filiform papil-lae ei!es an appearance ofan unripe strawberry. During the course ofscarlet fevet lhe coating disappears andrhe enlargcd red papillae extend above a smooth denuded surface, giving the appearance ofa red strawberryor raspberr). Penicillin is the drug of choice, Early diagnosis and ffcatmcnt are important to prevcnt com-plications, \\hich include local abscess fomation. rheumatic iever, anhritis. and glomcrulonephritis.Hrpangina is a viral infection, usually ofyoung childrcn, characterizedby mouth ulcers, but a high fever, sorethroai. and headache may precede the appearance ofthe lcsions- The lesions are generally ulcers with a whiteto whitish-gmy base and a red border - usually on lhc roofofthc mouth and in the throat. The ulcers may bevery 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, characterizedby the production of a systemic toxin. The toxin is panicularly damaging to the tissuc ofthe hart 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 stimulatedbleeding. 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 hrpti gingivostomatitis:

. I f diagnoscd with in 3 days of onsei, acyc Iovir suspcns ion should be prescribed. I 5 mg&g five tim esdaily for ? days.. All patients, including those presenting more than 3 days after disease onset, may receive palliativecare, 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.. Rcurrent 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 ero-sions 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 spirochets, as well as Prevotella intermedia, have been implicated inthe etiology ofANUG

12Coplrighi O 20ll-2012

. Hard and soft palates

. Soft palate only

. Alveolar process only

. Hard palate only

13CopFighl O 20ll-2012

ANUG is an acute fusospirochetal infection ofthc gingiva. It involves a progressive painful infection with ul-ceration, swelling and sloughing otrofdead tissue from the mouth and throat due to the sprcad ofinfection fiomthe gums. It is usually associated with poor oral hygiene and is most common in conditions where there iscrowding and malnutrition. It is rare in preschool children.It can be easily diagnosed because of the involvemnt of the interproximal papillae and the prescnce of apseudomembranous necrotic covering ofthe marginal tissues. The clinical manifestations of the disease includeinflamed, painful, bleeding gingival tissue: poor appetire; fever; general malaise; and a fetid odor. Treatmenrincludes debridement. hydrcgen peroxide mouth rinses, and antibiotic therapy.Not: Atrophic gingivitis is characrerized by gingival recession without a corresponding rate ofalveolar boneloss. Minor marginal and papillary gingival inflammation is found. The predominant clinical finding is the re-cession.P odontal disase in adolescents: the clinical and histologic manifestations ofgingival and periodontal dis-ease in adolescents arc similar to those seen in adults. Bone loss from pe odontitis does occur in a small per-ccntage ofteenagers, but the predominant condition noted in thi! age group is gingivitis.Pedodontal disease in children;

. A primary characteristic ofaggressiv periodontitis that differentiates it from chronic periodontitisis the rapid progression ofattachment and bone loss that is evident. Aggressive periodontitis may belocalized or generalized. The classic form oflocalized aggressive periodontitis was initially refenedto as 'periodontosis" and then as "localized juvenile periodontitis fl-lP/. Localized aggressive peri-odontitis 11,-rP) is the new classification designated to replace LJP.. LAP is defined by several distinguishing characteristics: onset around the time ofpuberty, aggres-sive periodontal destruction localized almost exclusively to the incisors and first mola6, and a fa-milial pattem ofoccurrence. A. is the dominant bacteria in LAP, other microorganisms that havebeen associated with LAP include P gingivalis, E. coftodens, C. rectus, F. nucleatum, Bacillus capil-lus. Eubaclerium brachy, and Capnocytophaga species and spirochetes. Important: The one ouFslanding negative feature is the rclative absence of local factors (plaque) to explain the severeperiodontal desfuction which is present.. Generalized aggressive pcriodontitis 1G.1P) is di{Tcrcntiatcd from thc localized form by the extentofinvolvement 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 ofthe premaxilla.. Class IV: involves the soft palate and continues through the alveolus on bothsides 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 thenose_

. Class III: same as Class II but extending into the floor ofthe nose.

. Class I!': any bilateral clefting ofthe lip whether incomplete notching or completeclefting.

*** 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

14Copyright 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 pflorwritteD pemission ofthe Unile6ity of washington. For infomarion. conlacr: licensea.!u.washin8ton.edu

15Coplright C 20ll-1012

Ectodermal dysplasir is a sex-linked recessive trait. Although both sexes arc affected, more males are af-fected 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 (par-tial akodontia). Alveolar bone development is lacking because of the absence ofpermanent teeth. Note: An-hidrotic ectodermal dysplasia is characterized by the conical shape ofthe antedor teeth free photo belov,).ltis 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 Pe-diatric Dnrisiry is govemed by a license. Unauthorized access or reproduclion is fo.bddenwirhout the prior lritien pmission oflhe Univelsiry ofWashington. For infomation, con-lact: license(4u.washinglon.edu

Cfeidocraniaf dysplasia (or d)'sostosis) is a ftre condition inherited as an autosomal dominant and chamc-terized by partial or complete absence ofthe clavicles, defective ossification ofthe skull, and faulty occlusiondue 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 fea-tures. 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 mesio-dens. Supemumerary teeth are also frequently found distal to the maxillary molars and in the mandibularpre-molar resion,

Gingivostomatitis is a disorder involving sores on the mouth and gingiva that result from aviral infection (HSV-|). k is characterized by inflammation ofthe gingiva and mucosa andmultiple mucosal ulcerations. This is a very painful condition. The patient often does not wantto eat or drink. The major concems are hydralion, secondary infection, and prevention ofcon-iagion. This disease is selfJimiting, and the acute phase generally lasts 7-10 days. Oral fluidsare very important in childrcn so that they do not become dehy&ated.lmportant: Pimary bcute) herpetic gingivostomatitis generally affects chil&en under theage ofthree. There are prodromal symptoms (ever, mqktise, irritobility, headache, dyspha-gid. \'omiting and lymphadenopathy) that occur l-2 days prior to the local lesions (ulcers) rnthe oral cavity.The treatment in children should be directed toward the reliefofthe acute symptoms so thatfluid and nutritional intake can be maintained. Symptomatic treatrnent for pdmary herpes con-sists 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 pri-mary 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 pa-tients with predominately gingival involvement without or with few discrete lesions is acutenecrotizing ulcerativ gingivitis (ANUG). Patietts etith ANUG also present with a suddenonset ofa sore mouth. Howevel ANUG can be differentiated fiom primary herpes by the factthat in ANUG the interdental papillae are necrotic while in primary herpes, the interdentalpapillae are intact. In individuals with primary herpes manifesting multiple oral ulcerations,aphthous stomatitis must be considered in the diagnosis. However, primary herpes can be dis-tinguished from aphthous stomatitis by lesion location and history. Aphthous ulcers occur onlyon mobile or unattached mucosa and there is a history of recurrnce. In contrast, primaryherpetic lesions occur on both mobile and attached mucosa and there is no history ofpreviousepisodes. Most patients with aphthous stomatitis do not have systemic symptoms such as feyer.

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

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16Coplrighr 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

17Coplnght I 201 l -201 2

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

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

If it involves the submandibular, sublingual, and submental space it is called "Ludwig'sangina." In this condition, the tongue and floor ofthe mouth become elevated and thepatient's airway is obstructed and swallowing is impossible. The treatment for cellulitisshould 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 nosoft tissue srvelling.2. Cellulitis: develops as the infection spreads from the bone to the adjacent soft tis-sue. Subsequently, inflammation and edema occur, and the patient develops a poorly lo-calized swelling. On palpation the area is often sensitive, but the sensitivity is notdiscrete.3. Suppuration then occurs and the infection localizes into a discrete, fluctuant ab-SCCSS

Down syndrome is a congenital defect caused by a chromosomal abnormaliry (trisomr-21 ). The prrmary skeletal abnormality affecting the orofacial structures in Down syn-drome is an underdevelopment or hypoplasia ofthe midfacial region. The bridge ofthenose, bones of the midface and maxilla are relatively smaller in size. In many instancesthis causes a prognathic Class III occlusal relationship which contributes to an openbite. The tongue may protrude and appear to be too large. With age, both the tongue andthe Iips in people with Down syndrome tend to develop cracks and fissures. This is a re-sult ofchronic mouth breathing. The eruption ofteeth in persons with Down syndromeis usuall,'" delayed and may occur in an unusual order. There is an extremely high rate ofmissing teeth in both the primary and permanent dentitions. The roots ofthe teeth in pa-tients $ 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, butcapable of leaming dental procedures. These children need a comprehensive preventiveprogram. These patients often have difficulty accepting dental care but cooperation canbe improved by using gradual exposure to the dental office.

. Type I

' Type II

. TYPE III

' TYPe IV

t8Copyflght O 201l-2012

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19Coplright O 201I 2012

Type I, or insulin-dpendnt diabetes mellitus, is the most common form in children. Ap-proximately 2 in 1000 children between the ages of5 and l5 years have the disease. The sus-picion ofdiabetes usually arises by one or more ofthe following:

. Family history

. Symptoms; polydipsia, polyuria, weight loss with polyphagia, enuresis, recurrent infec-tions, 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 di-abetes mellitus, These patients exhibit increased alveolar bone resorption and inflammatorygingival changes, which may mimic the clinical manifestations of localized aggressive peri-odontitis. Xerostomia and recurrent intraoral abscesses may be present.

The goal oftreatment is to control blood glucose to as normal a level as possible, thereby re-ducing the potential complications ofhyperglycemia and ketoacidosis. This generally involvesthe 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 ofhypoglycemia. lf the dental procedure is anticipated to be stressful, consult the patient's physician re-garding adjustment ofthe insulin dosage. Consider utilization ofprophylactic antibiotics for sr.rrgery, endodontics, and periodontaltherapy 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 leadsto a mass that resembles a neoplasm. Hemangiomas differ from other vascular birthmarksin 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 com-mon in girls than boys. They are common on lips, tongue and buccal mucosa. These le-sions appear as flat or raised, usually deep red or bluish red and seldomwell-circumscribed. They are removed surgically, others require no treatment.

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

';,,1r, ..'i:; nal medulla or other sites of sympathetic nervous tissue. The most common site

';!tt:t;t:"' 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 diagno-sis.2. A lymphangioma is a fairly well-circumscribed nodule or mass of lym-phatic vessels. They occur most frequently in the neck and axilla. These le-sions appear as red to blue translucent enlargements that are cornpressible andspongy. They are treated by excisional biopsy.3. A neurofibroma is a moderately fim, encapsulated tumor resulting from theproliferation of Schwann cells. They occur on the tongue, buccal mucosa,vestibule and palate. These lesions appear as solitary or multiple submucosalenlargements. May become malignant (5-15%). Multlple lesions are associ-ated with neurofibromatosis (von Recklinghausen's disease).

. Rampant caries

. Periodontal disease

. Overcrowding of teeth

. Supemumerary teeth

. Prominent mandible

. High arched palate

. Bifrd uwla

. Cleft palate

. Severely crowded maxillary teeth

. Class II malocclusion

. Shovel-shaped incisors

. Supemumerary teth

20Copyright @ 201 1,2012

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Achondroplasia is the most common form of short-limb dwarfisrr. It occurs in all racesand with equal frequency in males and females. An individual with achondroplasia has adisproportionate short stature -- the head is large and the arms and legs are short whencompared to the trunk length. Other signs are a prominent forehead and a depressed bridgeofthe nose. Many ofthese children die during the first year of life. Deficient growth inthe 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 vrv common.Rememben The oral manifestations ofthe following disorders in children:

. Gigantism: enlarged tongue, mandibular prognathism, teeth are usually tipped tothe buccal or lingual side, owing to enlargement of the tongue. Roots may be longerthan normal.. Pituitary dwarf: the eruption rate and the shedding of the teeth are delayed, clini-cal crorvns appear smaller as do the roots of the teeth, the dental arch as a whole issmaller 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/limbanomalies. It is primarily characterized by specific malformations ofthe skull, midface, handsand feet. Note: The retrusion ofthe midface is often conected by performing a Lefort III sur-eical procedure.

Remember:

I . Crouzon syndrome is an uncomrnon, autosomal dominant craniofacial disorder char-acterized by cranios)'nostosis and dysmorphic facial features.Clinical featurs 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 and protruding eyeballs

. Calcified stylohyoid ligaments

. 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 under-developed premaxillary area, cleft palate and a protmding lower lip.3. Treacher Collins Syndrome, also called mandibulofacial dysostosis, is a rare autoso-mal dominant disorder ofcraniofacial development. The oral manifestations are character-ized by cleft palate, shortened soft palate, malocclusion, ante or open bite, and enamelhypopoplasia.

. It is generally fatal

. It is best treated by injecting insulin

. They generally recover ifrestrained from self-injury and oxygen is maintained

. It can be prevented with antibiotics

22Copyrighl O 20ll -2012

. Bifid tongue

. Macroglossia

. Cleft palate and cleft lip

. Anodontia

23Coplright O 201I "2012

Of the multiple types of seizures, the tonic-clonic (grantl mal) type is the most lrighten-ing and the one that most often requires treatment. Grand mal seizures are manifested infour phases: the prodromal phase, the aura, the conr.tlsive (icla1) phase, and the postictalphase.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 neurologicexperience that the patient goes through immediately prior to the seizure. It is specificallyrelated to trigger areas of the brain in which seizure activity begins. lt may consist of ataste, a smell, a hallucination, motor activity, or other symptoms. As the CNS dischargebecomes generalized, the ictal phase begins. The patient loses consciousness, falls to thefloor, 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 CNSdepression is usually present dudng this postictal phase, and it may result in respiratorydepression.

Management of the seizure consists of gentle restraint and positioning of the patient inorder to prevent self-injury ensuring adequate ventilation, and supportive care, as indi-cated, in the postictal phase, especially airway management. Single seizures do not requiredrug therapy because they are self-limiting.Important: Should the ictal phase last longer than 5 minutes or ifseizures continue to de-velop 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 in-travenous 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,259'o are cleft palate alone and 7 5To are cleft lip with or without cleft palate.

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

The secondary palate develops at approximately nine weeks developmental age. Thepaired palatal shelves arise from the intraoral maxillary processes. These shelves, origi-nallv in a venical position, reorient to a horizontal position as the tongue assumes a moreinferior position. The palatal shelves fuse with one another and with the primary palateanteriorly, 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 preventingnonnal speech and swallowing. The child will almost always need orthodontic treat-ment once the palate is surgically repaired. Also, speech therapy will be needed becausethese patients have problems related to the inability of the soft palate to close the airflorv into the nasopharynx. Orthognathic surgery may be needed to correct the generalconcave appearance of the face. This concave appearance is generally due to deficientmaxillarv srowth.

. Acute myeloid leukemia

. Chronic myelocltic leukernia

. Acute lymphocltic leukemia

. Cfuonic lymphocytic leukemia

uCopynghr O 20ll -2012

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. Both statements are false

25Coplrighl O 201l-2012

Acute lymphocytic (lx-nphoblastic) leukemia is a life{hreatening disease in which thc cells thatnormally develop into lymphocytcs (h'mphoblasts) become cancerous and rapidly replace nor-mal cells in the bone marrow The peak age is around four ycars old, and it is the form of acuteleukemia that is most responsive to therapy. It can be successfully trcated, with a 60-80% 5-yearsurvival ratc.

The carly signs of acute leukemia in a child include fatiguc, palloq weight loss and easy bruis-ing. This will progress to fever, hemorrhages, extreme weakness, bone and joint pain, and re-peatcd infections.

Oral findings include:. Gingival oozing, petechiae, hematoma, or ecchymosis. Oral ulceration, pharyngitis, and gingival infection which is unrcsponsive to conventionaltherapy. Submandibular lymphadcnopathy

\ote: Candidiasis is common in children with leukernia because they are especially susccptiblcto 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 groupedinto v,hat is called the Non-Hodgkin's L1'mphomas). Thc most common symptom ofHodgkin'sdisease is painless swclling of the lymph nodes in the neck, underarm, or groin. The commonsymptoms 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 andrashes; 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. Theurine is burgundy in color, and thcre is discoloration ofteeth and boncs. Thc tceth are reddish-brownand 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 usu-alll not a reliable diagnostic criterion in itself. Clinical examination, patient history and radiographs arecssenrial in making a final diagnosis. The first diagnostic consideratjon relating to color is whether thecolor or stain in a particular case is intrinsic or extrinsjc. Prophylaxis utilizing pumice can be done to re-morc lreen stains orycllow pigmentation caused by vitamin elixirs, tobacco, or other sources. Ifthe coloris 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 inthe 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 oft.eth can bc the first signal ofan underlying problcm with thc dentition or of systemic discasc or an in-herrled svndrome.Orher causes of intrinsic tooth discolorationl. Children $ith cystic fibrosis have teeth that are dark in color, ranging from yellowish-gray to darkbrown. 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 teethmay have a characteristic blue-green color.. Tetrac!'.cline therapy oan cause the crowns of teeth to becomc discolored, ranging from yellow tobrown and from gray to black. The drug will stain permanent teeth that have not completed enamel for-mation 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 firstmolars 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, andmandibular anterior teeth

. Maxillary anterior teeth, mandibular arterior teeth, maxillary posterior teeth, andmandibular posterior teeth

. Mandibular anterior teeth, mxillary posterior teeth, mandibular posterior teeth, ardmaxillary anterior teeth

. Maxillary anterior teeth, maxillary posterior teeth, mandibular posterior teeth, andmandibular 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 thecheeks and lips, tongue, soft palate and the base of the gingiva

27CoplriShl O 201I -2012

Inappropriate feeding ofchildren can lead to tlpical nursing pattem decay. The teeth typically are decayed inthe following order: maxillary anterior teeth, maxillary poste or teeth, mandibular posterior teerh, andmandibular 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 child-hood caries /ECC), nursing caries, botle caries and infantcaries. Nursi[g-bottle caries is a rampant decay thatresults llom sleep limc bottle-feeding combined with the activity ofStrcptococcus mutans. The stagnation ofmilk 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 7lmonths /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),otgreater than 6 fdge J).

Prr'entive measurs include:. lnlants should not be put to sleep with a bottle containing a liquid other than watr. 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 neona-ral teeth, which grow in during the first 30 days after birth. Most develop in the mandibular incisor area. Fre-quentl). natal teeth are removed shortly after birth while the newbom infant is still ir the hospital, especiallyifthe 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 focalimmune dysfunction where T lymphocytes play a major role.These lesions appear as painful white or yellow ulcers surrounded by a bright red area. Lay pcrsonsrefer to aphthous ulcers as rrcanker sores". Thcy can be triggercd by stress, dictary doficicncicste.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 ul-cerates. Pain spontaneously decreases in 7 to l0 days, with complctc healing in 1 to 3 weeks.lmportanti Recurrent aphthous ulcem and lesions ofintraoral herpes arc distinguished largely onthcir location. Rccurrent aphthous ulcers occur primarily on mobile (unaltaclredJ mucosa whilelesions 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 weeksL Recurrent aphtholus major (l0-20 mn in diamelet) arc much less corrmon, last over 2 weeksand heal with scarring:. Recurrent herpetiform: multiple, small, diffr.rse, painful, superficial ulcers*** Paticnts $,ith lrequent recurrences should be screened for diabetes mellitus or Behcet'ssvndrome-

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

. Insulin

. Thyroxine

. Calcitonin

. Epinephrine

2ACop)right O 20ll-2012

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

. Both statements are true

. Both statements are false

29Coplrighl 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 andphysical development. Cretins have dwarfed bodies, with curvature ol the spine and apendulous abdomen. Their limbs are distorted, their features are coarse, and their hair isharsh and scanty. Severe mental retardation is caused by the improper development ofthe CNS. Note: Ifthis condition is recognized early, it can be markedly improved with theuse of thyroid hormones.

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

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

Remembr: Severe hypothyroidism in adults is called myxedema.

Cystic fibrosis is an autosomal recessive condition. The gene responsible is on the long armofchromosome 7. lt occurs predominantly in individuals ofCaucasian origin. The disease isprogressive and finally fatal, mostly as a consequence ofpulmonary complications and cor pul-monale.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'ec-irons. The most reliable diagnostic tool is the sweat test, which shows elevations of bothstrdium and chloride. Note: In CF cells, salt does not move properly because the protein prod-u 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 mouthDental 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)

30CopyriSnt O 201 l-2012

. Inattention

. Mental retardation

. Hyperactivity

. Impulsivity

31Copyrigbt 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 isI to 2 weeks before symptoms generally appear The oral lesions are pathognomonic ofthis 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 in-clude 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 cav-ity as small petechiae-like spots of the soft palate. The defects of congenital infectionfrom an infected mother are more severe

-enamel defects, hypoplasia, pitting and ab-

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

Attention Deficit Hyperactivity Disorder (ADHD) is a condition that becomes apparent insome children in the preschool and early school years (6e1rreen the ages of 3 dnd 5 but variesv'idely). lt rs hard for these children to control their behavior and/or pay attention. lt is esti-mated that between 3 and 5 percent ofchildren have ADHD, or approximately 2 million chil-dren in the United States. This means that in a classroorn of25 to 30 children. it is likely thatat least one will have ADHD.The cause is unknown. The disorder is l0 times more common in males than f'emales. Typi-cally affected children, whether intellectually handicapped or not, perform poorly in school be-cause ofthe inability to attend to tasks at hand or to sit still during the school day. Note: lfthereare any questions conceming the ability of the child to handle dental treatment, contact thechilds'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 effec-tive 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, andanorexla.

. Escherichia coli

. Viridans group Streptococci

. Staphylococci

. Bacteroides

Coplnghr O 20ll-2012

. Oral

. Inhalation

.IM

Cop''right O 201l-2012

Penicillin allergy

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

50 mgAg (max 2g)

I 5 mg/kg (rnax 500 mg)

Remember: I lb = .453 kgEndocarditis prophylaxis recommended: dental procedures known to induce gingivalor mucosal bleeding, including professional cleaning.Endocarditis prophylaxis not recommended: dental procedures not likelv to inducegingival bleeding, such as simple adjustment of onhodontic appliances or fillings abovethe 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 recom-mended that the clinician consult with the patient's physician if the complete medicalstatus of the patient is not fully known or thre is any doubt.

Ninous oxide is a slightlv sll eet smelling, colorless, inen gas. It must alu ays bc coupled with no less than 2070ox] gen. Nitrous oridc is quickly absorbcd from thc lungs and is physically dissolved in thc blood. There is noblotransformation, and thc gas is raprdly excreted by the lungs \\,hen the concentration gradient is reverscd. Itis 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 ccnralnen!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 breathctlrourh 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:

. Pentobaxbital

. Secobarbital

. Paraldehyde

. Chloral hydrate

34Coplright 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 inductiondoes not allect breathing, blood pressure or reflexes. It may be used before some surger-ies or procedures to help relieve anxiety and to induce sleep. When used in combinationwith analgesics, it can help n.ranage pain after surgery. It has an onset ofaction of 15 to30 minutes when given by mouth. Important: Children often enter a period ofexcitementand irritability before becoming sedated. As with barbiturates, pain may cause paradoxi-cal reactions.

Chloral hydrate is bitter tasting, rvhich can produce management problems during ad-ministration. A final disadvantage is that chloral hydrate can induce nausea and vomitingsecondary to gastric initability.The short acting barbiturates secobarbital (Seconal) and pentobarbital (Nentbutal) aresedative drugs. They are sometimes considered for pediatric conscious sedation by oraladministration. They are of very limited value. They are nonanalgesic. They may causehyper-excitability rather than sedation in some children.Note: Chloral hydrate and the barbiturates are classified as sedative-hypnotics whoseprrncrpal effect is

"edation or sleepiness.

Nlodcrate tluorosis *ill not occur since by agc 15 all ofhcr dentirion has undcrgone complete enamel calci-ficalion /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\otes mosl successful public health measure in history.

L II is eflective. safe, inexpensive. and nondiscriminatory. It is the classic public health meas-ure that u'orks. Survevs havc shown that community witer fluoridation results iD a reductiorrin deca) ol abou! fofy b fifty percenr in the primary dentition and about lifry io sixty pcr-cenr in thc pcrmanenr dentition.L Of rhe 50 largesr cities in the United States, 43 have community watcr fluoridation. Fluor-idarion reaches 629/0 ofthe population through public r'"ater supplies. morc than 1,14 nlillionleoplc.-1. \later fluoridation rnd diet supplernentation mry affect tooth morphology, while sclfandprofessionally applied topical treatments r,r,ill not.5. The typcs of lluoride added to different watcr systcms include lluorosilicic acid. sodiumfluorosilicare. and sodiunr fl uoride.6 Up to a levcl of I ppm fluoride. thcrc is an inveNc relation bct['ecn dental decav and fluor-rde concentration. As fluoride concentration increases beyond I ppm. ihere is an incrcasedprevalcnce 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 ofdecalciilcalion or opacification; (3) no radiographic or clinical evidence ofinterproximal caries in nccd ofresloration on iccth to be sealed. Contrlindicetions: (l) rampant carics; (2) intcrproximal carics; (3) wcll-coalcsccd groovesl (4) iDabil-ity 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), rinsefor 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-basedseilants. 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 rmineralization of enamel, inhibition ofand 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

36Copy.ighr O 20ll'2012

PEDIATRIC DENTISTRY Fluoride

Which of the following fluoride therapies should be recommended to athirteen-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

37CopynShr O 20ll'?012

: NoteJ,:ti*::il

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 re-places the soluble salts containing manganese and carbonate which were lost due tobacterial-mediated demineralization. This exchanse orocess results in the enamel becom-ing 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 en-zymatic production of glucosyltransferase. Glucosyltransfemse prevents glucose fromforming extracellular polysaccharides, and this reduces bacterial adhesion and slows eco-logical succession. Intracellular polysaccharide formation is also inhibited, preventing stor-age ofcarbohydrates by limiting microbial metabolism between the host's meals. Thus theduration 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 newlyerupted teeth, making it essential to have rinsing continued into the teen years to protect boththe second and third permanent molaru. It seems that fluoride rinses are most beneficial tosmooth tooth surfaces, although there are some benefits to pits and fissures as well.

l. Fluorine. from which fluoride is derived. is the l3th most abundant element andis released into the environment naturally in both water and air2. Fluoride is naturally present in all water Community water fluoridation is the ad-dition offluoride to adjust the natural fluoride concentmtion ofa community's watersupply to the level recommended for optimal dental health, approximately L0 ppm(parts per million). For warmer or colder climates. the amount can be adjusted ftom0.7 to 1.2 ppm.

*** Fluoride supplements would be contraindicated since the community water is fluori-dated at an appropriate level. Remember: "Rules of6s" iffluoride level is greaterthan 0.6ppm. 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 ifthe 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, thechild is susceptible to high caries activity (ani[' histo4,, caries treuds and patterns in cotlt-n 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 sodiumflvortde /0.050,4 sodium fiuoride).

Toothpaste is available with or without fluoride. Toothpaste tubes containing fluoride are nowlabeled and contain approximately 0.1% fluoride. Some tubes suggest covedng the bristleswith toothpaste. A'pea-sizd' portion weighs approximately 0.75 g and contains about 0.4 mgof fluoride; a 'full cover' portion weighs approximately 2.25 g and contains about 1.0 mg offluoride. Thus, brushing twice a day would deliver 0.8 to 2.0 mg of fluoride, depending onwhich regimen is used. lf swallowed. the amount of fluoride could be excessive and couldcont 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 andsodium monofluorophosphate. Amine fluo de and stannous fluoride. are less common.

. One minute

. Two minutes

. Three minutes

. Four minutes

38Coplright 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 theenamel surface

. Patients should be placed in a semi-supine position

39Cop)righl O 20l l -201 2

Prof'essionally applied topical fluo de agents are applied in the dental offlce or in other set-tings by health care providers. Cunently there are four types oftopical fluoride agents that areused 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 preweightedcapsule fonn; mixed with water immediately before use. Fluoride-containing vamishes

Each agent has advantages and disadvantages and all are used in various settings. Several ofthe professionally applied topical agents carry the ADA Seal ofAcceptance. All the agents areeffective and can be used in different situations to meet the range ofrequirements for topicalfluoride 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 withporcelain. glass ionomer, and composite restorations. They have been shown to remove theglaze liom the sud'ace of these restomtions. Neutral sodium lluoride (Na-Fi is best to use ifthese restorations are present. Also, APF should be avoided on implant patients. it may cor-rode the

'urface of titanium implents.Topical fltroride (abng v'ith occlusal sealants) is the pdmary prcventive agent during ado-lescence (pa.\t the age o/72l because the entire dentition except for the third melars normallyerupts by age 13. Theretbre, fluoride tablets may not be as beneficial.Remember: Caries activity is directly proportional to the consistency offermentable carbo-hydrates ingested, the frequency ofingesting fermentable carbohydrates and the oral reten-tion of f'ermentable carbohydmtes ingested.

It is best to thoroughly dry the teeth before applying thetiveness of the fluoride application and prevent dilutiondried rvith comnressed air or cotton rolls.

fluoride to maximize the effec-of the agent. The teeth can be

Agent Form Concentration Mode of Applicrtion Special NotsSodium fluorideOiaF)

pH = 9.2

Solution2%

9.040 ppm0.90% F ion

Painr on Cotton roll isolation absorbsexcess solution

Gclzvo

9,040 ppm0.90% F ion

Paint on or tray Take care not to overfill trayRequest Patient not to swallow

2%9,040 ppm0.90% F ion

Tray Less amount needed to fill trayLess risk ofswallowing becauseofconsistency

Vamrsh5ro

22,600 ppm2.36/oF ion

Paint on Sets promptly

Acidulatedphosphatefluoride(APF)pH= 3.0 to 3.5

Solution|.23./.

12,300 ppm Paint on Cotton roll isolation absorbsexcess soluttonAvoid cemmic and compositeresm rcslorutrons

Gel\.23%

12,300 ppm Paint on or tray Take care not to overfill trayAvoid ceramic and compositeresin restontions

Foam|.230/.

12,300 ppm Tray Smaller amount needed to filltrayl less FAvoid ceramic and compositerestn teslomhons

PEDIATRIC DENTISTRY Fluoride

You examine a ten-year-old boy in your practice and detrmine that he hasmultiple carious lesions. The family resides in a rural area and drinkswell 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 theamount ofnaturally occurring fluoride in the water. Then prescribe the appropriate doseof 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 recom-mend rt

. None ofthe above

40Copyright aq 20ll-2012

PEDIATRIC DENTISTRY Fluoride

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

. 1.0

.2.5

. 3.5

. 5.5

41Copyright (] 201 I 2012

Children who are not receiving fluoride in their water should receive dietary fluoride supple-ments. However, you want to avoid having the children receive too much fluoride, so youshould make sure their water is tested for any naturally occurring fluoride content ifyou haveany 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 de-livers approximately 0.5 mgs of flr.roride.

Important: Prenatal fluoride supplements are not approved by the FDA and are not recom-mended. However, prenatal fluoride does not cross the placental barrier. No studies to date sup-port the administration of prenatal fluo des to protect the primary dentition against caries.

The APF agent is L23 percent fluoride ion, which is over 12,300 ppm. It is acidic. with a pHof3.5. Clinical studies demonstrate that it is most effective at that pH.APF is formulated in solution, foam, and gel preparations. Foams and gels are the most use-ful. since the mate al stays in a fluoride delivery tray while in the child's mouth. They arealso easier to apply than a watery solution. All ofthe APF products should be applied for fourminutes in order to achieve the best results. Note: An APF gel has been developed which isadr enised as effective with a one-minute application. However, the four-minute products havenruch greater professional acceptance and, presently, only four-minute products carry the ADASeal.Important: You are going to encounter children who gag and vomit and have problems hold-ing the fluoride trays in their mouths for four minutes. All experienced care providers realizethat 1ou are asking for lots ofclean-up jobs and some unhappy children with spoiled clothesif l ou insist on the four-minute rule lbr all applications. Parents also are not pleased with theseL)urcomes. The first fallback position is a two-minute application, and a one-minute applica-tioll \\ ould be next.\ote: Eighty percent ofthe absorption offluoride into the enamel occurs dudng the first tworninutes ofa four-minute application. Consequently, you should strive fbr at least a two-minuteapplication. However, you should terminate the procedure immediately ifthe patient is show-ing signs ofbeginning to vomit. A one-minute application will result in some absorption, butnot as much as a two-minute application and certainly not as much as a four-minute applica-tion. 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')

6 years up to at leasr 16 yeals

. 100 mg

. 200 mg

. 350 mg

. 500 mg

. School water fluoridation

. Fluoridation ofthe communal water supply

. Fluoride rinses at home

. Frequent dental visits

a2coprridt O 201l-2012

/t3Coplright O20ll-2012

The studies and surveys link fluorosis to three factors:. Fluorosis is more common in geographic areas where the endemic levels offluoride in thedrinking 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 fluorosisIn acute fluoride toxicity, the goal is to minimize the amount of fluoride absorbed.Therefore, syrup of ipecac is administered to induce vomiting. Calcium-binding prod-ucts, such as milk or milk of magnesia, decrease the acidity of the stomach, forming in-soluble complexes with the fluoride and thereby decrease its absorption. Note: EMS s,fioaldbe qctivated /91I ).In acute fluoride toxicity, symptoms may appear within 30 minutes of ingestion andpersist 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 fluorideis absorbed through the stomach and small intestines. Fluorides are primarily elimi-nated from the body by way of the kidneys. However, the fluoride that does remain inthe body is found mostly in skeletal tissue. ln acute fluodde poisoning fu,liclr is rqre), themost common causes ofdeath are cardiac failure and respiratory pamlysis. Fluoride toxicityshor-rs up in Ihe bones as o.teosclerosis.Important: The lethal dose of fluoride for a typical 3-year-old child is approximately 500 mgand would be proportionately less for a younger child and smaller child. To avoid the possi-bility of ingestion of large amounts of fluoride it is recommended that no more than 120 mgof sr"rpplemental fluoride be prescribed at any one time.Not: If a six-yar 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 achild in thc samc age range (6-7) werc receiving 8 ppm of fluoridated water, thcrc wouldbe a good chancc of systemic toxicity and moderate to severe fluorosis occurring.

The optimal concentration in the communal water supply varies with mean arurual tem-perature. In most states, it is I ppm. Fluoride supplments are recommended if the waterfluoride content is less than 0.7 ppm.

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

The US Public Health Seruice (PHS) has, since 1962, recommended that public watersupplies 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 vithinIllis ra ge. or even higher).Fluoridation is now used in the public drinking water supplied to about two thirds ofAmericans. The types ol fluoride added to different water systems include fluorosilicicacid. sodium fluorosilicate. and sodium fluoride.

Other facts concerning fluoride:. It is deposited in calcified tissues /.r,te letal).It normally accumulates slowly in bonesas a person ages.. Proximal tooth surfaces derive the greatest benefit from fluoridation. It is excretd by the kidney. Dental fluorosis can occur in permanent and deciduous teeth. The U.S. Public Heatth Depanment sets the optimal fluoride level at 0.7 to 1.2 ppmfor public water. The cariostatic effect of fluoride is produced during the calcification stage of toothdeveloDment

. Primary mandibular canine

. Primary maxillary lateral incisor

. Primary maxillary canine

. Primary rnandibular first molar

uCoplrigbt 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

a5CopriShl @ 201l -2012

The most common congnitally missing permanent teeth with the excption of the maxil-lary and mandibular third molars, are the mandibular second premolars. followed by the max-illary 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 lat-

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

Important: ln the case of a congenitally missing second premolar, you want to hold ontothe 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 perrnanentreelh are congenitally missing or lost prematurely witch results in the l