pediatric dentistry

96
M|jor Topic Abbreviation Major Topic Abbreviation Abnormrl teeth Abn Tth Primarv Dentin Prim D€nt Behavior Management Behav Mgmt Pulp Treatment Pulp Tx Diseases & Conditions Dis & Cond Restorative Restorative Drugs Drugs Space Management Space Mgmt Fluoride Fluoride Tooth Development Tth D€v General Information Gen Info Tooth Trauma Tth Trauma Miscellaneous Misc. PEDIATRIC DENTISTRY Abn Tth The photograph shows an example of in a five-year-old girl. . Amelogenesis imperfccta . Dentinogenesis imperf-ecta . Fluorosis . Enamel hypoplasia Copyriglr 2000 200.1Unrve6iry ofWashingron. Allnel)rs resened Accessro rheArlas ofPediatrrc Dennsrry is golemed b! a license. Unau$onretl access or reproduction is forbidden without rhe prior wrilten pemission ofthc Unive.sity oflrashington l]or in fomation, contact: license(au.washingron.ed! 1 Copyright.C 201 I l0l2

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Page 1: Pediatric Dentistry

M|jor Topic Abbreviation Major Topic Abbreviation

Abnormrl teeth Abn Tth Primarv Dentin Prim D€nt

Behavior Management Behav Mgmt Pulp Treatment Pulp Tx

Diseases & Conditions Dis & Cond Restorative Restorative

Drugs Drugs Space Management Space Mgmt

Fluoride Fluoride Tooth Development Tth D€v

General Information Gen Info Tooth Trauma Tth Trauma

Miscellaneous Misc.

PEDIATRIC DENTISTRY Abn Tth

The photograph shows an example ofin a five-year-old girl.

. Amelogenesis imperfccta

. Dentinogenesis imperf-ecta

. Fluorosis

. Enamel hypoplasia

Copyriglr 2000 200.1Unrve6iry ofWashingron. Allnel)rs resened Accessro rheArlasofPediatrrc Dennsrry is golemed b! a license. Unau$onretl access or reproduction isforbidden without rhe prior wrilten pemission ofthc Unive.sity oflrashington l]or infomation, contact: license(au.washingron.ed!

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Copyright.C 201 I l0l2

Page 2: Pediatric Dentistry

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 are

blu€-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.eatm€nt of choice. Both the primary and permanent

denlitions 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 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 byfaulty 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 insullicientquantity ofenamel formed duc to areas ofthe enamel organ that are devoid ofinner enamel ePith€lium, 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 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 appear-

ance,

Page 3: Pediatric Dentistry

Abn Tth.PEDIATRIC DENTISTRY

What condition is depicted in the radiograph below?

. Concrescence

. Gemination

. Fusion

. Dens-in-dente

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PEDIATRIC DENTISTRY Abn Tth

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$ 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

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Page 4: Pediatric Dentistry

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 thoughtto 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 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 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 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 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 associated

1\'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 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 im-planr.

Page 5: Pediatric Dentistry

. 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

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Page 6: Pediatric Dentistry

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 sludies

over decades ofresearch and in various geogmphic setiings around ihe world.

Remember: Dentin Dysplasia is another group ofinherited dentin disorders resulting in characteristic l_eatures

inlol\ing the circumpulpal dentin and root moryhology. Two typ€s:

. 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 radi-olucencies and absenl pulp chrmbers.. Shields Type II: primary teclh are amb€r-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 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 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 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 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-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 re-condition 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) ^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

Page 7: Pediatric Dentistry

. 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

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Page 8: Pediatric Dentistry

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 hands

ovcr 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.

B€havior 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$, slap€paxcrrs 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 s

bchatior lhreugh appropriatcly

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

Dccrcalc likclihood ofmp|easarr p€rc€prcn or

Convcying reinforcem.nl and

BUidinS bchavjor throush contact,posrurc. and facial cxprcsions

Enlare effectivdes

lrv€ ma!.u8emert |e n-

Page 9: Pediatric Dentistry

. 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

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. 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

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Page 10: Pediatric Dentistry

*** 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 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 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 a

sLght 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 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. incombination 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 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.. Nloth€r'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).

Page 11: Pediatric Dentistry

. 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

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. Herpangrna

. Scarlet fever

. Diphtheria

. Mumps

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Page 12: Pediatric Dentistry

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 a

therapeutic 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 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. 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, musclc

pain. 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 and

rhe 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.

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

Page 13: Pediatric Dentistry

. 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 spirochet€s, as well as Prevotella intermedia, have been implicated inthe etiology ofANUG

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. Hard and soft palates

. Soft palate only

. Alveolar process only

. Hard palate only

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Page 14: Pediatric Dentistry

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 involvem€nt of the interproximal papillae and the prescnce of a

pseudomembranous 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 dis€ase 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 be

localized 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 have

been 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 the

nose_. Class III: same as Class II but extending into the floor ofthe nose.. Class I!': any bilateral clefting ofthe lip whether incomplete notching or complete

clefting.

*** Males more often affected

Page 15: Pediatric Dentistry

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

15

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Page 16: Pediatric Dentistry

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 D€nrisiry is govemed by a license. Unauthorized access or reproduclion is fo.bddenwirhout the prior lritien p€mission 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 a

viral 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 the

age 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 sudden

onset 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 recurr€nce. 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.

Page 17: Pediatric Dentistry

. 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

Page 18: Pediatric Dentistry

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 instances

this 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 syndrome

is 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 can

be improved by using gradual exposure to the dental office.

Page 19: Pediatric Dentistry

. Type I

' Type II

. TYPE III

' TYPe IV

t8Copyflght O 201l-2012

. The first statement is truei the second statement is false

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

. Both statements are true

. Both statemenls are false

19

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Page 20: Pediatric Dentistry

Type I, or insulin-d€pend€nt 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 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 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 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 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 the

proliferation 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).

Page 21: Pediatric Dentistry

. 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 t€eth

20Copyright @ 201 1,2012

2'lCopyrighl O 201| -2012

Page 22: Pediatric Dentistry

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 v€rv 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, hands

and 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 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 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.

Page 23: Pediatric Dentistry

. 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

Page 24: Pediatric Dentistry

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 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 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 because

these 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 general

concave appearance of the face. This concave appearance is generally due to deficientmaxillarv srowth.

Page 25: Pediatric Dentistry

. Acute myeloid leukemia

. Chronic myelocltic leukernia

. Acute lymphocltic leukemia

. Cfuonic lymphocytic leukemia

uCopynghr 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

25Coplrighl O 201l-2012

Page 26: Pediatric Dentistry

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 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-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 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 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 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 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.

Page 27: Pediatric Dentistry

. 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

27

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Page 28: Pediatric Dentistry

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).

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 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 pcrsons

refer 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 on

thcir 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 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'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 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.

Page 29: Pediatric Dentistry

. Insulin

. Thyroxine

. Calcitonin

. Epinephrine

2A

Cop)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

Page 30: Pediatric Dentistry

*** 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 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 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 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

Page 31: Pediatric Dentistry

. Smdlpox (Variola)

. German rneasles (Rubella)

. Mumps

. Measles (Rubeola)

30CopyriSnt O 201 l-2012

. Inattention

. Mental retardation

. Hyperactivity

. Impulsivity

31

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Page 32: Pediatric Dentistry

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 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 occunence

of 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 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 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, and

anorexla.

Page 33: Pediatric Dentistry

. Escherichia coli

. Viridans group Streptococci

. Staphylococci

. Bacteroides

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. Oral

. Inhalation

.IM

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Page 34: Pediatric Dentistry

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 kg

Endocarditis 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 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 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:<)

- r-or 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 thennirnum 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 the percent of local ancs-:herrc times 10, then multiply this by the size ofthe cartridge. tlpically L8 ml.,ibr exanplc.29:o r l0 x 1.8 ml:36 mg/cartridge

. Dir ide the maximurn rnilligram dosage by the numbcr of milligrams pcr canridgc to obtain the maximuma1lo\\'able cartridges of anesthetic.

- fbr example. 132 mg maxi'num dose / 36 mg/cartridge: 3.66 rartridgesImportant: 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 is usually all vou need to treat a child who is fearful

,,f{oteni: of thc dentisr fubng v,ith local dne.rlhesia).'--- 2 | he leelrng ol floating or !rddrne.s $ rlh trnglrng ol rhc dr! its is rhe proper response lo nirrous

o\tde3. Nitrous oxide is stored as a liquid under pressure. and is not flammable bllt will supporl com-bustion.4. Nitrous oxide is much less soluble in blood than alveolar air, thus allowing for rapid changesin alveolar gas concentration.

Page 35: Pediatric Dentistry

. Pentobaxbital

. Secobarbital

. Paraldehyde

. Chloral hydrate

34

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. 50olo reduction in dental caries

. Moderate dental fluorosis

. An increase in the amount offluoride stored in her bones

. Gastrointestinal problems

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Page 36: Pediatric Dentistry

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) are

sedative drugs. They are sometimes considered for pediatric conscious sedation by oraladministration. 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 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

Page 37: Pediatric Dentistry

Fluoride

Fluoridation has several mechanisms for caries inhibition.

are enhancement of r€mineralization 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

36

Copy.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

37

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Page 38: Pediatric Dentistry

: 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 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 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-siz€d' 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.

Page 39: Pediatric Dentistry

. 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 theenamel surface

. Patients should be placed in a semi-supine position

39

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Page 40: Pediatric Dentistry

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 are

effective 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 Not€s

Sodium 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 because

ofconsistency

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

Page 41: Pediatric Dentistry

PEDIATRIC DENTISTRY Fluoride

You examine a ten-year-old boy in your practice and det€rmine 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 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 recom-mend rt

. None ofthe above

40

Copyright 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

41

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Page 42: Pediatric Dentistry

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 are

also 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 have

nruch 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 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 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

Page 43: Pediatric Dentistry

. 100 mg

. 200 mg

. 350 mg

. 500 mg

. School water fluoridation

. Fluoridation ofthe communal water supply

. Fluoride rinses at home

. Frequent dental visits

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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 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 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-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 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 suppl€ments 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 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 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

Page 45: Pediatric Dentistry

. 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

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The most common cong€nitally missing permanent teeth with the exc€ption 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 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/orpermanent teeth can occur and the available space may be reduced by an amount sufl'icient tocause some degree of crowding in the pennanent dentition.

Replacement resorption, also known as ankylosis. results after ineversible injury to the pe-

riodontal ligament. Ankylosed primary teeth should be extmcted ifthey cause a delay in or ec-topic eruption ofa developing permanent tooth.

Rule of four: This simplifred rule will enable you topresent at any given time. It implies the eruption ofbeginning with four teeth at age seven months.

determine the number of teethfour teeth every four months

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

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

Page 47: Pediatric Dentistry

. There is greater blood and lymph supply

. The alveolar crest is flatter

. The cementum is thicker and more dense than that ofthe adult

. Gingival pocket depths are larger

. Attached gingiva is not as wide

46Cop)right O 201 I -201 2

. 5-6 years old

. 8-9 years old

.ll-12yeanold

. l3-14 years old

t7Copynghl O 201I -2012

Page 48: Pediatric Dentistry

*** This is false; the cementum is thinner and less dense than that ofthe adult. Cementumtends to increase with age.

The components ofthe gingival and periodontal structures are the same in childhood, adoles-cence, and adulthood. However, the clinical and radiographic images ofthe gingiva and peri-odontium ofchildren and adolescents differ fiom those seen in adults, owing to the significantchanges 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 asc-ular, 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 againstthe tooth. The PDL is also wider in the child. This is why you may see mobility in the child'steeth as well as a decreased resistance to forces. The fiber bundles ofthe PDL increase withag€.. Alveolar bone has fewer trabeculae, larger marrow spaces, is less calcified, has a thinnerlamina dura and wider periodontal membranes.. The width ofthe attached gingiva: (1) changes concomitantly to changes in the sulcusand crevice depth dudng eruption and shedding (2) increases with age in the primary den-tition (3) is signiticantly narrower in newly erupted permanent teeth than in their deciduouspredecessors (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 inchildren.

?,8

t2 l6

8-9

l l,ll

t0.l r

tvt2

I2-ll

2510

It l6

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

Page 49: Pediatric Dentistry

. 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

49Copyrighl O 201l-2012

Page 50: Pediatric Dentistry

*** On the average thcy takc l0 months for completion ofcalcification.

First Evidence ofCrlcillcstion

(we€ks in Utero)

Cmwtr Completed(Monlhs Aft€r

Birth)

RootCompleted

(Ye3rs)

Mrtill.rycenaal

Late€l

Canine

First molar

seco.d (i|olar

t4 /t3-t6)

t6 04 2/3 16 I/2)

17 (15 18)

t5|2(t4 I/2-t 7)

t9 (t6 23 1r)

5

9

6

l0-12

t4 ( 13-16)

t6 (14 2/3 I6 t/2)

t7l5-t8)

t5v2(14 1/2- t7)

ta ( 17- 19 1D)

4.5

9

6

l0-12

MrndibrltrCentml

Lareral

Canine

Fi$i moler

Second inolar

lNor.tlL The largest primary tooth is the mandibular second molar.2. The mandibular lateral incisor is the smallest primary tooth.3. The largest permanent tooth is thc maxillary first molar4. Thc mandibular central incisor is the smallest permanent tooth.

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 max-illary 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).

Page 51: Pediatric Dentistry

. Crouzon's disease

. Gardner's syndrome

. Down's syndrome

. Hallerman-Streiff syndrome

: l0x2=20

= 10 x2:20

: 12x2=24

: 16x2=32

50Coprighr O 20l l,20l2

51

Cop)'right @ 20ll-2012

.I

.I

]clnlv!

?"tt3

3"i*tr

]clnlnl

.I

.I

Page 52: Pediatric Dentistry

Syndromes Marifestirg BolhH,?erdordr rnd Hypodontir

Oral-facial-digital s).ndrome I

Hallermann-Streiff slndrome

SyDdrom€s DemonstratirgIlypodontia

Ectodermal dysplasia (bypohidroiic type)

Chondroeclodermal dysplasia

Ri€ger's syndrome

Incontinentia pigmenti

Seckel slndromeSyndromes DemorstratingSuperDum€rary Teeth

Cleidocranial dysplasia

Cardneis syndrome

Crouzon disease

Srurge-Weber s)ndrcme

oral-facialdigital syndrome I

Hallermann-Sreiff syndrome

Conditions DemonstrstingTaurodontism

Klinefeller's syndrome

Tricbodento osseus syndrome

Ectodermal dysplasia (hypohidrotic t)pe)

Amelogenesis imperfect, Tr?€ lV

Oral-facial-digital slndrome I

Down's syndrome

Syrdromes Demotrstr.titrgMicrodontia

Ectodermal dysplasia (hypohidrotic type)

Chondroectod€rmal dysplasia

Hemifacialmicrosomia

Down syndrome

Syndromes l)emonstratingMrcrodontia

Facial hemihypertrophy

Otodental slndrom€

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

I = IncisorsC : Canines\I : Molars

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

Page 53: Pediatric Dentistry

rlc\nlv'I

r!c{n}uf

rzrc trszrul..

126-ly3213

=16x2=32

=14x2:28

:16x2=32

=12x2:24

52

Copyright O 201 1"2012

. At bith

. One month

. Four months

. One year

53Copyright O 20ll-2012

Page 54: Pediatric Dentistry

, 2 - | ^ 2 _, 3 - 8 Der ouadranr = 16 neurch' ; t i o ; nt ; - ffi -ii*o", u,J - 32 total teeth

| : Incisors

C : Canines

B : Bicuspids (premolars)

1I = Molars

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 ofcalcifica-tion to root completion, except for the canines ( l3 vears).

First Evidence ofCalci{ication

(Weeks in Utero)

lltaxillaryCerrtral incisorLateral incisorCanineFint molarSecond molar

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

MandibulsrCenual incisorLateral incisorCanineFirst molarSecond 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)

3-4 monthsl0 months4-5 months1.5-1.75 ).rs2-2.25 yrsAr birth2.5-3.0 ),rs7-9 yrs

MaxillaryCenkal incisorLateral incisorCanineFirst premolarSecond premolarFirst molarSecond molarThird molar

MrndibularCentral incisorLateral incisorCanineFirst premolarSecond premolarFirst molarSecond molarThird molar

3-4 months3-4 months4-5 months1.75-2.0 yrs2.25-2.5 y,rs

Ar birrh2.5-3.0 ),rs8-10 yrs

Page 55: Pediatric Dentistry

. 6-8 years old

. 7-9 years old

. 9-12 years old

. 14- 16 years old

54Copyright 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 per-manenl counterpart

. The pulp homs of primary teeth are closer to the surface ofthe tooth

.The crown surfaces ofall primary teeth are much smoother than the permanentreeth (inother words, there is less evidence ofpix and grooves)

. Primary teeth have thinner enamel

Coplriehr @ 201l -2012

Page 56: Pediatric Dentistry

Primary teeth ate exfolialed bv thc phcnomcnon called resorption of the primarv roo!- The permanentrooth in its folliclc attempts to forcc its way in 1o the position hcld by its prcdecessor. Thc prcssurcbrought to bear against the primary rool evidentlv causes resorption of the root, which continucs untilthc 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 stilllirmly in place. thc bcst treatment is to €xlract the primary tooth and allow the pcmanent both toerupl.

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

\lore comparisons ofprimary and permanent teeth:.Thccro$nsoftheprimar]anteriorteetbarewidermesiodistallyandshortcrincisocervicallythanthcir pcrmanent coun{crparts.l hc aro\\'ns of the primar-"- molars are shoner and morc narrow mcsiodistally at the cen ical thirdrhan 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 pcrma-

nent couDlerparts to allorv room for the developing permanent dentition

ridg€

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

Primary\'l!rill,rl Permancnll\raxill.tC.ntral Incisor Certrrl Inchor

5

t0-12

4.5

lGt 2

Page 57: Pediatric Dentistry

. 6 months old

. 9 months old

. 1l months old

. 14 months old

56

Copright O 20ll-2012

. 5-10 mm greater than the permanent teeth that succeed them - premolars

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

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

. 5- l0 mm less than the permanent teeth that succeed them - premolars

57coplright O 20ll-2012

Page 58: Pediatric Dentistry

MaxillaryCentral incisorLateral incisorCanineFirst molarSecond molar

7.5

o

16-20t2-t620-30

1.5-2.01.5-2.02.5-3.02.0-2.53

MandibularCentral incisorLateral incisorCanineFilst molarSecond molar

6.5'7

t6-20t2-t620-30

1.5-2.51.5-2.52.5-3.O2.0-2.53

*** Eruplron datcs arc variablc. Some infants get them early, othcrs do so late. A 6-month varia-

rion in time of eruption is considered normal.

l. Whcn a prirnary tooth clinically crupts in thc mouth, one-half to two-thirds ofthcroot structure has usually developed.2. A primary tooth usually takes L5 to 2 months frorn thc beginning ofclinical erup-

tion 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.

\otes

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

Charaoteristics ofprimary molars /ds (on?pared to permanent nolars):. Crowns are shorter with pronounced buccal and lingual cervical ridges and a constrictedcervical 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 PermanentMaxillaryl'irst Molar First )Iolar

Remember: Leerray space is the size differential befiveen the primary postc.ior teeth /. anine, jirst andsecottl rnolar.s), andlhe permanent canine and first and sccond prcmolar- Usually the sum oflhc primarytooth 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 perside i the ma\illan, orc,/r.This space is often used to help relievc crowding. Ifnothing is done to pre-

scrvc this spacc, thc permanent first 1nolars almost always drift fonvard to close it-

Page 59: Pediatric Dentistry

. Molar bitewing radiographs

. Mandibular molar periapical radiographs

. Mandibular anterior periapical radiographs

. Maxillary molar periapical radiographs

58

@yrigbt O 20ll-2012

. Maxillary second molars

. Maxillary first molars

. Mandibular second molars

. Mandibular first molars

59Copyrighi O 201 l-2012

Page 60: Pediatric Dentistry

Molar bitewing radiographs are the most frequently taken views in pediatric dentistry Theyespecially are used to detect interproximal caries between molars. The film is placed in thebitewing tab and the patient bites on the tab to secure the film. The cone is positioned ten per-cent above the horizontal plane and is directed toward the contact areas ofthe molars. One filmis used on each side in the pdmary and mixed dentitions. When second permanent molars arepresent, two films are necessary on each side. The distal surface ofthe cuspid should be in-cluded in the radiograph and together with all posterior teeth, as well as the distal surface ofthe most posterior molar in the mouth. Note: A size 0 film is used with small children. A size2 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 thechild's teeth are spaced far apart and there is no clinical evidence ofdecay, bite-wings are notneeded until the establishm€nt of contacts on the posterior teeth. At age six a child shouldhave their first panoramic x-ray in order to get all vital information on developing teeth, rootsand any possible malocclusion. X-rays for growth and development depend on the patient'sstage of tooth eruption. The frequency of radiographs should depend on the child's risk fordecay. Situations that make a child at higher risk for decay include lack of fluoride in thedrinling 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€ntofthe 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 todiagnose early carious lesions). Bite-wing x-rays are required for the diagnosis

ofcarious lesions.

Primary mandibular firstmolar that needs sectioningfor 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 proxim-iry. This is especially true when placing the beaks of forceps into bifurcations ofprimary mo-lars 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 primarymolar, the best treatment is to imm€diately orient th€ tooth bud, replant the budusing digital pressure, and suture.2. The best way to extract a primary molar that has the permanent tooth budclose to (a,s in the photo above) it i.s to section the iooth and remove the pans in-dividuallv.

Page 61: Pediatric Dentistry

.30%

.50%

.80%

.90%

. Mandibular central incisor

. Mandibular first molar

. Maxillary central incisor

. Maxillary first molar

60

Coplrigbt O 201l-20| 2

6tCoplrighl O 201| -2012

Page 62: Pediatric Dentistry

Miscellaneous facts that you may need to know for boards:. At birth, thejaw is large enough to accommodate all primary teeth ifthey were toerupt 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 cranialbase are fully developed by age six.. In early life, tonsils function to filter bacteria and program the production of antibo-dies.. 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

time, genital tissue is developing,. Dentists are mandated by law to report suspected child abuse or neglect. Proof ofabuse or neglect is not necessary.. Failure to report suspected child abuse may result in significant legal ramifications forthe dentist, including a fine, jail sentence, and civil liability.. Neglect: Definition from the American Academy of Pediatric Dentistry is the "will-ful 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 andinfection."

. 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 molarkt 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 succeda-

neous teeth.

Page 63: Pediatric Dentistry

PEDIATRIC DENTISTRY

Ordinarily, a 6-year-old child would have whatteeth 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 firstmolars

PEDIATRIC DENTISTRY

When attempting a MO Class II amalgam preparation and filling on aprimary tooth, you encounter a very large mesial marginal ridge thatresembles r cusp. You also notice a transverse ridge from mesiolingualto 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:

Page 64: Pediatric Dentistry

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 hvo-thirds 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 prominent mesiobuccal cervical ridge. Class ll cavity preparations are diflicult due to morphology. It has no central fossa

Primary Mandibular Right First Molar

Buccal Lingual Occlusal Mesial DistalRcpnnrcd iion Aalh'Baloah. M.ry and ltlara.rcl J Fchnnb..h Dp,r,/ trraoloJ.'r I ti!!.|o{,. and .4nk,nt. S?ctnd atui,n O 2006. tr idr pcmission fsm

Page 65: Pediatric Dentistry

PEDIATRIC DENTISTRY Prim Dent

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

m@ffiw

. Primary mandibular right first molar

. Primary mandibular right second molar

. Primary maxillary right first molar

. Primary rnaxillary right second molar

2006. with

64

Copynghr a.lr 201 I l0ll

A neophl.te dental student, only about two w€eks into the program, gets scaredwhen her l0-year-old cousin g€ts hit in the face and looses a tooth. She calls youup 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 aprimary 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

PADIATRIC DENTISTRY Prim Dent

Page 66: Pediatric Dentistry

Primarymandibularright first

molar

Primarymandibularright second

molar

Primarymaxillaryright first

molar

Primar]marillary

right secondmolar

t',1ffi_l

ffiWw

[=-]

ffil[,qrum]ff_lFIIIL]

Lingual

ffimMru

Mesial

m

mlI tJ

I

^uMIMIiiI r *{ |lL rl

Distal

*** The permanent mandibular first molar has a morphology that closely resembles the pd-mary mandibular second molar Note: Amalgam prep outlines on these two teeth also re-semble one another.

Differences include:. Relative size ofthe distal cusp. The primary molar has its mesiobuccal, distobuccal, anddistal cusp almost equal in size. The distal cusp ofthe permanent molar, however, is smallerthan the other tu,o cusps.. From the buccal aspect, the primary mandibular second molar has a narrow mesiodistal di-mension at the cervical portion ofthe crown when compared with the dimension mesiodis-tally 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 pre-molar.. The orimarv molar has a more orominent facial crest ofcontour.

Permanent mandibular risht first molar Primary mandibular right second molar

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

Occlusal

; Not {4.'

11!;le*,

Page 67: Pediatric Dentistry

. The primary mandibular central incsor

. The primary mandibular lateral incisor

. The primary maxillary lateral incisor

. The primary marillary central incisor

. Permanent maxillary third molar

. Permanent maxillary second molar

. Permanent maxillary first molar

. Permanent mardibular second molar

66CopFight O20ll-2012

67CopyriShl O 20ll-2012

Page 68: Pediatric Dentistry

Primar)marillart.

right centralincisor

T-=:--'lt/ \lle"lIncisal

Labial Lingual IncisalThe primary mandibular lateral incisor rcscmblcs thc primary mandibular central incisor except thatit is slightly longcr and wider The cingulum and the mesial and disral marginal ridgcs are more pro-nounced 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 lnolats-

L)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 lhe ML cusp. Th(- largcst and longesl pulp ho.n is thc MB

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

BB KKLabial Lingual

Primarymaxillary

right lateralincisor

7\lY./l

Labial Lingual IncisalThc primary maxillarv lateral incisor is similar to thc central incisor e\cept i! is smallcr Anothcr dif--

ference is that it is longer than it is wide- The incisal cdgc ofthc primary maxillary latcral incisor is moreroundcd 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 in-cisor than its centml incisor counterpart. The crown ofthe tooth is slightly wider than the pernanent Iat-r'ral incisor lhc shape and foml of thc incisal edge is a lmost cxactl-v thc samc as that of the pcnnancntlaleral. The root is slender and rather Iong. Mesial and distal surfaces of the root are flat. while linSualand Iabial surfaccs arc convcx.primsrl -= l:l

,1, , . ". ; :..' m m primar)nrandihurar ltll lvl i1j rl " ' l\i I llJl mandiburar;;,';r".'r#,

@ b] lxl :,, , i i

H] N] o rir*"i-.

lncisal Labial Lingual

jry*,hJ

Primar! \Ia\illary Right Second Molar Permanent N{axillary Right f'irst Nlolar

Primarv Dentition (facial view) Primary Dentition (lingual rien)

Page 69: Pediatric Dentistry

DENTISTRY Prim Dent

A 10-1/2-year-old patient comes into your oflice. You are not sure whetherhis maxillary canines are permanent or primary. Which of thefollowing 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 perma-nent maxillary canine

. The mesial cusp ridge on the primary maxillary canine is shofier than the distal cuspridgel this is opposite ofall other canlnes

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

. The primary maxillary canine is much narrower and longer than the permanent maxil-lary canine

PEDIATRIC DENTISTRY

The occlusal form of the varies fromthat 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

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Page 70: Pediatric Dentistry

The most significant dilferences between the p mary maxillary canine and the permanentmaxlllary 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<lge ltltis i.s op|utsite ol all other (a-

*** 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[rttILabial

--r'--1t()lI I{ I

I lf ItulLabial

[fl,tlL_lLingual

Th€ Primar!

tdI f Y Itl;ltulI ingual

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!]]ml( ill(, ,|Buccal Lingual Occlusal M€sial DistalM€sial

BEIncisal Nlcsi.l

i\Iandibular Right Caninc

t-ll t--fl \v| \/ltti|ulllesial Distal

Distal

Incisal

Distal

Page 71: Pediatric Dentistry

. Pulpotomy

. Extraction

. Pulpectomy

. Observation

70Copyrighl @ 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

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Page 72: Pediatric Dentistry

This is treated the same way as you would treat the adult patient. At age eleven the rootof a maxillary central incisor should be completely formed, therefore an apexificationprocedure is not indicated. If the root were not fully formed, then an apexificationprocess should be started. This involves the placement of calcium hydroxide pastes intothe canal to stimulate continued apical closure.

The fact that the tooth is painful and there is swelling is a contraindication to a pulpo-tomy. You need healthy pulp tissue in the root for success of a pulpotomy. Il the toothwere non-restorable, then a pulpectomy procedure would be contraindicated and the onlyaltemative 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 expo-

surcs 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

Sarned in popularily and is probably the most common approach in curent use ln the singlc appointment

approach. a permancnt restoration is placed at the first appointnlellt, with Periodic monitoring of the

1.r6th

Calcir:m hrdroxide, hybrid ionomcr matcrials, or glass ionorncr maierials are often the dressings ofchorce for indirect pulp therapy- The ftlling material is placed over the pulp dressing on the first ap-

pornrment /.,.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 ofthetemporary restoration and remaining soft dcntin. For the primary dcntition, a glass ionomer, hybridionomer, 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.

Page 73: Pediatric Dentistry

A four-year-old child presents with acute pain associated with a primarymandibular 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 fractureofa permanent tooth with an immature apex?

. Pulpectomy

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

restoration

. Pulpotomy

. Obsene

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Page 74: Pediatric Dentistry

The first and probably most important indication for primary tooth endodontics (pulpectomy) is spacemaintenance- Ofcourse, the best space maintainer is the natural primary tooth. Saving the tooth is veryimportant 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 pulpec-tomy. If there wasn't any periapical pathology, a formocresol pulpotomy would be indicated. If thechild were older and there was a periapical radiolucency but successful pulpectomy could not be ac-oomplished, 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 withnecrotic tissue, which cannot be treated with a pulpotomy. A high-spccd bur is used to gain access intothe pulp chamber and Hcdstrom files arc thcn used for filing thc canals. The canals are irrigated withhypochlorite to wash out any remaining tissue and loose dentin. Thc canals and chamber are then filledrvith 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 per-mancnt 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 dtit 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)

In an older child with a fully forrned apex: Ifthere is a pinpoint exposure and it's been

a while (da-y) since tl're lracture, the treatment ofchoice would be conventional root canaltherapy using gutta-percha. If it is seen immediately, then a direct pulp cap with calciumhydroxide is indicated, lollowed by a permanent restoration.

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 temporaryrestoration. 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

Page 75: Pediatric Dentistry

PADIATRIC DENTISTRY Pulp Tx

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

Infl*nmation or infection ofpulp tissue beyond the coronal pulpcontraindicates 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

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PEDIATRIC DENTISTRY

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

. Cavity varnish

. Glass ionomer

.ZOE

. Calcium hydroxide

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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 ofthe pulp or inflammation ofthe coronal pulp. However. it is vcry important that thc inflammation and/orinfection not have extended beyond the coronal pulp tissuc. Important: The success ofa formocresolp 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 ofthese 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. includ-ing 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 fixationrs complcte.. Once the formocrcsol pellcts are rcmoved (after live inutes), ZOE is used to obturate the pulpchamber It is placed directly on the exposed pulp tissue.. Tooth is rcstorcd

r-ote: Formocresol willcause suface fixation ofthe pulpaltissue accompanied by dcgencration oftheodontoblasts.

Direct pulp caps fDPCi usually are not done in the primary dentition. In fact, most den-tal schools teach that the DPC is a contraindicated procedure in pdmary teeth. Howevetalthough seldom used in the primary dentition, it occasionally is used for primary teeth ifrormal exfoliation will occur in the near future (up to six months). Wten the tooth willerlbliare 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 widelyused 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 in-flammatory 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 dentinto 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 cavitypreparation.

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

situation.

Page 77: Pediatric Dentistry

. One-third

. One-quarter

. One-fifth

. Three-fifths

76Coplrighr 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 teeththerefore 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 prepsmust be conservative to avoid a pulpal exposure

. Primary molars have an exaggerated cervical bulge that makes matrix adaptationmuch more difficult

. The occlusal table is narrower on orimaw molars

77Coplridl @ 20ll-2012

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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 thepulp stumps and check for acceptable fixation before proceeding with obturation. You may experienccgreatcr dilTiculty in obtaining initial fixation with the diluted formocresol compared with the full-strengthformocresol. Your options arc to repeat the topical application ofthe fomrocresol or to proceed with pri-marl 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 po-tentially less toxic than formocresol. These properties have favored its use by some as a pulpotomyagent. [t does not invade systemically to the same degree as fomocresol fM.v?rJ/. This factor, alongwith its potentialJy less toxic form, has favored its use in some areas. A two percent solution ofglu-taraldehydc is used on cotton pellcts to fixate the pulp. Thc moistcncd cotton pellets are placed on thepulp 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 as-

sociated with toxicity and mutageniciry Thereforc, a milder agent is being placed on vital pulp tissuein 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 sul-fatc solution is dispcnsed into the tooth pulp chamber. Only a small amount is neccssaryJust cnoughto achieve hemorrhage control. Typically the color ofpulp tissue treated with ferric sulfate is red orslightly darkish red. Thc fcrric sulfatc is lcft in placc for approximatcly l5-20 seconds and then thepulpolomy 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 ma-

terial following pulpotomy in primary teeth after a shofi term evaluation pcriod and has a prornisingpotential to become a replacement for fomocresol in primary teeth. Furthcr long term clinical eval-uation of MTA as a pulpotomy agent needs to be carried out.

*** This is falsei the enamel and dentin are thinner in primary teeth, therefore amalgampreps are shaflower (0.5 mm into dentin, 1.5 mm overall). The thickness ofcoronal dentin inpnman 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 inre\rorations compared to the same type ofprocedure in permanent teeth. Some ofthese mod-itications are subtle, but they still are important. For example, the depth of Class I cavitypreparations in primary teeth is shallower than occlusal restomtions in permanent teeth. Thisis 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. Con-sequenlly. 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 inthe formation ofthe giogival floor in Class ll preps. Enamel rods in the gingival third ofpdmary teeth extend occlusally ftom the DEJ, elimin-ating the need in Class ll preps for the gingival bevel which is always required whenpreparing Class lI preps on permanent teeth

Important: When preparing a Class ll amalgam prep on a primary tooth, there are severalother 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

Page 79: Pediatric Dentistry

PEDIATRIC DENTISTRY Restorative

The success rates for rnandibular nerve blocks are lower in children than inadults because of the lnatomy ofless developed mandibles.

The anterioposterior position of the mandibular foramen is about the same orslightly 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

76

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PEDIATRIC DENTISTRY Restorative

The trulbous, conically shaped primary teeth also affect the amount ofextensionofthe occlusal outline of the preparation. The general rule is that the occlusal

outline is about of the intercuspal dhtance, betw€en the buccaland lingual cusps, on the occlusal surface of primary molars.

. One-half

. Onerhird

. Trvo-thirds

. Three-quarters

79CopyriSht O 201 I 2012

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The success rates for mandibular newe blocks are higher in children than in adults because ofthe analomyof less developed mandibles. The anterioposterior position ofthe mandibular foramen is about the sameor slightly more distal in childrcn than in adults. However, the vertical position ofthe mandibular fora-men jn young children is closer to the occlusal plane when compared with that in adulls. In adults, it is lo-cated roughly ten millimeters above the occlusal pLane. In young children, it is located somewhere belweenscvcn millimelers above lhe occlusal plane and slightly below the occlusal plane. Therefore, local anesthcticsolution can more easjly diftusc inferiorly liom the site ofdeposition olthe solution to thc target area. Fora child, the slringe barrel should bisecl lhe primary molan on the opposite side ofthe injection. Note: Animperfcct 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 performan inferior alveolar ncn'e block. Primary incisors. however. can be anesthetizcd using suprapcriostial in-jections - which ancsthetizes branches olthc incisive ncrvc. Not€: Local infiltration can be uscd fbr anes-

thetizing m.xillary primary teeth. Adequate diffusion of thc local ancsthetic readily occurs in childrcnbecause their bones are less dense than those ofadults.Remcmbcr: Young children don't always understand what "numb lip" means when you ask them this fol-lo\r'ing a mandibular block. The best indicator ofa profound block would be to probc the labial-attachcdgingiva 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.

1. The two most commonly used injectable local anesthetics in pediatric denlistry are lidocaine

No&3 27o wilh/without epinephrine (X.y/orairel and mepivacaine 3o/" (Carbocaifle).2. Do not excced the maximum rccommended dose (2 ng/lb) 300 nrg max.

3. Long-acting local anesthetics, such as bupivacaine (Marcaine), mrely are used in pediatricdentistry..1. The lwo most commonly used topical anesthetic agenls in pediatric dentistry are:

. 20 70 Benzocaine gel or liquid

. 2 -107o Lidocaine gel or liquid5. Remember to wam the child not 10 bite lhe "numb" cheek or lips. Cive the waming duringthe dental appointment as *ell al lhe end ofthe appointment.

*** Important: Class II amalgam rcstorations for primary tceth are prone to isthmus fractures. Sometextbooks even go so far as to recommend removing tooth sffucture at the axio-pulpa) line angle. so thatmore 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 ex-ample. because ofthe shallowness ofthe preparations and the relatively large sizc ofthe interproxim-al 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 re-tain 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 restor-rng \1irh composite resin or resin modified glass ionomer, it is possible to seal thc remaining pit andtliiurcs.. Fl.t pulpal floor. Be\eled iotoded)

^xio-pulpal line angle. This will hcip reduce stress in the amalgam and provide

Sreatcr bulk ofmaterial in lhis area.. Rounded angles throughout thc preparation. This will result in less concentation ofshesses and \4illallo\\ 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 self-cleansing 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 oc-clusally.. In Class II prcparations, thc gingiva] floor is not ideal in most cases as the preparation gets deeperin 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 andwedge 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 inter-proximal space to achicve slight separation ofthe teeth. Finally, a good visual check ofthc matrixadaptation before the tooth is restored will yield consistently excellent results.

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IEDIATRIC DENTISTRY

Depth cuts can be used as a gauge to help establish the depth of the occlusalreduction when preparing a primary tooth for a stainless steel crown,Approximately ofthe occlusal surface should be removed.

. I to 1.5 millimeters

.3 to 3.5 millimeters

. 4 to 4.5 millimeters

. 5 to 5.5 millimeters

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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 adultteeth

. Primary teeth are slightly more opaque on x-ray film than permanent teeth because ofaIower 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 as compared to perma-nent teeth

81

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Posterio. stainless steelcrowns on primary teeth are a fast, predictable, durable. and relatively inexpen-sive 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 per-

manent tecth, a given amount ofdecay causes the tooth structure to become thinner and lcss stable thanit would be in a larger permanent tooth. The larger pulp space ofprimary teeth limits the depth of amal-gam preparations; these factors result in less stable Class II amalgam rcstorations among primary mo-lars. 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 crowns2. Precontoured crowns

Once the rubber dam is placed, tooth prcparation can begin. There are three basic steps to tooth prepa-

ration 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. Approximately1-1.5 millimeters ofthe occlusal surface should be removed.. The next step involves the buccal and lingual reduction/beveling part ofthe preparation. It is bcst toslightly reduce the cewical bulges of some tccth (rsua\'by approximate\, l- 1.5 nillimeters) jnstabovc rhe gingival tissue. Note: In the case offirst primary molars, the buccal bulges often are verypromineat. [t is so]netimes necessary to remove them in order to get thc preformed crown to fit overthe 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 slightlybelo$ thc height ofthe ftee gingiva. Fortunately, the advent ofnew preformed crowns has made most

tlrmmlng unncccssary.

Importantr The most common eror in preparing teeth for stainlcss crowns is ao leave an intcrproximalIedge. This has been a popular question on national board examinations for decades. A prcparation 1litha ledge wil) not allow the stainless steel crown to scat complctely because it often will get caught on the

ledgc.

**r This is false; primary teeth are slightly less opaquc on x-ray film than pemancnt teeth because ofa hrsher inorganic content. Remember: Ttere must be 30-6070 loss in mineralization before caries is .a-

dio!:raphically cvidcnt with standard D-and E-speed intraoral films. Thereforc, the clinical progress ofa carious lesion is advanced, sometimes significantly, compared with its radiographic progress.

.{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

'raterials. Tha ncw mate als have many feafures that are more desirable than those of amalgam.

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 ofal-limati\ e materials rvith supcrio. features. Some ofthe newer materials have the following excellent fea-

fdr('s: lhev are casy to nse, they release fluoridc, they are tooth oolored, they adhcrc to enamel and dentin,

and their durability is satisfactory

Gla5s ionomers arc among the most notablc ofthe newer materials being uscd as altematives to amal-gam. Ionomen aftach to both dentin and enamel as well as telease fluoridc- They are composed offlu-Lrroalumino 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 in-

troduced in the 1980's. Thcy have the advantages ofboth glass ionomers and resins.. They adhere to enamel and dentin . Ttey can be light c|ied (manv h|brid ionomer produ.ls. They release fluoride also self-cure). They are reasonably user friendly . They are morc durablc than the glass ionomers

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 struc-

ture and are better caries inhibitors than the compomers.

Page 83: Pediatric Dentistry

. Two

. Three

. Four

. Five

a2CopFiglt O 201l-2012

Listed bclow are the usual events in the histogenesisof 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

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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 centersof calcification and are primary sections of fomation in the development ofthe crown of a tooth. They arcrepresented by a cusp on postedor teeth and mamelons and cingula on ante or te€th. They are alwayssepamted by developmentrl grooves, which are very prcminent in the posterior t€eth and form sp€cificpattems. 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 one lobe for each cusp

. 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

Usually mamelons are wom olf afler the tooth comes into functional position. The presence ofmamelons ina 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 maxil-lary incisors is shown. Note the promi-nent mamelons on th€ incisal edges ofthe 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.ccsrorrel)(xlucion is forbidden {ilhou $epnorwtten pcmlns.n ol thc Uni!.rsdyof \hshinston. r_or infom,ton, contacr: lic.nsc{dlu washingron cdu

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

, --,.. . l. Some texts include the deposition ofroot dentin and cementum as #5 in the

.,lNot{l histogenesis ola tooth.

'*;i 2. Korffs fibers is a name given to the ropelike grouping of fibers in theperiphery ofthe pulp that seem to have something to do with the formationofthe dentin matrix.

Rem€mber: Histogenesis means the formation and d€velopment of the tissues of the

body. in this case the tooth.

Page 85: Pediatric Dentistry

.Initiation

. Bud stage

. Cap stage

. Bell stage

. Apposition

. Calcification

. Eruption

. Attrition 8aCoplrighl O 201I '2012

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

. Dental papilla

. Dental lamina

. Dental sac

. Henwig's sheath

85

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l. Initiation (sixth to seventh weekr): ectoderm lining the stomodeum gives rise to oralepithelium and to the dental lamina, adjacent to deeper ectomesenchlme, which is influ-enced by the neural crest cells. Induction is the main process involved. Congenitalabsence ofteeth (anodontia) and supernumerary teeth result from an interruption in thisphase.

2. Bud stage (eighthweek): growth ofthe dental lamina into bud that penetrates growingectomesenchyme. Proliferation is the main process involved.3. Cap stage (ninth to tenth weeky': enamel organ forms into a cap, surrounding themass of the dental papilla from the ectomesenchyme, thus forming the tooth germ.Proliferation, differentiation, and morphogenesis are the main processes involved. Densin 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 intospecific tissue forming cells (ameloblasts, o(lontoblasts, cementoblasts, andfhroblasts)in the enamel organ. Histodifferentiation and morphodifferentiation are the main proc-esses involved. Macrodontia and microdontta (i.e., peg lateral incisors),as well as dent-inogenesis imperfecta and amelogenesis imperlecta occur during this stage.

5. Apposition (varies per tooth): cells that were differentiated into specific tissue-form-ing cells begin to deposit the specific dental tissu€s (enomel, dentin, cementum, andpulp1. Enanel dysplasia, enamal hypoplasia, concrescence, and the formation ofenamelpearls 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 epitheliunt) and OEE (outer enamel epithelium).

The cerrical loop begins to grow deeper into the surrounding mesenchyme ofthc dental sac, elon-gating and moving au,ay lrom the newly completed crown arca to enclose more ofthe dentalpapillatissue 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 single-rooted tooth, while medial outgrowths or evaginations of this sheath will producc multi-rootcdtecth.

Remember: Cementum, which develops from the dental sac, forms on the root after the disinte-gration of Hertwig's epithelial root sheath. This disintegration allows the undiflcrentiatcd cclls ofthc 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 devel-oped. 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 onlyfor aboul three years. Thc roots ofthc pennanent teeth arc completed between l0 and l6 years ofagc. 2 to 3 ycars aftcr eruption.

l. Accessory root canals are formed by a break or perforation in thc root shealh bcf-ore the root dentin is deposited.2. Tooth development is initiated by the mcsenchymc's induclive influencc on the over-lying ectodcnn.3. The enamcl of a tooth is derived from the ectoderm of lhe oral cavity. All othcr tis-suesofthe looth differentiate from the associatcd mcscnchyrne (mesoderm).

4. Ectodermal cells are responsible lor determining crown root and shape.

.: Noted'':&*'ia:,:

Page 87: Pediatric Dentistry

Tth TraumaPEDIATRIC DENTISTRY

A three-year-old patient reports to your oflice with an intrusion injury onteeth #E and #F (see photograph). You inform the child's parents about

the current standard ofcare regarding intruded teeth, Which of thefollowing 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 injuriesin primary tceth is controversial. Some authorsin the field advocate extraction and some advo-cate leaving the tooth to reerupt

. The intrudcd tccth should bc gcntly movedinto position with gauze and stabilizcd bysplinting 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 orrcprodu.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 andshow no radiographic changes are best treated by:

. No treatment

. Extiryation of the pulp tissue follorved by the placement of ZOE paste in the rootcanal space

. Extraction

. Pulpotomy

87Copyright C 20ll-2012

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Informed opinion is divided whethcr it is best to extract intruded teeih or to leave them alonc to reerupt. h isalways 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 reasonswhy. Bur parents need to be part ofthe process whcn the choice oftherapy is morc scientifically unsettlcd. Par-entbetically, 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 toothreeiupt.

Immediate attention should be given to sofl{issue damage. Howevet as in the case ofall luxation injuricsan 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 succedaneouspermanent 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 pur-poses 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 lux-ated maxillary teeth. Consequently, taking a radiograph and checking the palienfs occlusion arc both neces-

sary. 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 man-

rtisrs as a gra,v or gray-black color change in the crowr of the involved primary tooth at any time alter the in-Iu4 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 ten-

\ot€sr der to pcrcussion. Prognosis for concussed primary and permanent teeth is good.

. I l. Subluxrtion is dcfincd as an injury to the tooth without displacemeni but €xhibits mobilily. Pul--rtt';'-' pal necrosis is far morc common in permanent teeth than in primary teeth.Teeth should be moni-

tored closely with x-rays for at least I year, il pathologic changes are scen root canal is treatment.

**" Thel should be examined periodically by taking a radiograph.Primary !ee1h will olten d^rken (hecome grat) after injury. This is due to pulp bleeding and the ditfusion ofbili!.rdin into the dentinal tubules.

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 com-mon $ rrh rhe mandibular incisors.

Enamel ht pocalcification refers to quality deficiencies of enamel. These delects can be directly related tofaults 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 in-le.: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 tonecrosis.. Pufpsl bleeding /irternal hemoffhage): as a resull ofhyperemia, the capillarics in thc pulp occasionallyhcmo.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 pro-gressive 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 chamberor 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-

Page 89: Pediatric Dentistry

PEDIATRIC DENTISTRY Tth Trauma

An eight-year-old patient pres€nts to your o{fice with a small pulpexposure on the permanent maxillary left central incisor, resultingfrom a fracture ofthe tooth. The injury is about one hour old. Your

clinical and radiographic examinations show there are no otherinjuries. 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

88Coptright.e20ll20l2

PEDIATRIC DENTISTRY Tth Trauma

A nine-year-old patielt has fractured th€ root of the permanentmaxillary right lateral incisor. There is no other identifiableinjury. 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

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Fmctures ofpermanenlt teeth resulting in small pulp exposures, and where the cxposurc is ofrccenl dura-llon (usuoll)' less lhan t\,to hours), are lreatcd with direct pulp caps and a glass ionomer band-aid build-upat the time oflhc emergcncy appointmcnt. It is not necessary, however, to build-up the hybrid ionomer orglass ionomer band-aid to thc original morphology ofthe tooth, which might result in unnecessary manip-ulation ofthc tooth. Partial pulpotomy thcrapy is indicated in cases r\here the exposure is ol-longerdura-lion (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 du-Iation. 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-

-.- droxrdc pLrlpotomies. Thc hopc is that pulpal vitality lvill be maintained in the root canal pulp{n' 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 en-dodontic therapy is appropriate llor fraclured permanent teelh wilh large pulp exposures whenthe apices are already closed.

l. Traumatic injurics: a loolh with an open apex is more likely to ha\e a good prognosis. Thisconcept 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 pulpof lhe tooth ro .un i\ e a injury.3. Traumatic injurics: most iliuries to the primary teeth occur al I 112-2 l/2 ycars ofage. lhetoddler strge. The teeth mosl frequcntly injured in thc primary dcntition are the maxillary cen-

lral incisors. Children with protruding incisors, as in children with Class Il. Division I maloc-clusion arc more connnoniy atlected.,+. Avulsed primary tceth ar€ not replantcd. The prognosis lor replanted primary leeth is poorand. worse, ankylosis also can rcsult. Rcplanting an avulscd primary toolh involves forcing a

child 1() go through a lotally unnecessary and inappropriale proccdure-5. Underdeveloped motor coordination is thc most common cause of denlal lraunla irl veryyoung children.6. Remember: Recently traumatized leeth may givc false negativ€ rcsponses to pulp vitalitytests. This impaired nene conduction may be temporary or permancnt, only time willtell.

Splinting is fhe appropriatc immcdiatc choicc ofthcrapy lbr most root fracture injuries ofperma-nent recth. Endodontic therapy may be needed later if{hc tooth becomes necrotic. Doing nothingmat be tempting ifthe tooth sccms quitc stablc. Howcvcr, splinting thc tooth u,illprovide additionalstabilitt \\ hile eating; and it rvill reduce the chance for additional injury to an already compromisedtooth. lmportant: Fracturcs in the middle third ofthe root have the poorest prognosis. Howevetsplintrng still is thc trcatmenl ofchoice

1. Fixed splinting, as opposed to flexible splinting, is the preferred approach lbr root\otes 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 threemonths.3. Approximalely 75 percent ofpermanent teeth with root fractures maintain their vi-la lrty..1. Trcatmcnt ofroot fractures ofthe apical third ofthe root has by lir the best prog-nosis, You have a better chance of stabilizing and maintaining thc vitality of the toothifyou 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 ofinjury5.Thcse teeth should be monitored aggressively, with follow-up clinical and radi-ographic evaluations every three to six months lbr the firsl year. Any sign ofnecrosisor resorption waEants initiation ofroot canal therapy immediatell6. Root fractures involving primary teeth arc relatively uncommon because the morcpliable 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, Divi-sion 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 orthodonticwire or a 30 - to 60-pound test monofilamcnt fishing linc can be used. lt should be leftin place for l-2 weeks nraximum to prevent akylosis.

Page 91: Pediatric Dentistry

PEDIATRIC DENTISTRY Tth Trauma

What is the most reliabl€ method to determine the pulpvitalify 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

PEDIATRIC DENTISTRY Space Mgmt

The patient below is a five-y€ar-old child with acute pain associatedwith 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 reseNedAccess to thc Arlas ofPediaric Dcntisr) is go\enred by a liccnse.UDaudronzed access or reproduclion 6 tbrbiddcn wrthoul rhe priorwrilren pemNsion oi rhe UnNersny of\}hsbinSton. For infomarion.conract: I'cense(au {asfi ington edu

91

Copyright C 20ll-:0ll

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Often, traumatized teeth will not respond to vitality testing. Pulp vitality testing is not routinelyperformed 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 reportinga reaction.

Congestion ofblood within the pulp chamber a short time after injury can often be detectedin the exam. Shining a bright light on the facial surface and holding the mirror to view the lin-gual will usually show a reddish hue which is indicative of pulpal hyp€r€mia. Ifthis colorchange is evident after several weeks, it is often indicative ofa poor prognosis. Electric pulptests 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 re-

spond to heat is indicative ofpulpal necrosis,

Note: In young children, in cases ofavulsed and replanted permanent teeth with open apices,

the blood supply is usually regained within the first 20 days after replantation but nerve sup-ply lags behind.

Remember from Endodontics section: The chiefcause of failure of replantation of perma-

nent teeth is external root resorption.

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

Copyrighl 2000-2004 Unilcnnyof washinSlon. All nghrs 6.tucdAc.ess ro ft. Atlas of PediadcDdtisrry's gormedby r lice.*U.au$onzcd &cess or rt'odu-tion is rbrbiddd vithour the prior*itn pcmission ofrhe UnileFsn, oawlshi.eton For inlbmalio.conractliccnsc(@u wasningron

This appliance is called a distal shoe space maintainer ora distal extension space maintainer. It is usedto prevent unerupted first pemanentmola$ from moving mesially with the premature loss ofsecond pri-mary 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 exten-sion. also called a distal shoe, is used when the second primary molarc are lost prior to the eruption ofthe first permanent molars (i.e., very premature loss).

Ectopic eruption reflects the eruption ofa tooth in an abnormal position. The most frequently found ec-

topic 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 shouldbe 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 delayeduntil 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.

Page 93: Pediatric Dentistry

Space Mgmt

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

. Zinc phosphate cement

. Zinc oxide eugenol cement

.IRM

. Glass ionomer cement

92

Copyrighl er 20ll -2012

PEDIATRJC DENTISTRY Space Mgmt

. Maxillary right removable unilateral appliance

. Maxillary removable bilateral appliance

. Maxillary right band and loop appliance

. Distal shoe space maintainer

Copynghr ao 201l-2012

A mother ofa six-year-old female reports that her daughter has complained of asevere spontaneous pain on the upper right side ofher mouth. Your

indicates a large lesion on the distal aspect of the primary maxillary right firstmolar which extends to the pulp. All other maxillary teeth are present and arenoncarious. You decide that extraction of the tooth is warranted. What type of

space maintainer will you advise for the patient?

Page 94: Pediatric Dentistry

Glass ionom€r cement is the best choice, and it is especially helpfirl to choose among the newest gen-

eration glass ionomer cements. The glass ionomer cements are very user friendly since they mix easilyand clean-up easily in the mouth. Once in the mouth, they also set-up rapidly. They have low solubilityand therefore do not dissolve and leave voids between the tooth and the band. The ionomercements alsoadhere well, especially since they form attachments to both the tooth and the band. Zinc phosphate ce-ment 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 lut-ins cements and should not be used for band cementation

Tlis photograph shows an example of a fixed bilateral space maintainer The patient is four years ofage. 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

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 andloop space maintainer is the best choice. It is especially important to start space maintenance therapy priorto rhe eruption phase ofthe first permanent molar, since the force oferuption ofthe permanent molar willexefi a lot of prcsswe to push the second primary molar forward. The eruption phase ofthe pemanentmolar is the time ofgreatest force exerted against the primary molar

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

Coplrighi 2000-2004 Univ*siiy of\'6hing1or All ngh$ reseaed Ac-cess ro tie Atld ot Pediaric Dn-tisiry is govemed by a licensc.Unauihorted acce$ or reproductionis forbidde. vnnout th. prior Mittonpmission of rhe Uiiveuity ofWashinglon. For infomalion, con-l&l: license(au.washingion.edu

This photograph shows two band and loop space maintainers, an example ofthe bilateral use offixed uni-Jateral 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 ofover-all arch l€ngth, however, it may result in localized space loss, especially ifthere was no in-terdental primary spacing prior to the loss.

2. Space loss can occur very quickly after the loss of a permanent incisor, an applianceshould be constructed ASAP after the tooth loss.

3. Lingual eruption of permanent incisors is a very common problem in the early mixeddentition. 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). Thlsoften results in a midline deviation.

Page 95: Pediatric Dentistry

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 tolhe Atlas ofPediatric Dentisrry is govemed by a license. Uiaufiorized accesor reproduction ; forbidden n rrhoDr tlie prior wilren pemision ofrhe Unive6ity of \rrashinglon. For infom.tion. .onrdcr: licensca4,u.washington.edu

94

Copynghl O 20ll-2012

Page 96: Pediatric Dentistry

Note the small acrylic button that will rest against the palatal tissue with this appliance. Some clinicians ob-ject to the button since it can create tissue iritation. Therefore, it is important that patients and parents be in-structed 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 andpush the maxilla back so it won't grow. It's for kids that won't wear their headgears or lo help headgears workbetter3- Frankel appliances are used to correctjaw imbalances and crowding problems.

. . .. , l. The loss ofa primary canine can cause the lingual collapse ofthe permanent incisors, loss of,'NotcJl arch length, increased overbite, increased ov€det and midline deviation to the side ofthe canine

'i-..,-l'l loss. Note: Bilateral loss ofthe primary canines causcs the same things.,,w 2- Factofi to consider in planning space maintenance:

. Amount of resorption ofprimary roots: ifmore than one-founh ofthe rcot rcmains, spacemaintenance is likely necessary; ifless than one-fourth ofthe root remains and ifno bone is l€ftbetween 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 anydoubt, us€ a space maintainer to prevent space loss..Amount of root d€velopment: the average tooth erupts through ihe gingival tissue with one-halfto two-thirds root formation. Time elapsed since tooth loss: Most space loss occurs within lhe first 6 months