Pediatric Dentistry I OPGD 804-04

2002 Sophomore Spring Semester

University of Louisville School of Dentistry

Orthodontic, Pediatric and Geriatric Dentistry

Faculty

Dr. Guy M. Furnish, Course Director

Dr. Kim Hansford

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TABLE OF CONTENTS Course Schedule________________________________________________________ 5 Course Description______________________________________________________ 6 Topic: Development of the Dentition (Freshman Spring) ____________________ 10 Dental Development Review Questions_____________________________________ 18 Topic: Examination, Diagnosis and Treatment Planning ______________________ 22

Objectives ________________________________________________________________ 22

Slide Notes for Examination and Diagnosis _____________________________________ 24

Topic: Pediatric Dental Radiology and Radiographic Interpretation ___________ 34 Objectives ________________________________________________________________ 34

Slide Notes for Pediatric Oral Radiographic Technique __________________________ 35

Slide Notes for Radiographic Interpretation ____________________________________ 42

Panoramic Dental Radiology_________________________________________________ 55

Topic: Local Anesthesia & N20-02 Inhalation Sedation ______________________ 61 Lecture Notes for Local Anesthetic Injections and Child Management ______________ 63

Maximum Dosage of Lidocaine with Epinephrine 1:100,000 ______________________ 66

Slide Notes for Local Anesthesia ______________________________________________ 68

Lecture Notes for Nitrous Oxide-Oxygen Inhalation _____________________________ 74

Selection and Management of the Child Patient _________________________________ 74 Introduction ____________________________________________________________________ 74 Benefits to the Patient: ____________________________________________________________ 74 Benefits to the Dentist: ____________________________________________________________ 75 Characteristics __________________________________________________________________ 75 Contraindications ________________________________________________________________ 76 Equipment______________________________________________________________________ 76 Introducing N20-02 to the Child _____________________________________________________ 77 Technique of Initial Administration __________________________________________________ 77

Topic: Sealants and the Preventive Resin Restoration (PRR) ___________________ 79 Objectives ________________________________________________________________ 79

Lecture Notes for Preventive Dentistry, Sealants and Preventive Resin Restorations __ 81 Patient Record___________________________________________________________________ 81 Plaque Control __________________________________________________________________ 81 Diet Control ____________________________________________________________________ 81 Toothbrush vs. Rubber Cup Prophylaxis ______________________________________________ 81 Sealants________________________________________________________________________ 82 Supplemental Fluoride ____________________________________________________________ 82 Alternatives to Community Fluoridation ______________________________________________ 83 Practical Considerations of Supplementation ___________________________________________ 83 Topical Fluoride Therapy __________________________________________________________ 84 Office Therapy __________________________________________________________________ 85

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Home Therapy __________________________________________________________________ 86 Sample Fluoride Gel Prescription____________________________________________________ 86 Fluoride Recommendations for Orthodontic Patients_____________________________________ 86 Safety _________________________________________________________________________ 88 Safety with Topically Applied Fluoride _______________________________________________ 90 Safety with Home Fluoride_________________________________________________________ 90

Topic: Pediatric Restorative Dentistry _____________________________________ 91 Topic: Pulp Therapy for the Primary Dentition and Young Permanent Teeth _____ 93

Objectives ________________________________________________________________ 93

Lecture Notes for Treatment of Deep Caries, Vital Pulp Exposure, and Pulpless Teeth in the Child and Adolescent ____________________________________________________ 95

Diagnostic Aids _________________________________________________________________ 95 Evaluation of Treatment Prognosis before Pulp Therapy__________________________________ 97 Vital Pulp Therapy - Treatment of the Deep Carious Lesion - Indirect Pulp Cap _______________ 98 Direct Pulp Cap ________________________________________________________________ 102 Vital Pulp Therapy ______________________________________________________________ 104 Summary of Pulpotomy Studies ____________________________________________________ 107 Non-Vital Pulp Therapy - Pulpectomy _______________________________________________ 108 Non-Vital Pulp Therapy - Apexification _____________________________________________ 112

Past Examples Of Midterm & Final Exams ________________________________ 114

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COURSE SCHEDULE Pediatric Dentistry I - OPGD 804-04

Sophomore Spring 2002 Fridays - 1:00 P.M. - Room 103

DATE LECTURE TITLE SPEAKER

January 4 Course Introduction Furnish

Examination & Diagnosis Furnish

January 11 Examination & Diagnosis Furnish

January 18 Examination & Diagnosis Furnish

January 25 Pediatric Oral Radiology Furnish

February 1 Pediatric Oral Radiographic Interpretation Furnish

February 8 Pediatric Oral Radiographic Interpretation Furnish

February 15 Pediatric Oral Radiographic Interpretation Furnish

February 22 M I D T E R M

March 1 Local Anesthesia and N20-02 Inhalation Sedation Hansford

March 8 Prevention, Sealants and PRRs Hansford

March 15 Restorative Dentistry Furnish

March 22 Pediatric Pulp Therapy I Furnish

March 29 Pediatric Pulp Therapy II Furnish

April 5 S P R I N G B R E A K Furnish

April 12 Sample Cases/Treatment Planning Furnish

April 19 F I N A L

April 26 Finals Week

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COURSE DESCRIPTION 1. Course Title: Pediatric Dentistry I - OPGD 804-04 [1 credit hour] 2. Time and Location: Friday afternoons from 1:00 to 1:50 p.m. (Room 103) 3. Faculty: Dr. Guy Furnish (Course Director) Dr. Kim Hansford 4. Office Hours and Information About Course Director: Guy M. Furnish, DMD Associate Professor, Pediatric Dentistry Office room number: 306B University telephone number: 852-5126 Office hours: posted on office door Home telephone number: 451-1580 Department secretaries: Roxie Williams and Evelyn Tanner Room 319 [852-5124] 5. Required Text: Pediatric Dentistry, Infancy Through Adolescence, 3rd Edition, J. R.

Pinkham, W. B. Saunders Co., Philadelphia, 1999. This text is used for junior courses as well.

6. Course Content: You have just completed a lecture and laboratory course designed to acquaint students

with basic psychomotor skills pertinent to contemporary pediatric dentistry. Exercises on alginate impressions, diagnostic casts, amalgam restorations and stainless steel crowns were included. The Orthodontic Laboratory Course taken concurrently and other orthodontic courses in the near future will address psychomotor skills in arch length and cephalometric analysis and fabrication of appliances commonly employed to manage the developing occlusion, such as space maintainers, space retainers, crossbite correction appliances, oral habit appliances and Hawley appliances.

This lecture course presents a brief introduction to the Pediatric Dentistry Clinic designed

to give the basic knowledge and clinical skills necessary for management of the simplest and most basic pediatric patient needs. This will include an introduction to the Pediatric Dentistry Clinic and its forms, procedure, treatment planning and case presentation pertinent to dentistry for children, pediatric oral radiology, operative dentistry, preventive techniques and theories, pulp therapy and an overview of what to expect encountering the personality of the child patient. This course directly contributes to the attainment of skills listed under ULSD Major Competencies 2, 5, 7, 9, 10, 12, and 14.

It is the first of two lecture courses designed to fulfill the Curriculum Guidelines for

Predoctoral Pediatric Dentistry developed by the Section of Pediatric Dentistry of the American Association of Dental Schools. Objectives are given for each lecture as an aid

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in preparing for examinations. An excellent required text is utilized in this course and throughout the remaining pediatric dentistry courses given in your junior year. Buy it. You wont be sorry.

After reviewing suggestions for improving this course obtained from last year's students,

the Department has decided to make a few changes in the format of the course. Unfortunately, moving the class to another time slot, not after lunch or right before clinic was not possible.

This year, in an attempt to make the class period more stimulating, we are changing from

a strict lecture/slide format to one that is more interactive. There are pre-class reading assignment responsibilities. Each week you will be given a reading assignment that must be read prior to class time. During class you will be quizzed, either orally or in writing, on the material contained in the reading assignment. You will also be called upon at random to respond to questions concerning pertinent patient examples presented in a format that is similar to the format of the case analysis section of the Part II National Boards.

7. Grading/Remediation: Students will be evaluated on attendance, quizzes, a midterm and a final examination.

You will be responsible for material covered in all classes and handouts and assigned readings from the required text that should be brought to class. Testable material will be compatible with the objectives as outlined in the course description.

A one-hour midterm examination will count 30% of the final course grade and a one-hour

plus cumulative final examination will count 50%. Quizzes will be given most weeks and will count 20% of your grade.

Quizzes 20% Midterm 30% Final 50% The lectures offered in this course contain visual information we feel is necessary for the

student to successfully complete his or her clinical assignment. Attendance will be recorded off quizzes or by student signature on the class roster distributed from the start of the lecture until 15 minutes after the hour. Punctual attendance for lectures is expected. More than one unexcused absence will result in a drop of one letter grade.

The course grading scale is as follows: A 90 to 100 B 80 to 89 C 70 to 79 F 0 to 69 All scores on examinations will be adjusted such that test items that were clearly

negatively discriminating are eliminated.

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In the event of a failing grade, the student will have to perform satisfactorily on a written

make-up examination within two weeks of the end of the semester. The highest course grade attainable will be a "C," regardless of your performance on the make-up exam. Satisfactory performance on the make-up exam will raise that student's grade to a "C. Double failures, in the absence of extenuating circumstances, will require repetition of the course.

8. Unethical Behavior: The Department of Orthodontic, Pediatric and Geriatric Dentistry takes a grim view and

an aggressive stance on cheating and other unethical behavior. Students accused of a breach of ethical conduct will be reported in accordance with "The Code of Professional Responsibility and the Bylaws of the Student Review Council of the University of Louisville School of Dentistry (the official document given to all students). In any hearing resulting from such an accusation, the department's recommendations will usually range from a course failure with no available mechanism to make up the grade (until the full course is successfully completed the following year) to dismissal from school with the etiology of the dismissal clearly and permanently stated on school records.

9. Reading Assignments Covered on Quizzes:

DATE CHAPTER AND PAGES TOTAL PAGES

January 4

First 2 pages of Growth and Development handouts and Sophomore Preclinical Course alloy and stainless steel preps

January 11

Chapter 1 (3-11) Pediatric Dentistry Chapter 12 (139-183) Dynamics of Change Birth to 3 Chapter 13 (184-193) Infant/Toddler Exam

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January 18 Chapter 17 (251-264) Dynamics of Change Age 3-6 Chapter 18 (265-286) Exam/Diag./Tx. Planning, 3-6

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January 25

Chapter 29 (427-444) Dynamics of Change Age 6-12 Chapter 30 (446-474) Exam/Diag./Tx. Planning, 6-12 Chapter 36 (579-592) Dynamics of Change-Adolescence Chapter 37 (594-617) Exam/Diag. & Tx. Planning/General Orthodontics-Adolescence

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February 1

Chapter 18 (280-284) All previously read. Chapter 30 (469-474) All previously read. Chapter 37 (607-610) All previously read.

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February 8 & 15

Same as February 4

February 22 Midterm - All of the above

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March 1 Chapter 5 (69-73) Pediatric Physiology Chapter 6 (74-83) Nonpharmacologic Issues/Pain Control Chapter 7 (85-91) Pain and Anxiety Control/Pain Perception Control Chapter 28 (411-417) Local Anesthesia

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March 8 Chapter 32 (481-517) The Acid-Etch Technique/Sealants/PRR

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March 15 Chapter 20 (296-308) Dental Materials Chapter 21 (309-339) Restorative Dentistry for the Primary Dentition

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March 22 Chapter 22 (341-354) Pulp Therapy for Primary Dentition Chapter 33 (522-530) Pulp Therapy for Young Permanent Teeth

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March 29 Same as March 24 April 5 Spring Break April 12 Chapters 14, 19, 31, 38 Prevention of Dental Disease 36 April 19 Final Exam - All of the above

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TOPIC: DEVELOPMENT OF THE DENTITION (FRESHMAN SPRING)

Objectives:

Students should be able to: l. Identify the extent of development of the primary and permanent dentition at each of the

following times: 6 weeks in utero

Dental lamina begins as invaginations of the oral ectoderm; gives rise to the deciduous tooth buds at 6 weeks in utero.

14-18 weeks in utero

Calcification of all primary teeth begins in the following order: centrals, 1st molars, laterals, canines, 2nd molars

Birth

primary centrals, laterals, crowns nearly complete primary canines l/3 crown completion primary 1st molars 3/4 crown completion primary 2nd molars l/4 crown completion with occlusal calcification incomplete permanent 1st molars may show calcification

3 to 5 months

all permanent anterior teeth (centrals, laterals and canines) begin calcification with the exception of maxillary laterals that begin at 10 to 12 months

6 to 8 months

first primary tooth erupts (mandibular central incisor)

2 1/2 years all primary teeth erupted (2 l/2 years) 1st premolars begin calcification

3 years

primary teeth in occlusion, apices closed 2nd premolars and permanent 2nd molars begin calcification permanent 1st molar crown complete

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4 5 years permanent central and lateral crowns completed

6 years

first permanent tooth erupts (mandibular central or first molar)

7 years crowns of all permanent teeth are completed except 3rd molars (remember that 14

weeks in utero to 7 years of age is critical calcification time for esthetics)

6 8 years early mixed dentition Permanent 1st molars, central and lateral incisors erupt

8 years

Permanent 2nd molar crowns completed 8 - 10 years

middle mixed dentition lower canines erupt at 9 -10 and all first premolars erupt 3rd molars begin calcification

10 13 years

late mixed dentition 2nd premolars, upper canines, 2nd molars erupt apexogenesis of permanent incisors and first molars at approximately age 10 Note: The patients chronological age is of less value than the patients dental age when supervising the developing dentition. Root development is the best guide to dental age. Apexogenesis ages are an important consideration when planning endodontic treatment.

17 21 years eruption of 3rd molars

2. Identify the normal eruption sequence and eruption age in months of the primary dentition.

centrals (6 - 8) laterals (7 - 9) 1st molars (12 14) canines (16 18) 2nd molars (20 24) 12-month-old has 12 teeth, 16-month-old has 16 teeth, 2-year-old has 20

3. Define the terms natal and neonatal teeth.

Natal teeth are present at birth; neonatal teeth erupt within 30 days after birth.

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4. Identify the characteristics of the normal primary dentition.

Ovoid arch No curve of Spee - flat occlusal plane Shallow cuspal interdigitation with slight overbite and overjet Primary incisors stand more upright than their permanent successors Little crowding - usually interdental spacing (see #5) Terminal plane relationship (see #10): straight or flush 50% (most common), mesial step

25% (most ideal), distal step 25% 5. Identify the two morphological arch forms of the primary dentition.

There is normally spacing between all the anterior primary teeth. This is often a concern of the parents who miss the adult looking (lack of spacing) smile. However, while spacing may not be pretty, it is normal and desirable. Type I -- spaced (generalized interdental spacing -- primate spaces) Type II -- unspaced (no generalized interdental spacing -- no primate spaces)

No spacing appears interdentally as the child gets older if the child never had spaces. The more spacing there is the less chance of later crowding. A primary dentition with no spaces is quite likely to have crowding later. If there is crowding in the primary dentition, rest assured there will be crowding in the permanent dentition.

6. Define the term primate spaces.

Spaces found between maxillary canines and laterals and the mandibular canines and 1st molars in the primary dentition.

7. Differentiate between accessional and successional teeth.

Accessional teeth erupt distal to the primary dentition. Successional teeth replace teeth in the primary dentition.

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8. Identify the normal eruption sequence and eruption age in years of the permanent dentition. Sequence of permanent tooth eruption: maxillary arch 6-1-2-4-5-3-7

mandibular arch 6-1-2-3-4-5-7

Age of permanent tooth eruption in years: maxillary arch mandibular arch 1st molars 6-7 1st molars 6-7 centrals 7-8 centrals 6-7 laterals 8-9 laterals 7-8 1st premolars 10-11 canines 9-10 2nd premolars 10-12 1st premolars 10-12 canines 11-12 2nd premolars 11-12 2nd molars 12-13 2nd molars 11-13 3rd molars 17-21 3rd molars 17-21 9. Identify the characteristics of the transition from primary to permanent dentition.

There is an increase in the incidence of malocclusion with minor crowding. Slight mandibular anterior crowding is normal at age 7 to 8, when the permanent incisors and first molars have erupted but the primary canines and molars are retained. This crowding is later relieved by a slight increase in bicanine width, labial positioning of the permanent incisors relative to the primary incisors, and a slight distal and buccal repositioning of the canines as the lateral incisors erupt. There is a decrease in both arch length and arch circumference in the transition to the permanent dentition. Between 10 and 13 years of age the maxillary arch circumference decreases 1-2 mm and the mandibular arch decreases 3-4 mm. Bimolar width increases 4 mm in the maxillary arch up until age 10 and decreases slightly in the mandibular arch. Perhaps the main point to remember is that after age 3, there is no significant skeletal growth in the front of the jaws. Therefore, growth will not overcome any significant early crowding and the crowding will persists into the permanent dentition. That is why crowding of the incisorsthe most common form of Angles Class I malocclusionis by far the most prevalent form of malocclusion.

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10. Identify a distal step, mesial step, and a straight (flush) terminal plane relationship of the second primary molars and their impact on the position of the first permanent molars in the mixed dentition.

These primary molar relationships determine the position of the permanent first molars. Note that the word distal in distal step refers specifically to the distal surface of the lower primary second molar being distal to the distal surface of the upper second primary molar.

The flush terminal plane relationship, shown in the middle left, is the normal relationship in the primary dentition. When the first permanent molars first erupt, their relationship is determined by that of the primary molars. The molar relationship tends to shift at the time the second primary molars are lost and the adolescent growth spurt occurs, as shown by the arrows. If leeway space is inadequate and there is no differential forward growth of the mandible, the change will be that shown in the top line. With available leeway space but without good growth, the change will be that shown by the dotted line. With good growth and a shift of the molars, the change shown by the bottom double line can be expected. One can see that distal steps lead to Class II relationships, flush terminal planes usually lead to Class I relationships but can lead to a Class II. Mesial steps nearly always lead to a Class I but can lead to a Class III depending on the patients growth pattern.

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11. Define " leeway space" and identify its significance. Leeway space is the difference in mesial-distal dimension of the primary canine, 1st and 2nd molar, and the permanent canine, 1st and 2nd premolars in each quadrant. It is used to permit relief of permanent incisor crowding, mild amounts of which are usually present after incisor eruption. It also provides for a late mesial shift of the first permanent molars when necessary. Nance determined leeway space to be .9 mm in the maxillary arch and 1.7 mm in the mandibular arch. Moyer determined it to be 1.3 mm in the maxillary arch and 3.1 mm in the mandibular arch.

12. Identify how the arch forms (spaced and unspaced) and mesial and flush terminal planes can

occur in various combinations in different children and result eventually in proper Class I occlusions. A 5-year-old with a spaced dentition with mandibular primate spaces and a flush terminal plane relationship will undergo an "early mesial shift" closing the primate spaces and become a Class I molar relationship at age 6 to 7.

A 5-year-old with an unspaced dentition with no primate spaces and a flush terminal plane will undergo a "late mesial shift" utilizing the leeway space and become a class I molar relationship at age 10 to 13.

"Early mesial shift" denotes the closing of mandibular primate spaces on eruption of permanent 1st molars. "Late mesial shift" denotes the closing of the leeway spaces by the mesial drifting of the permanent 1st molars on loss of the primary 2nd molars.

Flush terminal plane mandibular primate space Early mesial shift closing primate space at 6-8 yrs. of age Class I molars 5 yrs. of age Late mesial shift utilizing leeway space 10-13 yrs. of age Flush terminal plane no mandibular primate space

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13. Identity the "ugly duckling" stage and its significance. Frequently, the maxillary incisors erupt into the oral cavity with a strong distal inclination of their crowns. This is because as the lateral incisors erupt, the canines higher up are literally sliding down the distal surfaces of the developing roots of the lateral incisors. This tends to force the apices of these roots toward the midline, while the crowns tend to flare laterally. As the canines continue to erupt, however, there is an autonomous straightening up of the lateral incisors. The temporary spacing that often occurs between the crowns of the centrals and laterals is usually closed (if no greater than 2mm) as the canines erupt into complete occlusion. This is a most hazardous time to place appliances due to the chance of damaging the apices of the maxillary laterals and the possibility of deflecting the permanent canines from their normal path of eruption. Illustrations and references: Contemporary Orthodontics. 3rd edition, William R. Proffit, C. V. Mosby Co.

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DENTAL DEVELOPMENT REVIEW QUESTIONS 1. There is no other organ of the human body that takes so long to attain its ultimate

morphology as the ________________. 2. There are six histogenic events or stages that participate in the progressive development

of the teeth. These are initiation (bud stage), ________________ (cap stage), __________________, ________________(bell stage), ______________, and ________________.

3. The first sign of human tooth development is seen during the __________ week of

embryonic life. 4. Interference with the stage of _______________________ may result in extra cusps or

roots, suppression of cusps or roots, fusion, or gemination. 5. Peg-shaped teeth, micro or macrodontia, dens-in-dente, Hutchinsons incisors, Mulberry

molars, or dilaceration could occur due to disturbances in the stage of ______________________________.

6. Interference during the stage of _________________________ may result in

amelogenesis imperfecta or osteogenesis imperfecta. 7. Missing or extra teeth could be the result of interference in the

____________________________ stage. 8. Hypocalcification may be the result of interference in the

______________________________ stage of tooth development. 9. Hypoplasia may be the result of interference in the __________________________ stage

of tooth development. 10. Calcification of all primary teeth begins between _____ to _____ months in utero. 11. Enamel deposition is completed in all the primary teeth before birth. True or False? (circle) 12. The crowns of all primary teeth have usually completed calcification by one year of age.

True or False? (circle) 13. The average eruption sequence and eruption age of the primary teeth is as follows: ____________________ (_________ to _________ months) ____________________ (_________ to _________ months) ____________________ (_________ to _________ months) ____________________ (_________ to _________ months) ____________________ (_________ to _________ months)

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14. Mandibular teeth usually precede their maxillary counterpart in eruption. True or False? (circle) 15. Inclusion cysts are relatively common in newborn infants. True or False? (circle) 16. Match the following: A. Bohn's nodules B. Dental lamina cyst C. Epstein's pearls ________ inclusion cysts found along the mid-palatine raphe ________ inclusion cysts found along the buccal and lingual aspects of the dental

ridges ________ found along the crest of the alveolar ridges in newborns 17. When encountering natal or neonatal teeth, you must decide if the teeth are

_____________________________ prior to deciding on treatment. 18. A bluish-purple elevated area of tissue that has developed on the gum pad a few weeks

prior to the eruption of a tooth is called a ____________________. Treatment is unnecessary.

19. A. _______________________________ B. _______________________________ C. _______________________________ D. _______________________________ 20. Spacing in the primary dentition ranges from 0 to 10 mm in the maxillary arch, with an

average of ______mm. The range in the mandibular arch is 0 to 6 mm, with a mean of by ______mm.

21. Ideal overbite in the primary dentition is _______ mm. Ideal overbite in the permanent dentition is______ mm. Ideal overjet in the primary dentition is _______ mm. Ideal overjet in the permanent dentition is _______mm. 22. The relationship of the maxillary and mandibular primary canines is one of the most

stable throughout the primary dentition. It is the best indication of the actual relationship of the maxilla to the mandible. True or False? (circle)

23. If the terminal plane relationship of the primary molars is a mesial step, the first

permanent molars will probably erupt into a Class ______ relationship 24. If the terminal plane relationship of the primary molars is a distal step, the first permanent

molars will erupt into a Class ______ relationship. 25. In a spaced dentition with second primary molars displaying a flush terminal plane, the

eruptive force of the first permanent molars will tend to close the spaces. With the

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_______________ spaces located mesial to the maxillary primary canines and distal to the mandibular primary canines, the shifting of the mandibular primary molars to allow a Class I molar relationship is favored. This is referred to as the ________________________________.

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26. The ________________________________ refers to a mesial shifting of the first permanent molar into a Class I relationship following the loss of the second primary molar. This relationship is possible due to a size differential between the primary posterior teeth and their permanent successors and has been termed by Nance as _______________________________.

27. The four average maxillary permanent incisors are 7.6 mm larger than the primary

incisors they replace. The four mandibular permanent incisors are 6.0 mm larger than the primary incisors they replace. This inverse size differential has been termed ___________________________________.

28. With luck, a combination of four factors, either singular or in combination, allows larger

permanent teeth to fit into the arch without crowding. They are: 1.______________________________________________________________ 2.______________________________________________________________ 3.______________________________________________________________ 4.______________________________________________________________ 29. Broadbent has referred to the period from the eruption of the maxillary lateral incisors to

the eruption of the maxillary canines as the ____________________ stage. This is often a time of patient and parental concern over anterior esthetics.

30. Permanent first molar root formation is completed by age _____. Permanent mandibular incisor root formation is completed by age _____. Permanent maxillary incisor root formation is competed by age _____. 31. Fill in the eruption ages of the following permanent teeth:

A. Mandibular canine _____ to _____ years B. Maxillary first premolar _____ to _____ years C. Mandibular first premolar _____ to _____ years D. Maxillary second premolar _____ to _____ years E. Mandibular second premolar _____ to _____ years F. Maxillary canine _____ to _____ years G. Mandibular second molar _____ to _____ years H. Maxillary second molar _____ to _____ years

32. A childs blood pressure increases with age. A 3- to 5-year-old has an average blood

pressure of 100 / 60. A childs pulse and respiration rates decrease with age. A 3-year-old has an average pulse of approximately 105 and a respiration rate of 30 / min. A 5-year-old has an average pulse of approximately 100 and a respiration of 26 / min.

33. Cleft lip is caused by a disruption of the developmental process in the 4th to 7th weeks of

fetal development. Cleft palate develops in the 8th to 12th intrauterine week. The mandibular symphysis is fused by the childs first birthday.

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TOPIC: EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

Reading Assignment Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham, Orientation to the text (pp. ix, and x) Chapters 1 (pp. 3-11) Section I (pp. 139-140) Chapter 12 (pp. 141-183) Chapter 13 (184-193) Section II (p. 251) Chapter 17 (pp. 253-264) Chapter 18 (pp. 265-286) Section III (pp. 427-428) Chapter 29 (pp. 429-444) Chapter 30 (pp. 446-474) Section IV (p. 579) Chapter 36 (pp. 581-592) Chapter 37 (pp. 594-617)

Objectives Upon completion of the reading assignment and attendance at class lecture, the student should be able to: 1. describe the physical changes (body, craniofacial and dental) taking place from

conception through adolescence; 2. describe the cognitive changes taking place from birth through adolescence; 3. describe the emotional changes taking place from birth through adolescence; 4. describe the social changes taking place from birth through adolescence; 5. describe the epidemiology and mechanisms of dental disease as it affects children from

birth through adolescence; 6. describe the objectives of the infant and toddler examinations; 7. describe the steps of the infant examination; 8. describe the emergency examination; 9. describe the management of electrical burns of the mouth; 10. describe the clinical implications of pre-term birth;

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11. describe the role of the dental personnel in introducing the child to dentistry; 12. describe the role of the parent in introducing the child to dentistry; 13. describe proper methods for separating a reluctant child from his/her parent; 14. describe the need for honesty in dealing with the child patient; 15. describe the purpose of a systematic approach to the examination and the components of

the physical assessment of a child patient; 16. describe the purpose for the medical and dental history questions appropriate for

children; 17. identify normal and abnormal in the child's mouth; 18. describe the rationale and method for entering progress notes in the pediatric dental

record; 19. identify factors that affect treatment decisions; 20. describe the rationale for sequencing treatments; and 21. describe a general systemic approach to treatment planning.

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Slide Notes for Examination and Diagnosis 1. The initial diagnosis begins with a telephone call from the parent. Your impression of the

child begins in the waiting room. Does the child hide behind Mom. Does the child cower or like the place. Don't confront the child with too bold an approach. Things that you should notice; stature, gait, speech, fast, slow, alertness. Smile. Compliment something, nice clothes, shoes, haircut, etc. Use a slow approach, a pleasant approach. Don't loom over the child. Talk to the child, be at ease, take your time, be prepared, have everything ready. Re-read your manual and review the chart beforehand. Know what you are going to do, and you won't fumble as much.

. The child can tell if you are under stress. If you are, the child is also. Stand back, look

and talk. Does the child give you eye contact? Is the child bright, alert, confident, scared, anxious, or evasive? This lets you know if you can approach the child and at what speed.

2. The parents will have filled out the first two pages of the chart before you see the child

on the first visit. Pay careful attention to the health history and the past dental history. 3. Most children will greet you with a smile. This is a new experience for them. If there is a

significant item noted in the medical history, a medical consult would have to be obtained before any treatment can be accomplished. If a consult has been obtained, it will be in the pocket of the chart. Look in the pocket of each chart to see if there is a medical consult form.

4. Children usually like some physical contact. If they will accept it, hold a hand, touch an

arm or shoulder when complimenting. "Hey, you are doing a good job! Thank you." Praise goes a long way. You may be the only person to ever thank them. Smile. Smell good. Be compassionate.

5. Everybody is somebody. We all like to be noticed, feel important, succeed. Use this

information to your benefit. Compliment the child about his clothes. Ask about pets, brothers and sisters. Everybody likes to succeed. Get the child on your side. A good assistant is invaluable.

6. If the child is anxious or afraid, you have to go slower. Talk softly and be assuring. Tell

the child what you are going to do. It's easy, we're going to have some fun today." 7. How does the child perceive you? Does he have bright eyes and a smile or a cold stare

and distrust? Use your personality and intuition. Get the child on your side. 8. A drawing from one of Dr. Walker's patients. This child saw the dentist as a bloodshot-

eyed, big person with a bloody drill, approaching a small scared child. Do you trust anybody in your mouth? Put yourself in their shoes.

9. If the child is anxious, or quiet and you want to get something started, ask if she has a

hand. Looking at a hand is not threatening. Turn it over and look at the other side. "Do you have another one?" Look at it. "You really have some hands there, young lady." Now I'm going to look at your lips. Look and write something down.

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10. On the initial visit and on recall, the child should be weighed and measured for height. This is a non-threatening way to get started. Talk to the child. Ask questions. Break the ice.

11. Hey, have you ever had your arm pumped up?" Check for nodes, look around, and dont

miss anything. 12. Recheck the chart. If the child is old enough, ask about health history. Fill out the rest of

the chart - the preventive page. 13. The oral exam begins with the fingers. Im going to look at your front teeth. If the child

won't open, push the lips apart and say "very good, that's a nice job." Write something down, be casual. Say "open" and look again. Great!" Usually you get a little more done each time. In and out. If the child is anxious, many in and outs are better than one long look. Get the child used to following directions. Don't let them talk on and on and thus evade the procedure. Say "open" and back up, praise the child. Look at soft tissue first, then the occlusion. Does the child have any oral habits?

After face, lips and all other soft tissue has been accounted for, look at the teeth. Check

for position, number, color and caries. What radiographs will be necessary for further information?

14. This is a nice looking lower arch of a child between three to five years of age. There are

ten teeth in each arch in the primary dentition - incisors, canines and molars - no premolars. When primate spaces are present, they are distal to the lower canines and mesial to the upper canines. You like to see primate spaces because they add additional room for the larger permanent incisors. Dry the teeth with short bursts of air. Demonstrate the air away from the patient first, then on the childs hand and finally in their mouth - a short burst. Talk while you are doing the exam. Don't ask for permission saying May I look at your teeth? If the child says no - then what are you going to do? Don't ask for permission - make declarative statements. Get in the chair so we can get started. Let's go take some pictures. Open.

Tell the child what you are going to do. "I am going to count your teeth." Count out loud. "Hey, you really have a lot of teeth. Did you know you have 20 teeth?" The upper arch is ovoid. Look at the color of the tissue. This is a healthy looking mouth.

15. Class I primary dentition. Mesial step. Upper central is wider than the lower central.

Upper central touches lower central and lateral. Upper lateral touches lower lateral and canine. This is what you want to see - each tooth in each arch touches two teeth in the opposing arch. You also want to see generalized spacing in the primary dentition.

A Class II primary dentition. In a Class II dentition, the upper arch is generally the

offender and is more forward with a resulting horizontal overjet. Now the teeth will not interdigitate when in occlusion but will occlude one on one.

16. Both slides depict Class II primary dentitions. The one on the left has a large overjet but a

near normal overbite. The slide on the right has a large open-bite but a near normal overjet. This is caused by two different habits. On the left - thumb. On the right - tongue.

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17. Class III primary dentition. This is usually a genetic pattern. Look at the parents. The lower arch is usually the offender in Class III malocclusion. It grows out from under the upper arch.

18. Prominent chin of a Class III dentition. Mixed dentition (both primary and permanent teeth present), with a maxillary

constriction resulting in a unilateral convenience cross-bite. If it were a simple unilateral cross-bite, the upper and lower centrals would line up.

19. A 7-year-old with caries in the distal of both lower 1st primary molars. You can see the

caries appears deep. Don't bury an explorer in the caries - it will hurt the child unnecessarily and you won't learn anything new. Lower 1st permanent molars will usually come in 6 months before the upper 1st permanent molars. The upper centrals will line up on their own if there is no habit and no excessive crowding.

20. Anterior view of the same child. Normal pigmentation. Fill out the caries chart the best you can before radiographs are taken. In this manner we

can best prescribe what radiographs to take. 21. After the charting has been finished up to this point - call an instructor over. The

instructor will review the chart, the patient and then indicate which radiographs are needed to finish the exam.

22. Protect the child with a lead apron and a collar Show the child the film and the machine. Explain that you are taking a picture of her

teeth and she will have to be very still. 23. If a panoramic film is indicated, you or an assistant will take it. 24. This is a nice bitewing of a three-year-old. A permanent molar is developing in the lower

corner of the film behind the 2nd primary molar. There is spacing between the teeth and this is good in the primary dentition. No caries present.

Panorex of a 3-year-old. Look for symmetry. Count the teeth. 10 primary teeth in each

arch. The developing permanent canines are the lowest teeth in the lower arch and the highest teeth in the upper arch. Get used to finding these teeth first when looking at a Panorex of the mixed dentition. From these teeth you ought to be able to name the rest of the teeth.

25. The interview and counseling portion of the visit is best accomplished prior to the

examination of the infant or toddler. When you are examining an infant, know what you are looking for. Youll take a short, loud look. The infant will cry as soon as you place him on his back and put your finger in his mouth. Use gauze to wipe saliva out of the way. Get a good long look and then give the child back to mom. Then talk about it, it will be quieter.

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If you want to demonstrate to the parent - an exam or brushing technique place two chairs

facing each other - knee to knee. The infant is on his back with his head in your lap, the heel of your hands on the infants cheeks. Mom has the infant's legs under her elbows and holds the infant's wrists. Do what you need to do and get it over with and the infant back up in vertical position.

26. This is the lower arch of a 6 1/2-year-old. It has nice ovoid form, 6-year molars are in,

and the tissue color looks good. The exam should be painless. If you don't dry the teeth before using an explorer and the caries entrance is the same size as the explorer - hydraulic pressure can be generated if you forcibly push the explorer in the hole. This increased pressure can cause a lot of pain. If the teeth were dry before doing the same exam - no problem and you can see so much better.

This is a good-looking ovoid upper arch. The upper teeth usually come in about 6 months

after the corresponding lower teeth. 27. This is a bitewing of an 8-year-old. Get used to looking at developing permanent teeth for

a guide to the age of the child. This is a Panorex of a 7-year-old with a missing permanent premolar. Always look for

symmetry and count the teeth. 28. This is an 8-year-old with a prominent frenum. Don't do any treatment for the frenum at

this age. Wait until the upper permanent canines erupt. They usually squeeze the centrals together and solve the problem. In any event, wait before treatment.

The upper arch of the same patient. 29. This is the lower arch of the same 8-year-old. Look for symmetry. The lower right 1st

permanent molar may be trapped at an angle behind the 2nd primary molar - ectopic eruption. This will have to be dealt with. Take a radiograph and find out.

Nice looking permanent dentition. This was an orthodontic case - molar bands are still in

place. 30. Class I permanent dentition. Look at the interdigitation - each tooth contacts two teeth in

the opposing arch. Panorex of a 14-year-old with a fractured central incisor. 31. This is a Panorex of an 8-year-old with a prematurely missing lower right primary canine.

Crowding caused this problem - a shifting of all anterior teeth toward the missing canine spot. Notice also that the upper left lateral resorbed the root of the primary canine next to it . This is also a sign of crowding - the resorption of two primary teeth by one permanent tooth.

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31. This is a Panorex of an 8-year-old with space loss caused by caries and loss of primary teeth. There is also a congenitally missing upper left permanent premolar. Look for symmetry. Count the teeth. Find the permanent canines first.

32. Thumbs up - everyone wants to succeed and be noticed. Use this to your benefit. Most

patient want to help you. This child has crowded lower anterior teeth. It may be an ortho problem. How old is this child? Probably around 8.

33. If you need to get an impression of a patient, know what you are looking for. You won't

get it if you don't know what you are after. This is a good impression and an excellent set of models.

34. Bacteria and the pellicle remaining on the tooth cause green stain. It houses the bad guys

and can cause demineralization of the tooth. The easiest way to remove it is to dry the teeth and paint them with iodine. It kills the bacteria and the stain is easier to remove. You may have to paint it on more than once. Don't splatter it.

Bacteria also cause Black stain but it causes no harm. It just looks bad. It is usually

associated with a caries-free mouth. It needs to be removed for esthetics. 35. There is a lot of caries here. Pain is not always present even though there is a hyperplastic

pulp in a lower primary molar. In all of this disaster the permanent teeth are lined up in good fashion. Don't punch holes in this, you can see that it is bad. Get radiographs to finish the diagnosis.

The upper arch of this 9-year-old is not as bad as the lower. These caries can be managed.

Keep the arch intact if possible to allow room for the permanent teeth. 36. This is a 4-year-old child with nursing caries. Taking a bottle to bed at night and falling

asleep with whatever is in the bottle pooled around the teeth usually causes this. This continual onslaught will destroy most of the upper anterior teeth. The teeth usually spared are the lower anteriors, which are protected by the tongue. When the child is asleep the saliva flow is shut way down. The buffering action by the saliva is reduced and whatever caries potential is in the liquid will be enhanced. Water in the bottle at night is OK - anything else can be disastrous.

Another nursing caries child with an erupting permanent central pushed off course by an

abscessed primary central incisor. The tooth is erupting into buccal mucosa and will not have any attached gingiva. This will have to be taken care of later with a periodontal procedure.

37. Restorations are the best space maintainers. You have to watch band and loops space

maintainers. Cuspids will distalize with the eruption of the permanent laterals. You may have to remove the band and loop and place a lingual arch.

Be able to read radiographs. Know the difference between primary and permanent teeth.

Be able to recognize pulp treatment and steel crowns. Look at the developing teeth to see if the child is on schedule in his eruption pattern.

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38. This 5-year-old girl has been up all night with an abscess. She is tired, has sad eyes, and would like help. She may be skeptical. She has pain now and doesn't want any additional pain. Can you examine her without adding to her discomfort? Ask if she wants help. Tell her what you are going to do. Do all of your looking as gently as possible. Get a radiograph of the area. Either extract the tooth today or put her on antibiotics and wait 5 days and then extract. You must keep in constant contact with the parent to make sure the infection doesnt progress into a cellulitis if you choose this course of action. If the gumboil pops, the pressure will be gone and the pain may go away. When the tissue heals over the opening again, the pressure will build up and the pain will return. Explain this to the child and the parents. They may think if there is no pain everything will be alright.

39. An abscess of a permanent tooth will show at the apex on a radiograph. On a primary

molar it is in the bi- or tri-furcation area. The floor of the pulp chamber of a primary tooth is porous and the by-products of an abscess will go right through the floor.

An 8-year-old with both permanent upper laterals in cross-bite. This has to be treated

before the upper cuspids come down and trap the laterals. Treat these right away. 40. Bruxism and attrition are common in children. They usually grow out of it when they get

their permanent teeth. The pulp chambers have filled up with reparative dentin. The parents are concerned but there is nothing you can do about it.

41. Ankyloglossia (tongue-tie) is not a severe problem. Most parents are concerned because

of the appearance and what they think may go wrong with speech. If the child is past 2 years of age the correction of the situation will usually not help change any speech patterns but it will help the looks.

This ankyloglossia case should be treated because of the damage being done to the tissue

between the central incisors. 42. The lower arch of this 5-year-old has a few problems. When the stainless steel crowns

were placed a salivary duct was irritated and closed up. A ranula resulted but opened up on its own within a few days, otherwise surgery would have been required. There is an abscessed lower left 1st primary molar that will need a pulpectomy and a crown or extraction and a band and loop. The facials of the lower canines have caries. This weak spot on the facial of upper and lower primary canines is common. I think it is caused by the position of the developing primary canine being pushed up against the facial bony plate of the alveolus while it is in the crypt.

This is an upper arch of an 8-year-old with Dilantin hyperplasia. Spend a lot of time with

this type of patient in developing good oral hygiene habits. If the tissue grows over the biting surfaces, periodontal surgery will be needed. 43. Internal resorption of a primary molar on a 10-year-old. By the time you see it like this, it

is too late. The thin root has been perforated. A pulpectomy has to be done early if it is to

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be successful. In this case you could leave the tooth in place (it is causing no harm) and it may hold space long enough for the premolar to erupt without space loss.

An occlusal film of an 8-year-old with a cleft palate. They may have missing teeth or

extra teeth in the area of the cleft. They need treatment like everybody else. You would like to retain arch length in the cleft area. Don't be befuddled by a radiograph in front of a patient. Do your homework prior to explaining the situation to the child or the parent..

44. This is an occlusal radiograph of a 2-year-old who has had trauma. Both primary centrals

will have to be removed. There is also a mesiodens present that will have to be removed to allow for the proper eruption of the upper centrals. If the mesiodens were near the apex of the developing permanent centrals you would postpone its removal until the centrals had erupted.

A ray of a central with dens-in-dente that should be restored. This mesiodens should not

be removed before the permanent centrals have erupted and the apexes have closed. 45. An occlusal radiograph of a 3-year-old with calcific metamorphosis. This is a response to

pulpal irritation - trauma in this case. The only problem with this - it may not resorb at the same rate as its partner and will have to be extracted. Keep an eye on it to assure both permanent centrals erupt at the same time.

Radiograph of an ankylosed primary molar in an 8-year-old. It is below the occlusal

plane and this can result in some space loss as other teeth tip over it. The crown may be built up with composite or a stainless steel crown placed. If the tooth is removed a space maintainer should be placed.

46. Gemination of a primary lateral in a 3-year-old. The crown tends to split into 2 crowns.

There is 1 root and 1 root canal. The crown is wider than normal and will take up more room in the arch. There is usually the right amount of teeth in the arch. Look for possible problems with the permanent successor.

Ray of a the geminated primary lateral. The pulp chamber is much wider than normal.

The permanent lateral looks OK . 47. Ray of fused primary incisors. There are 2 roots and 2 pulp canals. In the mouth these

teeth can sometimes look like gemination. But if you count the odd looking tooth as one unit, there will be one less tooth in the arch than normal. Look at the radiograph and you can make a decision.

Ray of a 9-year-old child. When this child was 3 years old, he traumatized his upper

central. They went to a pediatrician. She said it was just a baby tooth and it would be OK. This was their first dental visit and they only came because they suspected something was wrong because he still had a baby tooth in the front of his mouth. The primary tooth abscessed soon after the accident. You can tell this because there was no secondary dentin formation in the primary central. The resulting lesion caused the permanent central

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to deviate from its proper course and then cease developing altogether. There has been space loss and the midline has shifted. The permanent central has to be extracted. There is a large defect in the area. Orthodontics will be needed to correct the spacing problem. A costly mistake because "it was only a baby tooth."

48. This mesiodens should have been removed early on, it was low in the arch and impeded

the permanent centrals from erupting into their proper position. It is easy to remove but the centrals will now have to be moved orthodontically to align the roots. It would have been self-correcting if the mesiodens had been removed early in the game.

49. This 13-year-old boy has enamel dysplasia due to a disturbance during enamel formation.

His brother had the same kind of malformation. We couldn't trace anything that could have caused this much damage. These teeth can be restored with acid-etch composites. The canine on the right slide has been restored. A senior dental student here at U of L restored all the teeth and published the case in the Journal of the American Dental Association.

50. Hypoplasia. This was easy to restore with the acid-etch technique. There was virtually no

caries in this patient, who had a lot of allergies. Amelogenesis in a 4-year-old. Primary and permanent teeth are affected. What little

enamel he had has chipped away. This patient needs stainless steel crowns to maintain space and also to maintain vertical dimension.

51. The upper arch and the occlusion of this same amelogenesis patient. He had an abscess of

his upper central. The supporting structure was so destroyed that the tooth had to be removed.

If stainless steel crowns aren't placed soon, vertical dimension will be lost. 52. Panorex of the amelogenesis case. The bulbous enamel of normal teeth did not form and

the teeth look like square pegs. There is no width to the teeth. The permanent teeth are also involved in amelogenesis imperfecta.

The same patient with stainless steel crowns. There was little or no preparation required

on these teeth before the crowns were placed. 53. Same amelogenesis patient. Notice how the bite has been opened. Another amelogenesis patient with bands and composite used to restore the canines. 54. Full mouth and Panorex of the amelogenesis imperfecta patient. Permanent anteriors

were coming in and were very sensitive. Bands were cemented in place until complete eruption and a more esthetic restoration could be placed. Notice the lower right 1st permanent molar. It is in bad shape now. You can get behind in a hurry with this type of patient. Keep your eyes open.

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55. Dentinogenesis imperfecta in a 4-year-old child. The teeth are amber in color, iridescent.

Enamel is normal but not attached well to the dentin. It will chip away easily. These teeth will need to be covered with stainless steel crowns just like the amelogenesis case. The permanent teeth will be affected also.

56. Dentinogenesis imperfecta - teeth in occlusion before and after treatment. Vertical

dimension has been regained. 57. Congenitally missing teeth in a 5-year-old. When upper permanent laterals are missing

the permanent centrals sometimes are missing a lobe and are skinnier than normal. This compounds the problem of esthetically restoring the mouth. This child will need dental treatment over an extended period of time. Space management is a must. If this patient has children they will have a good chance of having missing teeth also.

58. The same patient with a lower partial for space maintenance and esthetics. 59.-62. Ectodermal dysplasia. These patients have fair complexions, sparse hair, saddle nose,

little or no eyebrows, and may be missing fingernails and sweat glands. There are a lot of these people in the state of Washington. They have missing teeth and cone shaped teeth. If they are missing primary teeth, there will not be a permanent successor. This child had 4 primary upper anteriors and 2 lower canines. The same number of permanent teeth was also present. All other teeth were missing. Overlay dentures are one answer to achieve function and esthetics. If there are congenitally missing teeth, there will be no alveolar bone in the area, just basal bone. If they don't have sweat glands, they have trouble in the summer time, they heat up in a hurry. Maybe that's why a lot of them are in the mild climate of Washington.

63. A common problem in the mixed dentition is ectopic eruption. Instead of the 1st

permanent molar sliding up the enamel of the 2nd primary molar like the tooth in the lower left slide, it will approach at a more acute angle and hit the root of the 2nd primary molar. It will then start resorbing the dentin and then get hung up under the enamel. This is the case with the molars in the upper left of the radiograph and also on the radiograph on the right. If no treatment is attempted, the permanent molar may be hung up for years or resorption may go on to completion and the primary molar will be lost prematurely, resulting in space loss. There are two modes of treatment. Push the permanent molar distally and retain the primary molar or extract the primary molar and then push the permanent molar distally and hold it in place with a space maintainer.

64. Habits. A thumb sucking habit will usually cause a symmetrical defect. A class II

malocclusion with a large overjet and overbite and a constricted upper arch resulting in a cross-bite. The lower anterior teeth will be tilted to the lingual, increasing the overjet. The upper and lower teeth will not interdigitate anymore, they will hit one on one.

65. Enlarged tonsils and adenoids can cause abnormal breathing patterns resulting in

unwanted tooth movement. If the child is a mouth breather, the lips and cheek muscles do not perform their job and the teeth will find a new equilibrium.

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66. Two cephalographs showing before and after pictures of a patient with enlarged adenoids. Controversy - Dr. Peter Vig says the amount of airflow is determined by nares opening, not the airway in the adenoid area. You have to correct the cause of the problem before correcting the problem or the teeth will go right back to their original position when you remove your appliance.

67. A constricted upper arch in a 7-year-old resulting in a convenience crossbite. When the

child occludes, the teeth hit end on and this doesn't feel good so the child shifts the lower jaw to one side or the other, ending up in a cross-bite. You can tell there was a lateral movement of the lower jaw by looking at the midline - it doesn't coincide. Have the child open and close and watch the movement.

A lip sucking habit can also cause a malocclusion. In all the habits we have seen, if they

are mild and are discontinued before major movements have occurred - the occlusion will remain normal. The cases I have shown are fairly severe. Habits cause trouble by the length of time and the energy involved in the habit.

68. After you have gathered all the information about this patient, write on a paper towel all

the procedures that have to be accomplished to put this patient in good shape. This is a draft of your treatment plan. Call an instructor over and we will work with you in finalizing the plan.

69. After the treatment plan is okayed, copy it in the chart. Write in the procedure codes and

the clinic fees. The parent will want to know - how many visits and how much will it cost me. Write the procedures in groups of what can be accomplished on each visit. Try to complete all the work in each quadrant to minimize having to repeat the same injections. Tell the parent approximately how many visit there will be. The instructor will OK the plan at this time but will not sign it until the parent agrees to the plan and signs it.

70. Present the treatment plan to the parent either out in the waiting room or if is quiet in the

clinic, you can bring them back. Answer any and all questions at this time. 71. One of the first items on the treatment plan is usually a PHP. Make all notations about the

preventive procedures on page 5 of the chart. 72. Explain the prophy procedure to the patient if they haven't had one before. Show the

patient the rubber cup and the suction apparatus before you start. You can have the patient by the sink during the fluoride treatment if you wish.

73. After all procedures are finished for the day, call an instructor over and get checked off.

Have your progress notes, and grade sheet filled in properly. Make sure all radiographs are mounted and dated.

Return the patient to the parents and explain what was accomplished and what to expect

on the next visit. Compliment the child in front of the parents. You will get better compliance from the child with repeated compliments during treatment.

74. If your patient comes in like this child on the left, try to have him leave like the child on

the right.

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TOPIC: PEDIATRIC DENTAL RADIOLOGY AND RADIOGRAPHIC INTERPRETATION

Reading Assignment

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham Chapter 18 (pp. 280-284), Chapter 30 (pp. 469-474), Chapter 37 (pp. 607-610)

Objectives Upon completion of the reading assignment and attendance at class lecture, the student should be able to: 1. describe possible difficulties in obtaining radiographs from children; 2. describe some patient management techniques for overcoming these difficulties; 3. describe how the guardian may be employed to obtain necessary radiographs; 4. describe how aids such as film holders, tape, etc. may be used to facilitate radiograph

making; 5. describe four measures that should be taken to ensure radiation hygiene; 6. describe the views of and the techniques for producing a preschool radiographic series; 7. describe three ways to make the taking of bitewing radiographs more acceptable to the

patient; 8. describe the views of and the techniques for producing a mixed dentition radiographic

series; 9. describe how to determine whether two or four bitewing radiographs will be sufficient for

diagnosis in the mixed dentition; 10. identify the structures reproduced in a routine panoramic radiograph; 11. describe the radiographs that would be appropriate for diagnosing injuries following

trauma to the teeth, face or head; 12. identify common pathology or anomalies in children by how they present on radiographs;

and 13. describe the guidelines of the Academy of Pediatric Dentistry concerning indications for

radiographs on children and adolescents.

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Slide Notes for Pediatric Oral Radiographic Technique 1. Title: Pediatric Oral Radiology Clinical slide of maxillary anterior occlusal technique 2. Parental concern must be addressed. Risks to patients if radiographs are not taken: irreversible damage, compromised

treatment, increased risk of failure, and more costly care. 3. Indications for radiographs: clinical evidence of injury, disease (caries), pulpal pathosis,

delayed or accelerated eruption or exfoliation, swelling, hemorrhage, pain, or ulceration 4. High-yield criteria for exposing radiographs in asymptomatic children: In the primary

dentition, take posterior bitewings if proximal contacts closed and the child is cooperative to determine presence of interproximal caries.

High-yield criteria are meant to identify patients who are most likely to benefit from radiographs.

5. In the early transitional dentition (permanent first molars erupted) take anterior occlusal

radiographs to detect supernumerary teeth or missing teeth. An exam that includes all tooth-bearing areas is recommended at this time to detect pathoses and proximal caries, and to aid in the early diagnosis of developmental anomalies. This may consist of posterior bitewings and one of the following: a. posterior periapical radiographs or, b. panoramic radiograph or, c. lateral jaw 45-degree projections.

In the early permanent dentition (postpubertal; late adolescence) radiographs are made to

evaluate the same tissues as in the early transitional dentition and to evaluate the position and development of the third molars. This examination should be made within two years of the eruption of the permanent second molars. The practitioner who is providing the orthodontic diagnosis and/or treatment may prescribe a cephalometric radiograph.

6. Risk of dental caries is classified as either high or low. A high risk to dental caries is

associated with; poor oral hygiene, fluoride deficiency, prolonged nursing,, high carbohydrate diet, poor family dental health, developmental enamel defects, developmental disability and acute or chronic medical problem, or genetic abnormality.

The child with a high risk should have bitewing radiographs made as soon as posterior

primary teeth are in proximal contact. The age of the patient is not an important variable, If interproximal caries are detected and restored, follow-up radiographs are indicated semi-annually until the child is caries-free and classified as having a low risk of dental caries.

7.-10. A child with a low risk of dental caries may be defined as a normal, healthy,

asymptomatic patient exposed to optimal levels of fluoride, performing daily preventive techniques and consuming a diet low in cariogenicity. The low risk patient with closed proximal contacts should have posterior bitewing radiographs made. If no caries are found, then radiographs may be made every 12 to 18 months if primary teeth are in

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contact, or up to 24 months if permanent teeth are in contact. Bitewing radiographs may be made more frequently if the child enters the high-risk category. The more rapid progression in primary teeth should be considered in determining the time interval between bitewing radiographs.

Exposing radiographs to document treatment result, when not needed to establish the

presence of pathosis or aid in establishing a diagnosis, is considered unnecessary and an unwarranted exposure of the child to ionizing radiation. These recommendations are an attempt to fulfill the professions obligation to establish guidelines for the optimal use of diagnostic radiography with minimal radiation exposure.

11. Film Size - #O, #1, #2, Occlusal Comparison of film sizes 12.. Appropriate Radiographic Surveys (Blank) 13. Eight Film Series - 2 anterior occlusals, 2 posterior bitewings, 4 posterior periapicals Example of eight film series 14. Panoramic Film - Posterior Bitewings Panolipse of an 8-year-old 15. Anterior maxillary occlusal film showing periapical lesion above right primary central,

impeding eruption Panoramic film of 5-year-old 16. Mesiodens (clinical and radiograph) - one of many reasons for taking radiograph.

Mesiodens between two centrals - should have been removed before centrals erupted. Tough to treat now.

17. Clinical slide of darkened F with calcific metamorphosis Radiograph of same patient showing the chamber and canal filling in 18. Introducing the Child to Intraoral Radiology Walking with child patient to x-ray room - talk to child, make a game of it - a new

experience - you are looking for cooperation. 19. Use Tell - Show - Do; tell the child using camera analogy; show the child a film packet,

unexposed and exposed; and do a dry run Dry run desensitizes the child and determines the childs ability to sit still 20. 3 to 6 year old - may have difficulty cooperating. Radiographs can be delayed until

cooperation can be managed Check all settings and position the tube before the film to allow for short attention span

and gagging. 21. Do easiest procedures first. Do anterior occlusal films before bitewings and periapicals

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22. Place apron and collar on patient - don't take films without lead protection. 23. Clinical picture demonstrating proper angulation for maxillary occlusal - 60. Radiograph of 4-year-old - should be able to see primaries and developing permanent

teeth.. 24. Important! When you push the button you are looking at the patient. Were Not Shooting A Movie 25. If You Cant Get The Child To Hold Still - Dont Expose The Child Blurred Film 26. A panoramic film is a good aid in the diagnosis of structures in the oral area. A typical

Panorex set up with a child patient in the chair. This Panorex of a 3-year-old demonstrates development you would expect at this age.

27. Clinical picture demonstrating proper angulation for lower occlusal film. Tilt head back

(chin up) + 30 and angle the tube up at a -30. Or use -15 and head tilt of +45O. Radiograph of 4-year-old - primaries and permanent teeth should be in view. 28-31. Another technique for obtaining anterior films on a child patient. Upper and lower anterior teeth on one occlusal size film Fold an occlusal film in half crosswise (crease perpendicular to the film's long axis) with

the writing side of the film toward the inside. Tell the child what you are going to do and why. Show the child how to hold the film in

his mouth by standing in front of him and mimicking a mouth by alternately opening and closing your thumb against its opposing fingers. Then put the film between your thumb and fingers and at the same time, clench your teeth with lips apart and say, 'Hold the film with your teeth just like a cracker and be very still so we can get a nice picture of your teeth." "This is not a moving picture camera, so you have to be still. It doesn't make any loud noises or ring bells, it just takes pictures of your teeth.

Adjust the back of the chair to its most upright position. Place the film in the child's

mouth with the crease toward the front of the mouth, and again mimic the closing yourself. Position the child's head so the occlusal plane is parallel to the floor, and direct the central X-ray beam at a 60 downward angle through the tip of the nose for upper anteriors.

Tell the child to stay closed. Raise his chin upward 30 to the floor, and reposition the

central X-ray beam at a 30 upward angle through the apices of the lower central incisors. This is a nice record of the relationships of upper and lower anterior teeth and unlike the regular series of anterior radiographs, the radiographs cannot be mixed up. This is a nice way to be able to show the child and parents the growth and development pattern of the child's developing dentition.

32. Bitewings - bend the corners of the film for patient comfort Round the film lengthwise over your finger to conform to shape of mouth

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33. Bitewing with all four corners creased and longitudinal crease that covers contacts. Dont

do this. Bitewing radiograph of a 3-year-old with interproximal caries. 34. Go To #2 Film on Eruption of Permanent First Molar Bitewing radiograph of 9-year-old 35. Two bitewings showing effects of not centering the tab of holder, giving unequal

coverage of maxillary and mandibular developing teeth, possibly missing important information..

Right bitewing shows missing second premolar. 36. Usually see second premolars at age 4; may not see until age 8. 37-38. For a readable radiograph - the central ray must be parallel with the marginal ridges of

the teeth This is an acute angle with the sagittal plane - not perpendicular to it. Have the child open

his mouth and look at the direction of the marginal ridges. Get a mental image of this so you can line up the tube head in the right direction. Most mistakes in bitewings are overlapping contacts caused by lining up the tube head at right angles to the sagittal plane.

Bitewing Technique: Tell the child, in words he can understand, what you are going to

do. Select the largest size film that will comfortably fit in the child's mouth. Show the child the film. Bend all four corners of the film (if necessary) and tell the child that bending it makes the film fit better. Show the child how you want him to close on the tab and stay closed, by gritting your own teeth with your lips apart. Use stick-on film cushions if you need to for painless placement..

Prior to placing the film in the child's mouth, put your own index finger in his mouth at the site of the first exposure. Put your finger between his tongue and lower molars and say, "This is where I will put the film and this is what it will feel like." This helps with little people.

Stand directly in front of the child. Start with the film horizontal and rotate it vertically

into the space between the tongue ant the lower molar area. Try to keep the film far enough distally so it won't irritate the anterior floor of the mouth.

Hold the film tab on the occlusal surfaces of the lower teeth. With the index finger of

your other hand, slightly bend the upper portion of film toward the midline. (This will help prevent the child from biting on the film instead of the tab.) Now ask the child to "close slowly," while guiding the upper portion of the film to the palatal side of the upper teeth. Withdraw this finger, but continue holding the tab with the other hand as the teeth Slowly (emphasize "slowly") come together, and close on the tab. (Note: Do not tell the young child to "bite" on the tab, as this often results in a chewing motion.)

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39. As the child is doing this, you mimic the action of his closing on the tab by again clenching your own teeth with your lips apart saying, Now keep your teeth together while I take the picture." The X-ray head should be positioned at +10, and the central ray should be directed parallel to the marginal ridges of the teeth involved and not perpendicular to the mid-sagittal plane.

If the child should gag and open up or spit the film out, it is best to acknowledge that the

child has gagged and say, "Let me make the film smaller (fold over corner more), so it won't bother you next time." Words of encouragement are never lost on a child. If the child should start to rebel on the next attempt, a firm command such as "stay closed" is usually enough to gain the child's cooperation.

Don't forget to thank the child for doing such a good job. Bitewing radiograph that was not positioned horizontally in the childs mouth. 40. Bite Vs. Close Sometimes kids chew when you say bite; close is better. 41. Acceptable bitewing - patient obviously has teeth tightly closed Not as acceptable - patient failed to closed completely together 42-43. The primary maxillary molar projection. The Rinn Snap-A-Ray is used to hold the size 0

film, which should be creased at the anterior to conform to the mouth. The child bites on the plastic that holds the film in the mouth. Be sure the occlusal

portion of the teeth is on the plastic. The central x-ray beam is directed at a point on the ala-tragus line directly below the pupil of the eye at a vertical angle of 40

The horizontal angulation is obtained by referring to the plastic holder as it protrudes

from the patients mouth. 44. The mandibular molar projection. The Rinn Snap-A-Ray is again used this time with the

patient biting on the plastic and holding the size 0 film against the primary mandibular molar teeth. A negative vertical angulation of 10 is used and the plastic film holder again determines the horizontal angulation. Be sure the film is anteriorly far enough to include the distal half of the canine.

If the film impinges on the tissue in the anterior floor of the mouth, crease the anterior

corner. If this is not done the child may not bite all the way on the film and the apices of the molars will be missed.

Mandibular molar periapical radiograph 45. A lateral jaw film may be taken in the absence of a panoramic setup. The tube head is

angled -14O under angle of mandible aiming at the occlusal plane in the area of the permanent first molar on the opposite side of the mandible.

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Here are three views of an adult patient using the lateral jaw technique. Every dentist should be able to take lateral jaw films to adequately diagnose areas outside of normal periapical views.

46. Lateral jaw film of a child Lateral jaw film of an adult 47-48. A lateral jaw technique to obtain both left and right views on one film is shown. Have the

child patient lie belly down on the dental chair. A lead shield divides the film cassette in half. Place the cassette under the child's head and expose the film. Have the child turn his head in the opposite direction and move the lead shield to the other side of the cassette and get your other view. This is a simple method and works well with children. Lateral jaw films of children are shown.

49. Behavior management is a must to obtain quality films. The child on the left will most

likely be an excellent patient and will offer no resistance to the new experience of film taking.

The child on the right is likely to be a problem. 50. If you have a lot of children in your practice, gear your operatory and radiology area to

be inviting to them.-- Place a fluffy animal on the X-ray head.. Little people are uncomfortable in unfamiliar and large surroundings. If you can make them feel wanted and needed, that is half the job,

51. Let the child inspect your equipment; tell them about it. Let the child hold the film and see for themselves it is not something to be afraid of. 52-54. A technique of obtaining anterior films on an eighteen-month-old. Have the child sit in his

mothers lap. Lead aprons on both if possible. Let the child feel the film, show him the camera. Let him put the film in his mouth and get the feel of it. Mother will have to steady the child's head and help hold the film.

55. Another method of obtaining an anterior film on a young child. The parent holds the film

(tape may help hold the film in your hand) and places it and hold it in the childs mouth. 56. Radiograph of parents finger on preceding film. 57. A partial denture can be used to help guide first permanent molars into their proper

position. In this case, a radiograph was taken to determine the distal extent of the partial denture using lead foil was to show the end of the acrylic. A little more acrylic needs to be removed from the appliance.

58. On some patients the only time films can be obtained is under general anesthesia on the

day of treatment. Place the film in the patient's mouth with a film holder and secure the placement with a towel and towel clip.

The resulting radiograph allows for proper treatment. 59. An occlusal film can be taped to the side of the head and used instead of a lateral jaw

cassette. On this radiograph, a supernumerary is seen apical to the anteriors.

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60-61. Angulation of the X-ray head is all important. The slide on the left shows what appears to be an ectopic permanent second molar. The radiograph on the

right is one year later and the upper permanent second molar appears to be resorbing the distal of the permanent first molar and being trapped in the process. The next film is seven months later and all appears normal. The resorbed root is now OK. Angulation was the culprit (super-imposition) Cervical burnout was also involved. Use films with different horizontal angles when diagnosing ectopic eruption.

62. Another "case" of ectopic eruption. Two different angles on the same appointment.

Maybe this is why some "ectopic eruptions" cure themselves if left alone. 63. Tooth fragments in lower lip. Look around when there are puncture wounds in trauma

cases. 64. Cephalometric Machine Lateral Ceph 65. A good looking cephalometric film showing hard and soft tissues and well-demarcated

airway. Ceph tracing for orthodontic diagnosis 66. "Jaws" A double exposure of a lateral cephalometric film and an anterior radiograph on

same film. Be careful - don't overexpose the patient with unnecessary radiation.

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Slide Notes for Radiographic Interpretation 1. Title slide Radiographic Interpretation 2. Dissected skull of 5 -year-old. The developing permanent anterior teeth are to the lingual

of the primary teeth in both arches. Crowns of permanent anterior teeth are fully developed at this time. The upper permanent canines are high and the lower permanent canines are low. Upper permanent laterals are lingual to the developing permanent centrals. Notice there is little or no bone between primary and permanent teeth at this time.

Anterior PA of 2-year-old. Upper permanent anteriors are partially developed. Always

look for symmetrical development. The upper permanent laterals are lingual to the permanent centrals normally. On a radiograph the laterals appear to be directly behind the centrals but in reality they are lingual and slightly lateral to the centrals.

3. Skull of a 5-year-old, lower anterior view. Notice the relationship of the developing

permanent teeth to the primary teeth. All permanent anterior teeth develop lingual to the primary teeth. If there is crowding at six to seven years of age, the centrals and laterals will erupt to the lingual with the primaries sometimes remaining in place. In a crowded mouth, the canines nearly always will go to the labial.

Lower anterior radiograph of a normal 3-year-old. Notice the generalized spacing; this

child will probably have a nice lower permanent arch. 4. Skull, upper right quadrant of a 5-year-old. The permanent canine is high. Premolars

develop between the roots of the primary molars. On a panoramic radiograph, the permanent canines appear high and low; this gives you a reference point when counting teeth.

Radiograph of upper posterior quadrant of a 6-year-old. The first permanent molar is in,

(child is over six years of age), permanent lateral is not in (child is less than eight years of age). Notice the normal position of the premolars developing between the primary roots. This is an important point if there is pulpal necrosis of a primary molar. Look at developing premolars on the skull and on the radiograph and notice the radiolucent areas.

5. Skull, lower right quadrant of a 5-year-old. Permanent canine is lying on basal bone, far

lower than other developing permanent teeth. However, it will catch up and usually erupt before the premolars. At an early age, there is bone between the developing permanent premolars and the primary molars. As time goes by, there is no bone between these teeth. This is a potential problem in the presence of an infected primary molar because the floor of the pulp chamber of the primary molars is very porous.

If there is an infection in a primary molar, the noxious acid by-products leak into the bi-

or trifurcation area around the developing tooth, which is not fully mineralized. The developing permanent tooth may end up with white or brown spots or may be fully arrested in development.

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Radiograph of lower posterior quadrant of a 5-year-old. The primary first molar has undergone pulpal necrosis and exhibits bifurcation involvement. The first permanent molar is about to erupt (5 1/2-year-old). This development pattern is normal.

6. Lateral view of a dissected skull of an 8-year-old. Upper centrals and laterals are more

angulated - flaring out, to allow more room in the arch. The roots of the central incisor and the permanent first molar will reach apexogenesis around 10 years of age.

Periapical film of upper right quadrant of an 8-year-old with normal arrangement of

primary and permanent teeth. 7. Anterior view of a dissected skull of an 8-year-old. Ugly duckling stage - upper

centrals and laterals are pinched in by the developing upper canines. This is a variation of normal. Parents may ask you to straighten the centrals and laterals at this time. Wait until the canines come down - it probably will be self-correcting. If you try to align the centrals and laterals - their roots may be resorbed by the canine during treatment.

Clinical photograph of a crowded arch of an 11-year-old. There is not enough room in the

arch for the canines. They are erupting to the labial. 8. Radiograph of an infant's upper primary anterior teeth just prior to eruption. Primary

incisor crowns are usually completed by thre