Pediatric Dentistry Dd2011-2012

8/20/2019 Pediatric Dentistry Dd2011-2012

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M|jor Topic

Abbreviation

Major

Topic Abbreviation

teeth

Abn

Tth Primarv Dentin Prim D€nt

Behav

Mgmt Pulp

Treatment

Pulp Tx

&

Conditions

Dis

&

Cond

Restorative

Restorative

Drugs

Space

Management

Space

Mgmt

Fluoride

Tooth Development

Tth

D€v

Information

Gen

Info

Tooth Trauma

Tth Trauma

Misc.

EDIATRIC DENTISTRY Abn

Tth

The

photograph

shows an example

of

in

a

five-year-old

girl.

imperfccta

imperf-ecta

hypoplasia

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access

or reproduction

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rhe

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I l0l2



imperfecta

1D1,

is an autosomal dominant trait.

its frequency of occurrcnce

is about 1 in

This inherited dentin defect originales

during the histodilferentiation

stage oftoolh dcvclopment.

Thc

matrix is defective resulting

in amorphic, diso.ganized, and atubular

circumpulPal

dentin. Teeih are

or bro$n

and

abrtde

rapidly.

Occasionally,

these teeth become

abscessed as a

result ofexposure

homs caused by

wear. Full

covcragc

is the t.eatm€nt of choice.

Both the

primary and

permanent

are afTected

in dentinogenesis imperfecta.

lmportant:

Radiogmphs

ofa

preschool

child

with

dentino-

impefecta

will

show

obliteration olth€

pulp chrmbers with

secondary

dentin,

a

chamcteristic

find-

of

te€th usually are narrower

tnd app€ar more fragile. Crowts

gcnerally

appear

more

bulbous

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.

imperfect is

one

ofthe

major defects of enamel.

It is a hcreditary disease

characterized by

deve)opment ofthc

enamel. There is normal

pulpaland

root morphology.

Thcrc are four

major catcgorics

to the stages oftooth

development

in wbich

each

is thought to occur

.

Hypopkstic Type:

occur

in the histodifferentiation stage oftooth

development.

There is an insullicient

quantity ofenamel formed

duc to

areas

ofthe

enamel organ that

are

devoid

ofinner

enamel ePith€lium, 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,



Abn

Tth

PEDIATRIC

DENTISTRY

What condition

is

depicted

in

the

radiograph

below?

2

Copyrighr

e 20ll-2012

EDIATRIC DENTISTRY Abn Tth

What condition

is

depict€d below?

hypoplasia

fetalis

caries

dysplasia

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is

lovemed

br

a

license.

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accessor

reprcduction

is

forbidden wirhout

the

prior*nuen

pemissior

ofthe

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Washingron.

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3

Coplighr

a{i

20ll-2012



tcrm

Dens-in-dente

(also

called

clens

inNaginatus)

means

a

"tooth

within a toothri

and

results

the

invagination ofthe inner enamel

epithelium.

Most

frequently involves the maxillary lateral in-

clinical significance ofthis

anomaly results

folm

potential

carious involvement through com-

ofthe

invaginated

portion

ofthe

lingual

surface ofthc tooth

with thc

outside environment.

and dentin in

the

invaginated

portion

can be both

dcfective

and abscnt, allowing dircct

cx-

of thc

pulp.

evaginatus is an extra cusp. usually in the central

groove

or ridge of a

posterior

tooth and in thc

area

of central

and

lateral incisors. In incisors,

these cusps appear

talon-shaped. It

results

the evagination

of

inner enamel epithelial cells. This extra

portion

contains not only enamel

but

dentin and

pulp

tissue, therfore, care must be taken with any

operative

procedure.

is

a

proccss in

which

a

singlc

tooth

gcrm

splits

or

shows

an

attempt

at

splifting to form

two

or

partially

separated crowns. This

process

results in incomplete formation ofnvo teeth. Likc

it is also more common in the

primary

dentition. It results in a bifid crown

with

a single

pulp

It most frequently occurs

in

the incisor region. Concrescence is

a

twinning

anomaly invoJv-

union of two teeth by ccmcnfllm only. Its etiology is thought to be hauma or adjacent tooth mal-

ofteeth is a

condition

produced

when t$,o tooth buds arejoined together during development and

as a macrodont

(a

single large crown). It is morc common in the

primary

dentition. It may involve

entire length of two leeth

(enamel,

dentin, and cemenlum) ot

jvst

the rcot

(dentin

and cenenlum).This

is usually seen in the incisor area. Although fused teeth can contain two separate

pulp

cham-

many

appear as

large bifid crowns with one

chamber

Note: A radiograph is needed to confirm

thcre is fusion or

gemination.

.

I

.

Taurodont teeth are chamcterized by a significantly elongated

pulp

chamber with short

Not{dt

stuntedroots resulting from

the

failure

ofthe

proper

Ievelofhorizontal

invagjnation

ofHer-

t\r

ie's

cpithclial

root sheath.

.a

-

l.

dilace.ation refers ro an abnormal bend ofthe root during its developmcnt; it is thought

to result from a traumatic episode, usually to the

primary

dentition. It is a consistcnt

finding

in children with congenital ichthyosis.

hypoplasia

lEIl)

is a

defect

in

tooth cnamcl

that

results in less

quantity

ofcnamelthan

normal.

can

be

a

small

pit

or dent

in

the tooth or can

be

so

widespread that the entire

tooth is small

mis-shaped. This type ofdcfcct

may cause

tooth sensitivity

may bc

unsightly

or may be more sus-

to dental cavities.

Some

genetic

disorders cause all the teeth to

have enamel h)'poplasia.

EH

can

any tooth or on

multiple teeth. It can appear whitc,

yellow

or

brownish in color

with a rough

pifted

surface.

In

some

cases.

the

quality

ofthe

enamel is affected

as

well

as

the quantity.

and

genetic

factors that interfere

with tooth formation are thought

to be responsible for

.

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)

depend on

the

severity ofthe EH on

a

particular tooth and the symptoms

associated

it. The most conservative

treatment consists ofbonding

a

tooth colored

matcrial to the tooth to

pro-

it t'rom

further

wear or sensitiviry

[n

some cases, the nature

ofthe

enamel

prevents formation

of

an

bond. Less conservative

treatment options, but frequently

necessary include

use ofstainless

pe(nanent

cast crowns

or extraction of affected

tccth and replacement

$ ith

a

bridge or im-



part per

million

million

million

parts per

million

(ZSD)

reinforcement

communication

1

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2



offluoride in caries

prevention

is

a

very

important one. Indeed. one oflhe most significant contribu-

ofworld free enierprise systems to the health of

people

is to market fluoridated tooth

paste.

Huge re-

in

caries

prevalcnce

have been made in the

populations

of

numerous countries where fluoridated

arc uscd rcgularly.

major reason for the decrease in decay rates is that low concentralions offluoride

are

prescnt

in

peoples'

this is very etlective in the remineralization ofdemineralized teeth. For examplc,

over ninety

per-

ofihe toothpastes sold

in thc

United States contain

fluoride. This amounts to a massive

public

health un-

by rhe

private

sector Tle significant impact

on decay rates demonstrates

thc importancc offluoridc

caries

prevention.

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.

studics and surveys link fluorosis

to

three

factors:

.

Fluorosis is more

common

in

geographic

areas where the endemic levels offluoridc

in lhe drinking waler

is higher than three

parts

per

million

.

Fluorosis is associated

*,ith

fluoride supplementation at inappropriately

high levels

.

Tle

use

offluoridated

tooihpaste has been implicated in fluorosis

Excessive fluoride

levels in

drinking

water are associated with fluorosis. Fluoride

levels

in

elcess

parts per

million

begin to

pose

a

risk for fluorosis. This has been demonstrated in

numerous

sludies

decades ofresearch and in

various geogmphic

setiings

around ihe world.

Dentin

Dysplasia is another

group

ofinherited dentin disorders

resulting in characteristic

l_eatures

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.

palients

usually will

not know what to

expect

during dental appoinhrents and

many

will

be at an

$

hen thev have considcrablc

fcars

ofthe unknown.

The TSD shategy is dcsigned

to deal with those

-

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 watch

the

procedure

in

the

hand-held mirror seems to diffuse anxiety.

-

This approach

$orks esp€cially well when trcating

a

child

with a different cultural

background.

The

clinical

cxamination

ofthe infant and toddler should be

accomplishcd

with

thc

par-

in a non-threatening environment.

Most often. it is neither

necessary nor recom_

that

the

dcntal

chair be used. The

parent

and

dentist

sit facing

cach other

in a knee-to-knee

supporting the child

l'ith

the head cradled on the dentist's

lap.

.

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

conditioning:

is a

form

ofbehavior

training or

modification

jn

whioh

a

noxious evcnt

is

uscd

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



restraint

technique

(HOME)

the child to express his feax

reference

to the child's fear

conhol

communication

6

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behavioral pattems

afe motivated by anger

and fear. The crying child is

NOT

an abnormal

child.

is easier to treat than fear. Fear is most

likely to be exhibited

by a

young

child on

his

first visit to

dentist. This is related to the anxicty

over being separated from

a

parent. The parent,

not the dentist,

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

cation of bchavior:

.

Cooperative:

children

with minimal

apprchcnsion and respond well to behavior shaping

.

Lacking cooperative ability:

children are deficient in

comprehcnsion

and/or communication

skills

(i-e.,

re^

roung

children and children wilh ce ain disabililies).

.

Potentially

cooperative: chid.en are capable ofbehaving but are disruptive in the dental setting.

-

Uncontrolled:

characterized

by

temper tantrums.

Typically

3-6

years

ofage.

-

Defiant: characterized by

"l

don't want to" attitude or

passive

resistance.

All

ages.

.

Timid: typically

preschool

and younger grade

school children.

Hide

bchind

parent

or put hands

ovcr

thcir mouth and face.

.

Tense-cooperative: coopentive but are very nervous. "White-knuckler"

patients

because they

grip

the dental chair arm rests so tightly.

.

Whining:

they

whinc throughout

the

\r'hole

appointment.

means

providing the

child

with cues and reinforcements

that

dircct

them toward de-

bchavior.

Positive reinforcement

al every stage

ofthe treatment

proccss is rccommended, to in-

to the child that he is making successful

steps in the process ofreceiving

treatment. The frequent

ofpraise dudng a child's appointment,

when the

child

performs

an appropriatc

behavior is essential.

Positive reinforcement may be

verbal

or nonverbal and should be

immediate and spccific

to

thc

bchavior.

obie.live

Explanat(rns

tarlored

to

cognitne lc\cl. folloscd by

demonnral'on.

iollowcd by

.

Allry fea$, slap€

paxcrrs

resporsc

.

Giv€

expecrations

of

comm n'catc

re8ard'es

Modulalion

on vo'cc olume,

ronc

or

pace

lo influcnce

and

direcr

pancnt

s bch6vio.

avoidaco bchaviors

.

Sstablish au$ority

Proccss

of

shapingpalicnf

s

bchatior lhreugh appropriatcly

Di\cnin8

palrcnl

s

attcnnon liom

pcrc.i cd

nplcasant

p.occdurc

Dccrcalc likclihood of

mp|easarr

p€rc€prcn

or

Convcying

reinforcem.nl and

BUidinS

bchavjor

throush

contact,

posrurc.

and

facial cxprcsions

Enlare effectivdes

lrv€ ma .u8emert |e n-





This is false;

you

should

keep

appointments short.

addition

the

following

procedures

are also

helplul

when treating mentally retarded

.

Cive

a tour

to the

patient

before attempting

to

do

any

treatment. Introduce the

patient

to the office

personnel.

.

Give only one

instruction at

a

time,

Reward the

patient rvith

compliments

after the

successful completion

of the

procedure.

.

Schedule the

patient early in

the

day. The staff, the dentist,

and

the patient

are

less

fatigued

at

this time.

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.

The dentist should

assess the degree of mental retardation

by

consulting

the

belore starting dental

treatment.

age and

maturity ofthe

child often determine

the t)?e

ofanesthesia

best suited

for the intended

pro-

Childrcn

bcloll

the age ofrcason

gcnerally

are

best managed undcr

general anesthesia, since a

ofdiscomfort

is always

associated with the administration of

a local anesthetic. It is

very

to have total

anesthesia before starting the

procedurc.

Usc both

buccal and

palatal

infiltration

maxillary teeth and block anesthesia on

mandibular teeth with infiltration,

ifnecessary

ven young

patient

is best managed under

general

anesthesia, usually

ofthe

inhalation type o. in

with

small

doses of intravenous barbiturates.

The most common

premedication prior

to

anesthesia is Versed.

Premedication

wi h a barbiturate

may cause

pandoxical

excitement

in

a

young

child.

extracting a

tooth

on

a child

patient,

the biggest

post-operative concern

is the pre-

oflip

biting.

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

that influence the child's behaviot

in the dental settingl

.

Age:

(

l) less than

2

years

old:

usually are lacking in cooperativc ability.

(2)

2

years

old: Tell-Show-

Do technique works

well and/or

parent

in operatory

(3)

3-7

years

old:

generally cooperative;

(4)

8

years

old and older: usually cooperative.

.

Nloth€r's anxiety:

there is a direct conelation bctween

the mother's anxicty and

a

child's negative

bchavior

in

the

dental

setting.

.

Past medical history:

if

a

patient has had

positive

medical experiences

in the

past thcy

are

more

apt to have

positive dental experiences

as

far

as

behavior

is concemed.

The

grcat majority of children require

minimal

management

efforts other

than

providing

on

what is

going

to happcn

(e.g,

lell-show-do).



presence

of

fxed

orthodontic

appliances

patient

with congested nasal

pa.ssag€s

or other nasal obsauction

nervors or anxious

patient

erupted tooth that

will

not retain

a clamp

lo

@yriiht

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fever

11

Cc''rittu O 20tt:2o12



ofthe main advadtages

ofusing

a rubbe. dam is that it can

aid in

the managemcnt

ofthe chiid. It

to

quict

and calm thc

paticnt

bccause the dam acts as a separation or barier, both

physically

and

advantages include:

l. Better access

and

visualization

2. Control ofsaliva and moisture in the operating field

3. Decreased operating time

4.

Provides

protection

from aspiration or swallowing offoreign

bodies

5. The

child bccomes

primarily

a nasal breather when the rubber

dam

is in

place.

This then enhances

the

effects ofnitrous oxide

ifapplicable.

oride

sedation

for children: for

the

production

of

conscious sedation, the

inhalational route

is

one agent.

nihous oxide. Desirable

characteristics

ofnitrous oxider it

is analgesic,

anxiolytic,

Note: Minimum

oxygcn conccntration

:

30o; or

minimum

oxygen

flow rate: 3 L/min.

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%.

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.

is an exotoxin-mediated

disease arising from

group

A beta-hemol)4ic streptococcal

infection. The

incidencc olscarlet fever occurs

in

childrcn

4 to 8

years

old.

It is usually accompanicd

by symptoms ol

throat. such as sudden onset of

fever,

sore

throat,

headachc, nausea,

vomiting, abdominal

pain,

musclc

and fatigue.

enlargement

ofthe fungiform

papillae

extending above

the level ofthe white desquamating

filiform

papil-

ei es

an

appearance

ofan

unripe strawberry. During

the course

ofscarlet fevet

lhe

coating

disappears and

papillae

extend above a

smooth denuded surface,

giving

the appearance

ofa

red

strawberry

raspberr).

Penicillin is the drug of choice, Early diagnosis and

ffcatmcnt are important

to

prevcnt

com-

\\hich include

local

abscess

fomation. rheumatic iever, anhritis. and

glomcrulonephritis.

is

a

viral infection, usually ofyoung

childrcn, characterizedby mouth ulcers,

but a high fever, sore

and headache may

precede

the appearance

ofthe

lcsions- The lesions are

generally

ulcers

with

a

white

whitish-gmy

base and a

red

border

-

usually

on lhc roofofthc mouth and in

the throat. The ulcers may be

painful.

Generally, there are only

a few lcsions. Thc disease usually runs

its

coursc

in less than a

week.

is

palliative.

The cause

is

often

an infection by

a

strain ofcoxsackie

A virus.

is an acute, contagious

disease caused by rhe bacterium Corynebacterium

diphrheria, characterized

the

production

of a systemic

toxin. The toxin is

panicularly

damaging to the

tissuc ofthe h€art and CNS.

against diphtheria is available to all children

in the U.S.

.

Puberty

gingivitis:

chamcterizcd

by thc enlargement

ofinterdental

areas, spontancous

or easily stimulated

bleeding. Treatment includes

profcssional cleaning and improved oral hygiene.

.

Herpes

simplex

infectio

i

-

Primary

herpetic

gingivostomatitisi

HSV-l

infection,

usually

occurs in children

under 3

years

old.

Vast majority are subclinical.

- Acute h€rp€ti€

gingivostomatitis:

.

I f

diagnoscd

with in 3 days of onsei,

acyc Iovir suspcns ion should be

prescribed.

I

5 mg&g five tim es

daily

for ?

days.

.

All

patients,

including those

presenting

more than 3 days after disease onset,

may receive

palliative

care,

including

plaque

removal, systemic

NSAIDs, and topical anesthelics.

.

Recurrent herpetic simple\

(Herpes

labialis):

vesicles located at the mucocutaneousjunclion

ofthe lips.

comers ofthe

mouth. and beneath the nose.

Associatcd wilh

cmotional

stress.

.

R€current aphthous ulcer:

painful

ulcers on

unattached mucous membranes.



is also called

Vincent's infection, Vincent's

angina

or

"trench

mouth"

is a

gingival

disease chaxacterized

by

painful

hyperemic

gingiv4

punched

out ero-

ofthe

interproximal

papill4

covered by a

gray

pseudomembrane

with

an accom-

fetid odor

include

poor

oral

hygiene,

poor

nutrition,

smoking, and emotional stress

usually affects children

and spirochet€s, as

well

as Prevotella intermedia, have been implicated

in

etiology ofANUG

12

Coplrighi O 20ll-2012

and soft

palates

palate

only

process

only

palate

only

13

CopFighl O

20ll-2012



is an acute fusospirochetal infection ofthc

gingiva.

It involves

a

progressive painful infection

with ul-

swelling and sloughing otrofdead tissue from the mouth and throat

due

to the

sprcad

ofinfection

fiom

gums.

It is usually associated with

poor

oral

hygiene

and is most common in conditions

where

there

is

and malnutrition. It is rare in

preschool

children.

can be easily diagnosed because of the involvem€nt of the interproximal

papillae

and the

prescnce

of

a

necrotic covering ofthe marginal tissues. The

clinical

manifestations of the disease include

painful,

bleeding

gingival

tissue:

poor

appetire;

fever; general

malaise; and a

fetid odor. Treatmenr

debridement. hydrcgen

peroxide

mouth rinses, and antibiotic therapy.

Atrophic

gingivitis

is characrerized by

gingival

recession without

a corresponding

rate ofalveolar bone

Minor marginal

and

papillary gingival

inflammation

is

found.

The

predominant

clinical

finding

is the

re-

odontal

dis€ase

in

adolescents: the

clinical

and

histologic manifestations

ofgingival

and

periodontal dis-

in

adolescents arc similar

to those

seen

in adults. Bone loss from

pe

odontitis does

occur in a small

per-

ofteenagers, but

the

predominant

condition noted in thi

age

group

is

gingivitis.

disease in children;

.

A

primary

characteristic ofaggressiv€

periodontitis

that differentiates it from chronic

periodontitis

is the rapid

progression

ofattachment and bone loss that is evident. Aggressive

periodontitis

may be

localized

or

generalized. The classic form oflocalized aggressive

periodontitis

was initially refened

to as 'periodontosis" and then as

"localized

juvenile

periodontitis

fl-lP/.

Localized aggressive

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 ouF

slanding

negative feature

is the rclative

absence

of

local factors (plaque)

to

explain the

severe

periodontal

desfuction

which is present.

.

Generalized aggressive

pcriodontitis

1G.1P)

is

di{Tcrcntiatcd

from thc localized form by the extent

ofinvolvement

around most

ofthe

permanent

teeth, and

it

is considered to include

rapidly progress-

ins neriodontitis.

Classes

of Cleft

Palate:

.

Class l: involves

only

the soft

palate.

.

Class

II: involves soft

and hard

palates

but not

the

alveolar

process.

.

Class

III:

same as

Class

Il

but

with

alveolar

process

involvement

on

one side

of

the

premaxilla.

.

Class

IV:

involves

the

soft

palate

and

continues through

the alveolus on both

sides of

the

premaxilla.

Females

mor€ often affected

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



Dis & Cond

Ectodermal

dysplasia

is

chrracterized

by a lack of sweat

glands,

sparse hair,

dry skin,

a concave nasal

bridge,

and:

crowns

roots

enlarged

mandible

absence

ofteeth

14

Copyright

aq

l0ll-2012

DENTISTRY

Dis

&

Cond

child

below

is

most

likely

suffering

from

what €ondition

on the

lower

face?

pox

herpetic gingivostomatitis

fever

Coplrighl 2000-2m4 Universily of

[/a$ ington. All rights leseNed.

Access to rle Ades ofPediatric Dentistry is

govemed

by a license.

Undurhorized

access

orreproducrron

s

forbidden w'rhoul rhe

pflor

writteD

pemission

ofthe Unile6ity of

washington. For

infoma

rion. conlacr: licensea. u.washin8ton.edu

15

Coplright C 20ll-1012



dysplasir

is

a sex-linked recessive trait. Although

both sexes

arc affected, more males

are af-

than females. It is characterized by a lack

of

sweat

glands,

sparse

hait dry skin,

a concave

nasal

b

dge,

the absence

ofteeth.

There may

be complete failure ofthe teeth to develop

(anodontia\

ot oligodontia

(par-

Alveolar bone development is lacking because of the absence ofpermanent teeth. Note: An-

ectodermal

dysplasia

is characterized

by

the

conical shape

ofthe

antedor

teeth

free

photo

belov,).lt

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.bdden

wirhout the

prior

lritien

p€mission

oflhe Univelsiry ofWashington.

For infomation, con-

lact: license(4u.washinglon.edu

(or

d)'sostosis) is a ftre condition inherited as an autosomal

dominant and chamc-

partial

or complete absence ofthe clavicles,

defective

ossification

ofthe skull, and

faulty

occlusion

missing. misplaced, or supernumeBry teeth. lt is equally common in

males and females. Prolonged r€-

ofprimary

teeth

and delayed or

complete failur€

oferuption

ofpermanent

teeth

are

characteristic fea-

The

presence

ofnumerous supemumenry

and unerupted

permanent

teeth is very common.

Supemumerary

teeth are most often found in the maxillary midline region and

are

called

mesio-

Supemumerary teeth

are also frequently found distal to the maxillary molars and in the

mandibularpre-

is a disorder

involving

sores on

the mouth

and

gingiva

that

result

from

a

infection

(HSV-|).

k is

characterized

by

inflammation

ofthe

gingiva

and

mucosa

and

mucosal

ulcerations.

This is a very

painful

condition.

The

patient

often does not want

eat

or drink.

The

major

concems are

hydralion,

secondary

infection,

and

prevention

ofcon-

This

disease

is

selfJimiting,

and

the

acute phase

generally

lasts

7-10 days.

Oral

fluids

very

important in childrcn so

that they do not become dehy&ated.

Pimary

bcute)

herpetic

gingivostomatitis generally

affects

chil&en

under

the

ofthree. There are

prodromal

symptoms

(ever,

mqktise,

irritobility,

headache, dyspha-

\'omiting

and lymphadenopathy)

that occur

l-2

days

prior

to the

local lesions

(ulcers)

rn

oral cavity.

treatment in

children

should be directed toward the

reliefofthe

acute symptoms so that

and nutritional intake can

be maintained. Symptomatic treatrnent

for

pdmary

herpes con-

of

rinsing

with a 50:50 suspension

of

Benadryl Kaopectate

and/or Viscous Lidocaine.

anti-viral drug used

most frequently today to shoften the duration and severity

ofth€

pri-

is

acyclovi

(Zovirax).It

is

prescribed

(400

mg.

q.i.d.)

for

I -2 weeks.

The main dillerential diagnosis

for

primary

herpetic

gingivostomatitis in

pa-

predominately

gingival

involvement

without

or

with

few

discrete lesions is

acute

gingivitis

(ANUG).

Patietts etith

ANUG

also

present

with

a sudden

ofa

sore

mouth. Howevel ANUG can be differentiated

fiom

primary

herpes by

the

fact

in ANUG the interdental

papillae

are necrotic

while

in

primary herpes, the interdental

are

intact. In individuals

with

primary

herpes manifesting multiple oral

ulcerations,

must be considered in the diagnosis.

However,

primary

herpes can be dis-

from aphthous

stomatitis by lesion location and history.

Aphthous ulcers occur only

mobile

or

unattached mucosa and there

is

a

history

of

recurr€nce.

In

contrast,

primary

on both mobile and attached mucosa and there

is no history ofprevious

Most

patients

with aphthous stomatitis do not have systemic

symptoms such as feyer.



first

statement

is true;

the

second

statement is

false

first

statement is

false; the

second

statement

is true

statements

are true

statements

are

false

16

Coplrighr

O

20tl-2012

extremely

low

the

same as the

general population,

extremely high

relatively the same as the general population

low, extremely high

17

Coplnght

I

201

l

-201 2



may be caused by a necrotic

primary

or

permanent

tooth. It

often causes con-

swelling

of

the face or neck,

and

the tissue

appears

discolored.

lt is

a

very

seri-

infection

and it can be life-threatening. The child

will

appear acutely

ill

and may have

very

high temperature

with

malaise and lethargy.

Note:

The most common causative

are Group

A

Streptococci and Staphylococcus aureus.

Cellulitis

in a child is

harder

to treat

because

dehydration

occurs more fre-

rapidly,

zurd

severely in children thim in adults.

it

involves

the submandibular,

sublingual,

and submental space

it

is

called

"Ludwig's

In

this condition, the tongue and

floor ofthe

mouth become

elevated and the

airway is obstructed

and

swallowing

is

impossible.

The treatment for

cellulitis

include having

the

child

go to the hospital

if

the

signs

and symptoms

warrant

il.

the

case of

Ludwig's angina,

it is

mandatory.

clinical

stages

of

odontogenic infection:

l

Periapical

osteitis: occurs

when the infection is localized

within

the alveolar bone.

Although

the

tooth

is sensitive

to

percussion

and often

slightly

extruded,

there is no

soft tissue srvelling.

2.

Cellulitis:

develops as the infection spreads from

the

bone

to the adjacent soft 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

not

discrete.

3.

Suppuration

then occurs and the

infection

localizes

into

a

discrete, fluctuant ab-

SCCSS

syndrome

is a congenital defect caused by a chromosomal abnormaliry

(trisomr-

).

The

prrmary

skeletal abnormality

affecting

the

orofacial

structures

in Down

syn-

is an

underdevelopment

or hypoplasia

ofthe

midfacial region.

The bridge

ofthe

of

the

midface

and

maxilla

are

relatively

smaller

in

size.

In

many

instances

causes a

prognathic

Class

III

occlusal

relationship

which

contributes

to

an

open

The tongue may

protrude

and appear

to

be

too large. With

age,

both

the tongue

and

in

people

with

Down syndrome tend to develop cracks

and fissures. This is a re-

ofchronic mouth breathing.

The eruption ofteeth in

persons

with

Down syndrome

delayed and

may occur in an unusual order. There is an extremely

high rate

of

teeth

in both

the

primary

and

permanent

dentitions.

The roots

ofthe

teeth in pa-

$

ith Down syndrome

tend to

be small

and conical.

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

child

with Down syndrome is said to be affectionate,

fearful

ofquick

movements,

but

of leaming dental

procedures.

These children need a comprehensive

preventive

These patients often have

difficulty

accepting dental

care but cooperation can

improved by using

gradual

exposure

to the

dental

office.



I

II

III

IV

t8

Copyflght O

201l-2012

first

statement

is

truei the

second statement is false

first

statement

is false;

the second statement is true

statements are

true

statemenls

are

false

19

Coplright O 201I 2012



I,

or insulin-d€pend€nt

diabetes

mellitus,

is the most common

form in children. Ap-

2 in 1000 children between the ages

of5

and

l5

years

have the disease.

The

sus-

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

findings include

a history

ofpolydipsia,

polyuria,

polyphagia'

and

weight

loss.

fasting blood

glucose

level

above

120

mg/dl

is

indicative of

Type

I

diabetes

mellitus.

disease

is the most consistent oral

finding in

patients

with

poorly

controlled di-

mellitus, These

patients

exhibit increased alveolar

bone resorption

and inflammatory

changes,

which

may mimic the clinical manifestations

of

localized

aggressive

peri-

and recurrent intraoral

abscesses may be

present.

goal

oftreatment

is to control blood

glucose

to

as

normal

a

level as

possible, thereby re-

the

potential

complications

ofhyperglycemia

and ketoacidosis.

This

generally involves

administmtion

ofan

intermediate-acting

insulin

(NPH

and Lente).

management

ofthe

well-controlled diabetic

consists

ofthe

follou'ing:

.

Advise the

patient fo

eat

a normal meal before

the appointment

to avoid development

of

hypoglycemia

.

lf the dental

procedure is anticipated

to be stressful, consult

the

patient's

physician

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

are

vascular birthmarks in which the

proliferation

of blood

vessels leads

a mass that resembles a neoplasm. Hemangiomas differ from other

vascular birthmarks

are biologically active;

their growth is independent from the

growth

ofa

child.

hemangiomas appear

within

a week or two after birth. They are 5

times more com-

in girls

than boys. They

are

common

on

lips, tongue and buccal

mucosa.

These

le-

appear

as

flat or

raised,

usually

deep

red or bluish

red

and

seldom

They are

removed

surgically, others

require no treatment.

L

Neuroblastoma

is

one

ofthe

most common solid tumors

ofearly

childhood

rn

rL*t.)

usually

found in babies or

yor.urg

children. The disease originates

in the adre-

..'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 and

spongy. They are treated by excisional biopsy.

3.

A neurofibroma

is a moderately

fim,

encapsulated

tumor resulting from the

proliferation

of

Schwann

cells.

They occur on

the tongue, buccal

mucosa,

vestibule and

palate.

These lesions appear as solitary

or

multiple

submucosal

enlargements.

May

become malignant

(5-15%).

Multlple

lesions are associ-

ated

with

neurofibromatosis

(von

Recklinghausen's disease).



caries

disease

of

teeth

arched

palate

uwla

palate

maxillary teeth

II malocclusion

incisors

20

Copyright

@

201

1,2012

2'l

Copyrighl O 201|

-2012



is the most common form of

short-limb

dwarfisrr.

It

occurs

in

all

races

with equal frequency

in

males and females.

An

individual with

achondroplasia

has

a

short

stature

--

the head is large

and the arms and

legs are

short

when

to the trunk length. Other signs are a

prominent

forehead and a depressed bridge

nose.

Many ofthese

children die during the

first

year

of life. Deficient

growth

in

cranial base is evident in many children that survive.

The maxilla may be small with the resultant

crowding

of the teeth.

Class

lll

malocclusion is v€rv common.

The

oral

manifestations ofthe following

disorders in children:

.

Gigantism: enlarged

tongue, mandibular prognathism, teeth are usually tipped to

the

buccal

or lingual

side,

owing

to enlargement

of

the tongue. Roots may be longer

than

normal.

.

Pituitary

dwarf:

the

eruption

rate

and

the

shedding

of

the teeth are delayed,

clini-

cal

crorvns appear

smaller as do the roots

of

the teeth, the dental arch

as a

whole

is

smaller causing malocclusion, and the

mandible

is underdeveloped.

This is falsel a Class

III malocclusion is common.

syndrome is a

genetic

defect

and falls under the broad classification of cranial/limb

It is

primarily

characterized by

specific malformations ofthe skull,

midface, hands

feet.

Note:

The

retrusion

ofthe

midface

is

often conected by

performing

a

Lefort

III

sur-

procedure.

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 enamel

hypopoplasia.



is

generally fatal

is best treated

by injecting

insulin

recover

ifrestrained

from

self-injury

and oxygen is maintained

can be

prevented

with

antibiotics

22

Copyrighl O 20ll

-2012

tongue

palate

and

cleft lip

23

Coplright O 201I

"2012



the multiple types

of

seizures, the

tonic-clonic

(grantl

mal) type is the

most

lrighten-

and the

one that

most

often

requires treatment.

Grand mal seizures are

manifested

in

phases:

the

prodromal phase,

the aura, the

conr.tlsive

(icla1) phase,

and the

postictal

prodromal phase

consists

of

subtle changes that may occur over minutes to hours.

is usually not

clinically

evident to the clinician or the

patient.

The

aura

is a neurologic

the patient

goes

through immediately prior to the seizure. It is specifically

to trigger

areas

of

the brain in

which

seizure activity begins.

lt may consist

of

a

a smell, a hallucination, motor activity, or other symptoms. As the CNS discharge

ictal

phase

begins.

The

patient

loses consciousness, falls to the

and tonic, rigid skeletal

muscle

contraction ensues. This usually

lasts

I

to 3 minutes.

this phase

ends,

the muscles relax and movement

stops.

A

significant degree

of

CNS

usually

present

dudng

this

postictal

phase,

and

it may

result in respiratory

of

the seizure consists

of

gentle

restraint and

positioning

of

the patient

in

to prevent

self-injury

ensuring adequate ventilation, and supportive

care, as

indi-

in the

postictal phase,

especially airway management. Single seizures

do not require

because they are

self-limiting.

Should

the ictal

phase

last longer than 5 minutes or ifseizures

continue to de-

with little

time between them, a condition called status epilepticus

has

developed.

may

be a

life-threatening

medical emergency. This condition

is

best

treated

with in-

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,

are cleft

palate

alone and

7

5To are cleft

lip with

or without cleft

palate.

lip and primary

palate

begin to develop at

four

to five weeks

gestational

age.

The two

nasal

su'ellings

and the

maxillary

swellings fuse to form the upper

lip.

Failure

ol

results in

cleft

lip.

Clefts

of

the lip are more frequent

in

males.

Cleft

lip in-

olr ement

is

more

frequent

on

the

left

side

than the right.

secondary

palate

develops at approximately

nine

weeks developmental

age. The

shelves

arise from the intraoral

maxillary processes.

These shelves,

origi-

a

venical position, reorient to a horizontal

position

as the tongue assumes a

more

position.

The

palatal shelves fuse

with

one another and

with

the

primary palate

arises

lrom

the

fusion

of

maxillary

and mandibular

processes.

results

in

a cleft

palate.

Cleft

palate is more frequent in females.

severe

handicap imposed by

cleft

palate

is

an impaired mechanism

preventing

speech

and

swallowing.

The

child

will

almost always

need

orthodontic

treat-

once the

palate is

surgically

repaired.

Also,

speech

therapy

will

be needed because

patients

have

problems related to the inability

of

the

soft

palate

to

close the air

the nasopharynx. Orthognathic surgery

may

be

needed

to

correct the

general

appearance of

the face. This

concave

appearance

is

generally

due

to

deficient

srowth.



myeloid

leukemia

myelocltic

leukernia

lymphocltic

leukemia

lymphocytic

leukemia

u

Copynghr

O 20ll

-2012

first

statement

is true;

the second statement is false

first

statement

is false; the

second statement is true

statements are

true

statements are

false

25

Coplrighl O 201l-2012



lymphocytic

(lx-nphoblastic)

leukemia is

a

life{hreatening

disease

in which thc cells that

develop into

lymphocytcs

(h'mphoblasts)

become cancerous and rapidly

replace

nor-

the bone

marrow The

peak

age is

around four

ycars

old, and it is

the

form of

acute

is most responsive to therapy. It can be successfully trcated, with a 60-80% 5-year

ratc.

carly

signs of

acute leukemia in a child include fatiguc,

palloq

weight loss and easy bruis-

will

progress

to fever, hemorrhages, extreme weakness, bone and

joint

pain,

and

re-

infections.

findings include:

.

Gingival oozing,

petechiae,

hematoma, or ecchymosis

.

Oral ulceration,

pharyngitis,

and

gingival

infection which is

unrcsponsive

to conventional

therapy

.

Submandibular

lymphadcnopathy

Candidiasis

is common in children with leukernia because they are especially

susccptiblc

this fungal infection.

Nystatin rinses

or

popsiclcs

are cffcctivc in clearing up

this

infection.

or

Hodgkin's Disease is

a

malignant

growth

ofcells in the

lymph

system.

Discasc is the better known fomr

of

lymphoma

(the

other

lyuphomas are

grouped

v,hat is called the

Non-Hodgkin's L1'mphomas). Thc most common symptom

ofHodgkin's

is painless

swclling of

the

lymph

nodes

in

the neck, underarm,

or groin.

The common

N-on-Hodgkin's

disease include:

painless

swelling in the lymph

nodcs in thc ncck,

or

groin;

persistent

fever; feeling of fatigue; unexplained

weight loss;

itchy

skin and

small

lumps in skin; bone

pain;

swelling in the abdomen;

livcr or spleen enlargement.

is a rare metabolic error resulting in fai)ure

ofthe

conversion

ofporph)'rins. The

is

burgundy

in color, and thcre is discoloration ofteeth and boncs.

Thc tceth

are

reddish-brown

fluoresce

undcr ultraviolet

light. These features are characteristic oftissucs containing

porphyrins.

in tooth color are important in diagnosing abnormalities in tecth.

Horvevet, color is usu-

not a

reliable

diagnostic

criterion

in itself. Clinical examination,

patient

history and

radiographs are

in making a final diagnosis. The first diagnostic consideratjon

relating to color is whether the

or

stain

in a

particular

case is intrinsic or extrinsjc.

Prophylaxis

utilizing

pumice

can be done to re-

lreen

stains

orycllow

pigmentation

caused by vitamin elixirs, tobacco, or other

sources. Ifthe color

intrinsic. ir

\\'illbc

necessary to consider its distribution and thc

paticnt's history,

pJacc

ofresidence,

illnesses. and family background.

thc first evidence ofvariation

from normal in the human dentition is an observable difference

in

color ofthe teeth. Somc ofthcsc

variations are apparent only to the trained eye, and

others arc

so ob-

rhat

ihev

are

a cause

ofgreat concem to the

parents

and/or children.

Questions

about the color of

can bc

the first signal ofan underlying

problcm with

thc dentition or

of

systemic discasc

or

an

in-

causes

of

intrinsic tooth discolorationl

$ith

cystic

fibrosis have teeth that are dark

in

color,

ranging from

yellowish-gray

to dark

may be related

io

the usual

high

doscs

oftetracycline

given to children with cystic

fibrosis.

fetalis

is

characterized by

an

excessive

desfuction oferythrocytes.

The

primary

teeth

have a characteristic

blue-green color.

therapy

oan cause the crowns

of

teeth to becomc discolored,

ranging

from yellow

to

and from

gray

to black. The drug will stain

permanent

teeth that

have not completed enamel for-

at the tjme the drug

is

given.

For erample:

Ifa

five-year-old child

receives tetracycline therapy.

will bc

thc

canines,

premolars,

and second molars. Important:

The incisors and first

have already completed

enamel formation.

imperfectai teeth vary in color

from white

opaquc

to

yellow

ao brown.

imperfecta:

opalescent

teeth.

fluorotis:

ycllou ro brown

pigmenration.

jaundicc-likc

ycllow-green tint

on

the tooth

surfaces.



Maxillary

posterior teeth, mandibular posterior teeth,

maxillary

anterior teeth,

and

mandibular

anterior

teeth

anterior

teeth,

mandibular

arterior

teeth,

maxillary

posterior

teeth, and

posterior

teeth

anterior teeth, mxillary posterior

teeth,

mandibular

posterior

teeth, ard

anterior teeth

anterior

teeth,

maxillary posterior

teeth, mandibular

posterior

teeth, and

anterior teeth

Copright

@

20l

l

-201

2

occur in women more than men

may occur at any age, but usually

first

appear between the ages

of

10 and 40

cause is a coxsackie

virus

appear to be associated witl stress

appear on nonkeratinized

oral

mucosa including the inner surface

of

the

lips, tongue, soft

palate

and

the

base of

the

gingiva

27

CoplriShl O

201I

-2012



feeding ofchildren can lead to tlpical nursing

pattem

decay. The teeth typically are decayed in

following order: maxillary anterior teeth, maxillary

poste

or

teeth, mandibular

posterior

teerh, and

anterior

teeth. The mandibular incisors

are

in

general

less

affected since

the tongue covers them.

Nursing-boftfe caries

is

also called baby bollle tooth decay

(BBTD),

bottle-mouth s)'ndrome,

eady child-

/ECC),

nursing caries, botle caries and infantcaries. Nursi[g-bottle caries

is

a

rampant decay that

llom

sleep

limc bottle-feeding combined with

the

activity ofStrcptococcus

mutans.

The

stagnation

of

about the necks olanterior

teeth and the fermentation

ofthe disaccharide

lactose. a susar found in milk.

to this caries

process

as \r'ell.

ECC definition by

the

Amcrican Acadcmy

ofPcdiatric

Dcntistry:

the

presence

ofmore than one decayed

or caitecl). missing

(due

to decd)r, or filled tooth surface in any

primary

iooth in a child 7l

/6

rea,.t

or younger.

ECC:

.

Younger

than 3

years:

any sign

ofsmooth

surface decay

.

Ages

3-5:

one

ormore cavitated,

missing

/drle

1() drcd_l'./

or

filled smooth surtace in

primary

anterior

teeth,

or, a

decayed,

missing, or filled surface

(dzf)

score ofgreater than.l

fdg€

J),

greater

than 5

(ag?

4),ot

greater

than 6

fdge

J).

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

Natal tceth

are teeth

that

are already

present

at

the time

ofbinh.

They are diflerent

fiom neona-

teeth, which

grow

in during the first 30 days after birth.

Most

develop

in the mandibular

incisor

area.

Fre-

natal

teeth are removed shortly after birth while

the

newbom infant is still ir

the

hospital,

especially

iooth is loose

and

the child runs

a

risk ofaspiration, or "breathing

in" the tooth.

This is false; the

cause

is unknown, however evidence supports

they are related to thc focal

where

T lymphocytes

play

a major role.

lesions appear as

painful white

or

yellow

ulcers

surrounded by

a

bright red area. Lay

pcrsons

to

aphthous ulcers

as

rrcanker

sores". Thcy can be triggercd by stress,

dictary doficicncics

ircn,./blic

acid,

or

vitomin

B

l2),

menstrual periods,

hormonal

changes,

food

allergies.

similar situations.

Lrsuail_v- begin with a tingling or burning sensation,

followed by a rcd spot or bump

that

ul-

Pain spontaneously decreases

in

7

to l0 days, with complctc healing

in 1 to 3 weeks.

Recurrent aphthous ulcem and lesions ofintraoral

herpes arc distinguished

largely

on

location. Rccurrent

aphthous ulcers

occur

primarily

on mobile

(unaltaclredJ

mucosa while

of

jntraoral

herpcs occur on tissue bound

(aftached)

to

periosteum.

L

Recurrent

aphtho\s minor

((0.5

mm-

10

mnt in diameter.l

are common, last

over 2 weeks

L Recurrent aphtholus major

(l0-20

mn in diamelet) arc

much less

corrmon,

last

over

2 weeks

and heal

with

scarring

:.

Recurrent herpetiform: multiple, small, diffr.rse,

painful,

superficial ulcers

***

Paticnts

$,ith

lrequent

recurrences

should be

screened

for

diabetes

mellitus

or

Behcet's

svndrome-

steroids

have bccn suggcsted for the

relief of

symptoms

as follows:

Rx: Triamcinolone acetonide

(Kenalog

in

Orabase)

Disp:

5

g

tube

Sig: Dry lesion. Coat

lesion with a thin film after each

meal

and at

bedtime

Nlechanism: Dccreases

infl an'rmation.

Side

effects:

Do not use on

fungal

ulcerations.

Do not use for diabetics

*lfsignificant

improvemcnt

has

not occurr€d in

7

days, discontinue

treatmcnt and

reassess the

diagnosis.



2A

Cop)right O 20ll-2012

first

statement is true; the second statement is false

first

statement is false; the second statement is true

statements are

true

statements are

false

29

Coplrighl O 201l-2012



Thyroxine

is a

hormone

secreted

by the thyroid

gland.

is severe hlpothyroidism in a

child

and is characterized

by defective

mental

and

development. Cretins have dwarfed bodies,

with

curvature

ol

the spine and a

abdomen.

Their limbs

are

distorted,

their features

are

coarse, and their hair is

mental retardation is caused by the

improper development

of

CNS. Note:

Ifthis

condition

is

recognized

early,

it

can be

markedly

improved with the

of thyroid hormones.

a

child

with

cretinism

(hypoth,vroidism)

include an underdeveloped

with an overdeveloped

maxilla, enlarged

tongue

which

may

lead to rnaloc-

delayed eruption

ofteeth,

and deciduous teeth being retained

longer. An anterior

bite

is

common

and flaring

ofthe

anterior teeth often occurs.

This may be related to

ofthe

tongue.

intraoral

findings include: thickened lips due to

glycosaminoglycan

deposits,

yet

fully developed

permanent

dentition.

Severe hypothyroidism in adults

is

called

myxedema.

fibrosis is an autosomal recessive condition. The

gene

responsible is on

the long

arm

7.

lt

occurs

predominantly

in individuals ofCaucasian

origin.

The

disease is

and

finally fatal, mostly as a consequence ofpulmonary complications

and cor

pul-

glands

most affected

are

those

in

the pancreas, the

respiratory

system, and

sweat

glands.

tibrosis

is

usually

recognized in infancy or early childhood.

Early

signs

are

a chronic

foul-smelling

stools

(steatorrhea);

and

persistent

upper

respimtory inl'ec-

The

most reliable diagnostic

tool

is the

sweat

test, which shows elevations of both

and chloride.

Note: In

CF cells, salt does

not move

properly

because the

protein prod-

of the CF

gene

is defective and makes a

faulty

channel

for

the

chloride to

exit.

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

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



(Variola)

rneasles

(Rubella)

(Rubeola)

30

CopyriSnt

O

201 l-2012

31

Copyrigbt O 20ll-2012



(also

called Rubeola) is a highly contagious viral illness characterized by a fever,

a spreading rash. It is caused by

a

paramyxovirus.

The incubation

period

is

to

2 weeks before symptoms

generally

appear

The

oral

lesions

are

pathognomonic

of

disease. These characteristic

"Koplik's

spots" usually occur

on the buccal mucosa.

1-2 mm,

yellow-white

necrotic ulcers that are surrounded by a

bright red mar-

(or

Cerman measles)

is a

fairly

benign

viral

disease.

The symptoms

usually

in-

a red, bumpy rash, swollen

lymph

nodes

fno. /

ofien

arcund

the ear.s and neck),

a mild fever. Sorne

people will feel

a

little achy. The virus can manifest

in the

oral cav-

as

small

petechiae-like

spots

of

the soft palate. The defects

of

congenital

infection

an infected mother are more severe

-enamel

defects,

hypoplasia,

pitting

and ab-

tooth morphology.

lpox

(Variola)

is an acute viral disease, it manifests

itselfclinically

by the occunence

a

high fever,

nausea, vomiting, chills,

and

headache. The skin lesions

begin as

small

and

papules which

first

appear on the face, but rapidly spread

to cover much

of

Oral

manifestations

include ulceration

of

the

oral

mucosa and

pharynx. ln

the tongue

is swollen and

painful,

making swallowing

difficult.

is an acute

contagious

viral

infection

characterized

chiefly

by unilateral

or

bi-

ofthe

salivary

glands,

usually

the parottd

(pat'cttitis).

Although

it

is usu-

a disease

ofchildhood,

mumps may also

affect adults. The

papilla

of

the opening of

parotid

duct on the buccal

mucosa is often

puffy

and reddened.

Disorder

(ADHD)

is a condition that becomes

apparent

in

children in the

preschool

and early school

years

(6e1rreen

the ages of

3

dnd

5

but varies

lt rs hard for

these

children

to control their behavior and/or

pay

attention. lt is esti-

3 and 5

percent

ofchildren

have ADHD, or approximately

2 million chil-

in

the

United

States.

This

means

that

in

a

classroorn

of25

to

30

children.

it

is

likely

that

least one

will

have ADHD.

cause is unknown.

The disorder

is l0

times more common

in males than

f'emales.

Typi-

affected children,

whether intellectually handicapped

or

not,

perform

poorly

in school be-

ofthe

inability to attend to

tasks

at

hand

or

to sit still during the school day.

Note:

lfthere

any

questions

conceming

the

ability

of the child to handle dental

treatment, contact the

ln

most

cases,

th€ child doesn't

need any special treatment.

Medications used to

treat ADHD: The medications that seem

to

be

the most

effec-

are a class ofdrugs

known as stimulants.

.

Riralin

(

Met

hlp

h en

id ate

)

.

Concena

lMethl'lphenidate

extended releqse)

.

Adderall (Amphetanirte

and dext"oamphetamine)

the more serious adve$e

reactions ofthese medications

are

nervousness, insomnia, and



coli

Streptococci

Coplnghr

O

20ll-2012

Cop''right O 201l-2012



Penicillin

allergy

50 mglkg

(rnax.

2

g)

20 mg/kg

(max

600 mg)

50 mgAg

(max

2g)

I

5

mg/kg

(rnax

500

mg)

I lb

=

.453

kg

recommended: dental procedures

known to

induce

gingival

mucosal

bleeding,

including professional

cleaning.

recommended:

dental

procedures

not likelv to

induce

bleeding, such

as

simple adjustment

of

onhodontic appliances or

fillings

above

gingiVal

margin.

injection

oflocal

anesthetic

(except.fbr

intrctligamentary injections),

exfoliation

of

primary

teeth.

Because

ofthe

diversity

of

circumstances

with

each

patient,

it

is

recom-

that the

clinician consult with

the

patient's physician

if

the complete medical

of

the

patient

is

not

fully

known or

th€re is any

doubt.

oxide

is

a slightlv sll eet smelling, colorless, inen

gas.

It must alu

ays

bc coupled with no less than 2070

gen.

Nitrous

oridc

is

quickly

absorbcd from thc lungs

and is

physically

dissolved in

thc

blood.

There

is no

and thc

gas

is raprdly excreted

by

the lungs \\,hen

the concentration

gradient

is reverscd.

It

recommended that lhe

paricnt

be m|intained on 1007o

oxygen for

3

to

5

minutes

after

the

sedation

pcriod.

oxide basicallv creates

an altered

state of

awareness

with impaircd rnolor function. It is a ccnral

svslem depressant. h produces

litlle

analgesia.

The combined

vol

me

ofgases being

delivered /o].r

.rr,? nir?r/r/ should be at least

3

to

5

liters/minute,

The operator should encourage the

patien

to breathc

lhe nose

\\'ith

Ihe mouth closed.

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 the

nnirnum rnilligram

dosage.

-

lor e\ample, 30 kg

x

4.4 mg/kg lidocaine - 132 mg

.

Calculete rhe nunrber of milligrams

per

caftridge of anesthetic by multiplying 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 maximum

a1lo\\'able

cartridges of anesthetic.

- fbr example.

132

mg

maxi'num

dose

/ 36

mg/cartridge:

3.66

rartridges

The maximum recommended

dose oflocal anesthetic with/without vasoconstriclors, whcthcr it be

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

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\tde

3. 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

changes

in alveolar

gas

concentration.



hydrate

34

Coplright e 201I,2012

reduction in dental caries

fluorosis

increase in the amount

offluoride

stored in her bones

problems

CopFight O 201l-2012



acts

on the

CNS

to induce

sleep.

At nonnal

doses,

the sleep induction

not allect breathing, blood

pressure

or

reflexes.

It

may

be used

before

some

surger-

or

procedures

to

help relieve

anxiety and

to induce

sleep.

When

used

in combination

analgesics, it can

help n.ranage pain

after

surgery.

It

has an onset

ofaction

of 15 to

minutes when

given

by mouth. Important: Children often enter a

period

ofexcitement

irritability

before becoming sedated. As

with

barbiturates,

pain

may cause

paradoxi-

reactions.

hydrate

is

bitter

tasting, rvhich can produce management

problems

during

ad-

disadvantage is that

chloral

hydrate can induce nausea

and

vomiting

gastric

initability.

short

acting barbiturates secobarbital

(Seconal)

and

pentobarbital

(Nentbutal)

are

drugs.

They are sometimes considered

for

pediatric

conscious

sedation by oral

They are of very limited value. They are nonanalgesic.

They may cause

rather than sedation in some children.

Chloral hydrate and the barbiturates are classified as

sedative-hypnotics

whose

effect

is

"edation

or sleepiness.

*ill not occur since by agc 15 all

ofhcr dentirion

has undcrgone complete enamel calci-

/r

ir, rrc

porrlble

exception of the third nohrs).

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 reductiorr

in 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 nlillion

leoplc.

-1.

\later

fluoridation

rnd

diet supplernentation mry affect

tooth morphology, while sclfand

professionally

applied topical treatments

r,r,ill

not.

5.

The typcs

of lluoride

added

to

different watcr systcms include

lluorosilicic

acid. sodium

fluorosilicare.

and sodiunr fl

uoride.

6

Up

to

a

levcl of I

ppm

fluoride. thcrc is an inveNc relation bct['ecn dental decav and fluor-

rde concentration.

As fluoride

concentration

increases

beyond

I

ppm.

ihere is an incrcased

prevalcnce

offluorosis and no increase in the reduction oldental decay.

and

fissure sealrnts

'

Indications:(1) deep.

retentive

pits

and

fissures:

(2)

stained

pits

and

fissures

with minimal

appearancc

of

decalciilcalion or opacification;

(3)

no radiographic

or clinical evidence ofinterproximal

caries in nccd of

resloration on iccth to be sealed

.

Contrlindicetions:

(l)

rampant carics;

(2)

intcrproximal

carics;

(3)

wcll-coalcsccd

groovesl

(4)

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),

rinse

for

l0

seconds,

dry

with comprcsscd air for l5 scconds. apply scalant, chcck occlusion

.

Resin-based

sealanls

arc most common and have supcrior rctcntion as compared to

glass

iolomer-based

seilants.

The tag formation

in

the enamel is

about

.10

Fn1-

.

Any

saliva contamination

follo*,ing

isolation requires repeafing the *hole

proccdure



Fluoride

Fluoridation

has several mechanisms

for

caries

inhibition.

are enhancement

of r€mineralization

of

enamel,

inhibition

of

and the

incorporation of fluoride into

the

enamel bydroxyapatite

crystal.

first

statement

is true; the

second statement is false

first statement is false; the second statement is true

statements are

true

statements are false

36

Copy.ighr O

20ll'2012

PEDIATRIC DENTISTRY

Fluoride

Which of

the following fluoride therapies

should

be

recommended

to a

thirteen-year-old child

who

is

prone

to

decay

and

lives

in

a

community

where the

water

is

fluoridated

at

an

appropriate

level?

every six months

toothpaste

supplements

low

concentration

fluoride mouth rinse

concentration fluoride mouth rinse

37

CopynShr O 20ll'?012



NoteJ,

:ti*::il

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 to

bacterial-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

from

forming

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 the

duration

ofcaries

attack is limited to periods

during and immediately after eating.

Fluoride mouth rinses have been

shown

to

have

the

greatest

eft'ect

on newly

teeth, making it essential to

have

rinsing

continued

into

the teen

years

to

protect

both

second

and third

permanent

molaru.

It

seems that fluoride rinses are

most

beneficial

to

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

and

is released into the environment naturally in both water and

air

2. Fluoride

is naturally

present

in

all

water

Community

water fluoridation is the 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 ftom

0.7

to

1.2

ppm.

Fluoride supplements would be contraindicated

since

the

community

water is fluori-

appropriate level. Remember: "Rules of6s"

iffluoride

level is

greaterthan

0.6

ifpatient

is

Iess

than

6

months old,

and

ifpatient

is

older

than

16,

no supplemental

sys-

fluoride is indicated.

fluoride should

be administered

only from

the age

of six months,

and

only

if

tbllo$

ing conditions

prevail:

.

The concentration

offluoride

in drinking water is less than

0.3

ppm

.

The child does not brush his or her teeth

(or

haw

them brushed

b1'

o

parent

or

guardian)

at least

i\

ice a day; and

if,

in the

judgment

of a

dentist or other

health

professional,

the

child is

susceptible

to high

caries

activity

(ani['

histo4,, caries

treuds and

patterns

in 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 sodium

flvortde

/0.050,4

sodium

fiuoride).

is

available

with

or

without fluoride.

Toothpaste

tubes

containing fluoride

are

now

and contain approximately 0.1%

fluoride.

Some tubes suggest covedng

the

bristles

toothpaste. A'pea-siz€d'

portion

weighs approximately 0.75

g

and contains about 0.4 mg

a

'full

cover'

portion

weighs approximately 2.25

g

and contains about 1.0 mg of

Thus,

brushing

twice a day would

deliver 0.8 to 2.0 mg

of

fluoride, depending

on

regimen is

used.

lf

swallowed.

the

amount

of

fluoride could

be excessive and

could

bute to the development

offluorosis.

Important:

Children

should use

only a'pea-sized'

oftoothpaste,

and

be encouraged

not

to swallow the

excess.

The most common forms

of

fluoride found

in

toothpastes are sodium fluoride and

Amine fluo de and stannous fluoride. are less common.



minute

minutes

minutes

minutes

38

Coplright

O

201l-2012

is applied

to

protect

ary

teeth

with

sealants

should be

dry to

prevent

dilution ofthe fluoride concentration

bacterial

plaque

must

be

removed to

prevent

interference with fluoride uptake by the

should be

placed

in a semi-supine

position

39

Cop)righl O

20l l -201

2



applied topical fluo de agents

are applied

in

the dental

offlce

or

in

other set-

by

health

care

providers.

Cunently there are four types

oftopical

fluoride agents that

are

on the teeth

by

health care

providers.

.

Acidulated

phosphate

fluoride

1,4PFl

-

in

geJ.

foam,

or solution fonn

.2olo

neutral

sodium

fluoride - in

gel,

foam,

or solution

form

.

87o

stannous fluoride

- in

porvder

fbrm supplied in bulk containers or

powder preweighted

capsule

fonn; mixed with

water

immediately

before use

.

Fluoride-containing

vamishes

has advantages and disadvantages and all are used in various settings. Several of

professionally

applied

topical

agents

carry

the

ADA

Seal

ofAcceptance.

All

the agents are

and can

be

used in different situations to meet the range

ofrequirements

for topical

agent$ in

pediatric practice.

Acidulated

phosphate

fluoride

/,4PF)

is the most

populaf

topical fluoride used

in pedi-

of'fices.

APF solutions

and stannous

fluoride

fSNF2,/

should not be used on

patients

with

glass

ionomer,

and

composite

restorations.

They

have been

shown to remove

the

liom the sud'ace of these

restomtions.

Neutral sodium lluoride

(Na-Fi

is best to use

if

restorations are

present.

Also, APF

should be avoided on

implant

patients.

it

may cor-

'urface

of

titanium

implents.

fltroride

(abng

v'ith occlusal sealants) is the

pdmary prcventive

agent during ado-

(pa.\t

the age

o/72l

because the

entire dentition

except for the third

melars normally

by

age

13.

Theretbre,

fluoride

tablets may not be

as

beneficial.

Caries

activity is directly

proportional

to the consistency offermentable carbo-

frequency ofingesting fermentable carbohydrates and

the

oral reten-

of

f'ermentable carbohydmtes

ingested.

is

best to thoroughly dry the teeth before applying the

of

the

fluoride

application

and

prevent

dilution

rvith comnressed air or cotton rolls.

fluoride to maximize the effec-

of the agent.

The

teeth can be

gent Form

Concentration

Mode of Applicrtion

Special Not€s

odium fluoride

iaF)

pH

=

9.2

Solution

2%

9.040

ppm

0.90% F ion

Painr on Cotton

roll

isolation absorbs

excess solution

Gcl

zvo

9,040

ppm

0.90% F ion

Paint on or tray Take care not to overfill tray

Request Patient not to swallow

2%

9,040

ppm

0.90% F ion

Tray

Less amount

needed to

fill tray

Less risk ofswallowing because

ofconsistency

Vamrsh

5ro

22,600

ppm

2.36/oF ion

Paint on Sets

promptly

pH=

3.0

to

3.5

Solution

|.23./.

12,300

ppm

Paint on

Cotton

roll isolation absorbs

excess

solutton

Avoid cemmic and composite

resm rcslorutrons

Gel

\.23%

12,300

ppm

Paint on or tray Take care not to

overfill

tray

Avoid

ceramic and composite

resin restontions

Foam

|.230/.

12,300

ppm

Tray

Smaller amount

needed to

fill

trayl less F

Avoid ceramic

and composite

restn teslomhons



PEDIATRIC DENTISTRY

Fluoride

You examine a

ten-year-old

boy

in

your practice

and

det€rmine that

he

has

multiple carious

lesions. The

family

resides

in

a rural area and

drinks

well wrter. What

is

your

advice

regarding lluoride

supplementation?

fluoride tablets for the

patient

immediately

for

a sample

of

the

patient's

well

water

to be sent to a

laboratory to assess the

ofnaturally

occurring fluoride in the water. Then

prescribe the

appropriate

dose

fluoride

supplementation

in lieu

ofthe

fluoride that is occurring

in the water, if any.

child

is too old

for fluoride supplementation to be

ofbenefit,

so

you do not recom-

rt

ofthe above

40

Copyright

aq 20ll-2012

PEDIATRIC DENTISTRY

Fluoride

Clinical

studies demonstrate

that acidulated

phosphate

lluoride

is most effective at

what

pH?

41

Copyright

(]

201 I 2012



are not receiving fluoride in their

water should receive dietary fluoride

supple-

However,

you

want to avoid

having the children receive too

much

fluoride,

so

you

sure their water is tested for any naturally

occurring fluoride content

ifyou

have

doubts about the amount

of

fluoride already in the water

You

want

to avoid fluorosis.

supplementation is

generally

recommended

at least until age sixteen

years.

Fluoride

is

particularly efficacious

as

long

as

teeth

are

still

forming.

Sodium fluoride is approximately twice the

weight

of

fluoride. So L

I

mg of NaF

de-

approximately 0.5 mgs of flr.roride.

Prenatal fluoride

supplements are not approved by

the

FDA

and are

not recom-

prenatal

fluoride

does

not

cross the

placental

barrier. No

studies to date sup-

the

administration of

prenatal

fluo

des

to

protect

the

primary

dentition against caries.

APF agent

is

L23

percent

fluoride ion, which is over 12,300

ppm.

It is acidic. with a

pH

Clinical

studies demonstrate that

it

is most effective at that

pH.

is formulated in solution, foam, and

gel preparations.

Foams and

gels

are the most use-

since

the

mate

al stays in a fluoride delivery tray while in the child's

mouth. They are

easier to apply than a

watery

solution.

All

ofthe

APF

products

should be

applied for four

order

to achieve the best results.

Note: An

APF

gel has

been

developed which is

enised as effective

with

a

one-minute

application.

However, the

four-minute

products

have

greater professional

acceptance

and,

presently,

only four-minute

products

carry

the

ADA

You are

going

to encounter children who

gag

and

vomit and have

problems

hold-

the

fluoride

trays in their mouths for four minutes.

All

experienced

care

providers

realize

1ou

are asking

for

lots

ofclean-up

jobs

and some unhappy children

with spoiled clothes

l

ou

insist

on the

four-minute

rule

lbr all

applications.

Parents also are not

pleased with these

The first fallback

position

is

a

two-minute application, and

a

one-minute

applica-

\\

ould be next.

Eighty

percent

ofthe absorption

offluoride

into the enamel occurs dudng

the first two

ofa

four-minute application.

Consequently, you should strive

fbr

at least

a

two-minute

However,

you

should

terminate the

procedure

immediately

ifthe

patient

is show-

signs ofbeginning

to

vomit. A

one-minute

application

will

result in some absorption, but

as much as a two-minute

application

and

certainly not

as

much as a four-minute applica-

Nevertheless, a one-minute application

is

better

than nothing.

***

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



mg

mg

mg

mg

fluoridation

ofthe

communal water supply

rinses

at

home

visits

a2

coprridt

O

201l-2012

/t3

Coplright

O20ll-2012



surveys

link

fluorosis

to three factors:

.

Fluorosis

is more common in

geographic

areas where

the endemic levels

offluoride

in the

drinking

water is higher than three

parts per

million

.

Fluorosis is associated

with

fluoride

supplementation at inappropdately high levels

.

The use

offluoridated

toothpaste has

been implicated in fluorosis

acute

fluoride

toxicity, the

goal

is to

minimize the amount

of

fluoride absorbed.

of

ipecac is administered

to

induce vomiting.

Calcium-binding

prod-

as

milk

or

milk

of

magnesia,

decrease the

acidity of

the stomach, forming in-

complexes with the fluoride and thereby decrease its

absorption.

Note: EMS s,fioald

qctivated

/91I

).

acute

fluoride

toxicity,

symptoms may appear

within 30

minutes

of

ingestion

and

for

up

to

24

hours. Patients may

experience some nausea,

vomiting,

diarrhea,

abdominal

cramping.

This may

be due

to

the fact that 90-95% of ingested fluoride

absorbed through

the

stomach and

small

intestines. Fluorides are

primarily

elimi-

from the

body

by

way

of

the kidneys.

However, the

fluoride

that does

remain

in

body is found mostly in skeletal tissue.

ln

acute fluodde

poisoning

fu,liclr

is rqre), the

common causes

ofdeath are cardiac failure and respiratory

pamlysis.

Fluoride toxicity

up

in Ihe

bones

as o.teosclerosis.

The lethal dose of fluoride for a typical

3-year-old child

is approximately 500 mg

would

be

proportionately less for

a

younger

child and smaller child.

To avoid the

possi-

of

ingestion

of

large amounts of fluoride

it

is recommended that no more

than 120

mg

sr"rpplemental

fluoride

be

prescribed

at

any one time.

If a

six-y€ar old child

were receiving fluoridated water

in

thc

amount

of

3

ppm,

result would

most

likely

be fluorosis but

not

systemic toxicity. On the other hand, if

a

in

thc samc age

range

(6-7)

werc receiving 8

ppm

of fluoridated water,

thcrc would

a

good

chancc of

systemic

toxicity

and moderate to severe fluorosis occurring.

optimal concentration

in the communal water supply

varies with mean arurual tem-

In most states,

it

is

I

ppm.

Fluoride

suppl€ments are

recommended

if

the water

content

is less than 0.7

ppm.

water

fluoridation

optimal

concentration

is

4.5 times that

ofcity

water sup-

because

of

less

water

consumption

at

school.

US

Public Health Seruice

(PHS)

has, since 1962, recommended

that

public

water

contain between 0.7 and

1.2 milligrams

of

fluoride

per

liter of drinking

water

Z/ to lrelp

prevent

tooth decay

fsome

naturql bater sources havefluoride

levels vithin

ra

ge.

or

even higher).

is

now

used

in

the

public

drinking

water supplied

to

about

two thirds

of

types

ol

fluoride

added

to

different

water systems include

fluorosilicic

fluorosilicate. and sodium

fluoride.

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

ppm

for

public

water

.

The cariostatic effect of

fluoride

is produced

during

the

calcification

stage

of

tooth

develoDment



Primary

mandibular

canine

Primary

maxillary

lateral

incisor

Primary

maxillary

canine

Primary

rnandibular

first

molar

u

Coplrigbt

O

201l-20|

2

lateral incisors

and canines

canines and

first

molars

canines

and second molars

and

lateral incisors

first and second molars

a5

CopriShl

@

201l

-2012



common cong€nitally missing

permanent

teeth with

the exc€ption of the maxil-

and

mandibular third molars, are the mandibular second

premolars.

followed by the

max-

lateral incisors, and the maxillary

second

premolars.

,

L The

naxillary

lateral incisor is most

often atypic al

in

size

(peg-shaped,

etc.).

nines anterior to the

premolars

most likely has congenitally missing

pemanent

lat-

eral

incisors.

is most frequently responsible for the

congenital absence ofteeth.

'Ihe

roots

ofthe

tooth wiJl resorb slower than normal

without the

presence

ofthe

permanent tooth.

As

general

rule,

if

only

one

tooth is

or

a

f u,

teeth are

missing, the

absent

tooth

will

be the

distal tooth ofany

given

type.

Ifa

molar tootb is congenitally nissing, it

is

almost always

third

molar [f

an

incisor is missing,

it

is nearly always the lateral.

If

a

pretrolar

is

miss-

it

almost always is the second mther than the first. Rarely is a canine

the

only

missing

the case of a congenitally missing second

premolar, you want to

hold onto

primary

second

molar as long as

possible.

If it

is

still

present

it may

be

ankylosed.

Cessation oferuption

(tooth

is out ofocclusion) is most diagnostic ofan

ankvlosed

pri-

molar,

Space maintenance

is

of utmost

importance u'henever

primary

or

perrnanent

are

congenitally

missing or lost

prematurely

witch

results in the loss

ofarch

integrity. The

of space. arch length,

perimeter,

or circumference

may result.

Migration ofprimary and/or

teeth

can occur and

the

available

space

may

be

reduced by

an

amount

sufl'icient to

of

crowding in the

pennanent

dentition.

resorption, also known as ankylosis. results after ineversible

injury to

the

pe-

ligament. Ankylosed

primary

teeth should be extmcted ifthey cause

a delay in or ec-

eruption

ofa

developing

permanent

tooth.

of four:

This simplifred rule

will enable

you

to

at any

given time.

It

implies the

eruption of

with four

teeth at

age seven

months.

determine the

number

of

teeth

four

teeth

every

four months

from

question

on

front

of

card:

At

age

l5

months.

l2 teeth

are

erupted

-

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



is

greater

blood and lymph supply

crest

is flatter

cementum is

thicker

and

more

dense than that

ofthe

adult

pocket

depths are larger

gingiva

is not as wide

46

Cop)right O

201

I

-201

2

years

old

years

old

years

old

t7

Copynghl O

201I

-2012



This is false; the cementum is

thinner

and less

dense

than that

ofthe

adult. Cementum

to increase with

age.

components ofthe

gingival

and

periodontal

structures are the same in

childhood, adoles-

and adulthood. However,

the clinical and radiographic images

ofthe

gingiva

and

peri-

ofchildren

and adolescents

differ fiom

those seen in adults,

owing

to the

significant

that

take

place

during

growth

and development.

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 against

the tooth. The PDL is also wider in the child. This is why

you

may see mobility

in

the child's

teeth as

well

as a decreased

resistance

to forces. The fiber bundles ofthe PDL increase with

ag€.

.

Alveolar bone has fewer trabeculae, larger marrow

spaces, is

less

calcified,

has

a thinner

lamina dura and wider

periodontal

membranes.

.

The

width

ofthe

attached

gingiva:

(1)

changes concomitantly

to

changes

in the

sulcus

and crevice

depth

dudng eruption and

shedding

(2)

increases

with age in the

primary

den-

tition

(3)

is signiticantly narrower in newly erupted

permanent

teeth than in their deciduous

predecessors

(4)

is

nonnally

minimal

to none

in newly

erupted permanent

teeth.

A

labial eruption

path

is the most common

cause

of

inadequate attached

gingiva

in

?,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 root

Aper is fully deveJopcd two to threc

years

after cruption.



1.5

to

2

months in

utero

to

6

months in

utero

.5

to

9 months

in

utero

0

to 12 months

in

utero

1A

Cop),ridt

O

201l-2012

permarent

maxillary

and mandibular

premolars

permanent

maxillary and

rnandibular

first molars

permanent

maxillary and

mandibular

second molars

permanent

maxillary and

mandibular

third molars

49

Copyrighl O 201l-2012



On the average

thcy

takc

l0

months

for completion ofcalcification.

First

Evidence of

Crlcillcstion

(we€ks

in Utero)

Cmwtr

Completed

(Monlhs

Aft€r

Birth)

Root

Completed

(Ye3rs)

Mrtill.ry

cenaal

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

Mrndibrltr

Centml

Lareral

Canine

Fi$i moler

Second

inolar

L 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 molar

4. Thc mandibular central

incisor is the smallest

permanent

tooth.

permanent

tooth that moves

into

a

position

formerly

occupied

by

a

primary

tooth is

a succedaneous

tooth.

In

each

quadrant,

five permanent teeth,

the

incisors,

and

premolars.

succeed or take the

place

ofthe

five

primary

teeth.

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

primary

tooth to

be

replaced by

a

permanent

tooth

is

usually

the max-

canine

(the

permanent

maxillary

canine

usuall - erupts betueen the age oJ I 1- 1 2).

permanent

mandibular canine usually erupts between

the age of 9- | 0.

Permarent

molars

do not

replace primary teeth

(see

above).



disease

syndrome

syndrome

syndrome

:

l0x2=20

=

10 x2:20

:

12x2=24

:

16x2=32

50

Coprighr

O

20l l,20l2

51

Cop)'right

@

20ll-2012

]clnlv

?"tt3

3"i*tr

]clnlnl



Syndromes

Marifestirg Bolh

H,?erdordr

rnd Hypodontir

Oral-facial-digital s).ndrome I

Hallermann-Streiff

slndrome

SyDdrom€s Demonstratirg

Ilypodontia

Ectodermal

dysplasia

(bypohidroiic

type)

Chondroeclodermal dysplasia

Ri€ger's syndrome

Incontinentia pigmenti

Seckel slndrome

Syndromes Demorstrating

SuperDum€rary Teeth

Cleidocranial dysplasia

Cardneis syndrome

Crouzon disease

Srurge-Weber s)ndrcme

oral-facialdigital syndrome I

Hallermann-Sreiff syndrome

Conditions

Demonstrsting

Taurodontism

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.titrg

Microdontia

Ectodermal dysplasia

(hypohidrotic

type)

Chondroectod€rmal dysplasia

Hemifacialmicrosomia

Down syndrome

Syndromes

l)emonstrating

Mrcrodontia

Facial hemihypertrophy

Otodental slndrom€

1.,2

=

5 ner ouadrant

-

l0

oerarch

-

20

total

teeth

=

Incisors

:

Canines

:

Molars

There are no

premolars

(bicuspids)

in the deciduous dentition.



rlc\nlv'I

r c{n}uf

rzrc

trszrul..

126-ly3

213

=16x2=32

=14x2:28

:16x2=32

=12x2:24

52

Copyright

O

201

1"2012

bith

month

year

53

Copyright

O

20ll-2012



2

-

|

^

2

_, 3

-

8 Der ouadranr

=

16

neurch

;

t

i

o

;

nt

;

-

ffi

-ii*o",

,J

-

32

total

teeth

:

Incisors

:

Canines

:

Bicuspids

(premolars)

=

Molars

takes 4 to 5

years

for most

permanent

crowns to complete

formation, except for the

molars

(J.l,earrl

and canines

(6-r€drs).

It takes approximately l0

years from the start ofcalcifica-

completion,

except for the canines

(

l3

vears).

First

Evidence

of

Calci{ication

(Weeks

in Utero)

lltaxillary

Cerrtral incisor

Lateral incisor

Canine

Fint

molar

Second molar

l4

(

l3-

l6)

t6

(t4

213-16 | /2)

l7

(r5-18)

t5

v2

(r4

t/2-t7)

t9

(t6-23

V2)

Mandibulsr

Cenual incisor

Lateral

incisor

Canine

First molar

Second molar

14

(13-16)

t6 (t4

2/3-16

|

12)

l7

(ls-18)

ls

t/2

(14

r/2-r7)

t8

(r7-19

t/2)

3-4 months

l0 months

4-5 months

1.5-1.75

).rs

2-2.25

yrs

Ar birth

2.5-3.0

),rs

7-9

yrs

Maxillary

Cenkal incisor

Lateral incisor

Canine

First

premolar

Second

premolar

First molar

Second molar

Third molar

Mrndibular

Central incisor

Lateral incisor

Canine

First

premolar

Second

premolar

First molar

Second molar

Third molar

3-4

months

3-4

months

4-5 months

1.75-2.0

yrs

2.25-2.5

y,rs

Ar birrh

2.5-3.0

),rs

8-10

yrs



years

old

years

old

years

old

16

years

old

54

Copyright

O

20ll-2012

primary teeth

are

lighter in color than the

permanent

teeth

primary

teeth the

interproximal

contacts are broader and

flatter than

permanent

teeth

pulp

cavities are

proportionately

smaller in the

primary

teeth

general,

the crowns

ofprimary

teeth

are more bulbous and constricted

than their

per-

counterpart

pulp

homs of

primary

teeth are closer to the surface ofthe

tooth

crown

surfaces

ofall

primary

teeth are

much

smoother than the

permanentreeth (in

is less evidence ofpix and

grooves)

teeth have thinner enamel

Coplriehr

@

201l

-2012





months

old

months old

months

old

months

old

56

Copright O 20ll-2012

mm

greater

than the

permanent

teeth

that

succeed

them

-

premolars

mm less

than the

permanent

teeth that succeed them

-

premolars

mm

greater

than the

permanent

teeth that succeed them

-

premolars

l0

mm

less

than the

permanent

teeth

that

succeed

them

-

premolars

57

coplright O 20ll-2012



Maxillary

Central incisor

Lateral incisor

Canine

First molar

Second

molar

7.5

o

16-20

t2-t6

20-30

1.5-2.0

1.5-2.0

2.5-3.0

2.0-2.5

3

Mandibular

Central

incisor

Lateral

incisor

Canine

Filst molar

Second molar

6.5

'7

t6-20

t2-t6

20-30

1.5-2.5

1.5-2.5

2.5-3.O

2.0-2.5

3

Eruplron datcs arc

variablc.

Some

infants

get

them early, othcrs do so

late.

A 6-month varia-

in time of eruption is considered

normal.

l.

Whcn

a

prirnary

tooth clinically crupts in thc mouth, one-half

to two-thirds ofthc

root

structure

has

usually

developed.

2.

A

primary

tooth usually

takes L5 to 2 months frorn thc beginning

ofclinical 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-

I mm thick,

as opposed

to

that

ofpermanent

molars.

which

is

2.5 mm thick.

ofprimary molars

/ds

(on?pared

to permanent

nolars):

.

Crowns are shorter with

pronounced

buccal

and lingual

cervical

ridges and a constricted

cervical area.

.

The

occlusal

table is narrower faciolingually.

.

Anatomy is shallower

(i.e..

lhe

cusps

are short, the ridges are nol

as

protlou

ced

and the.fbssae

dre nol us aleep.).

.

A

prominent

mesial cervical

ridge

lrrdfes

it easr to dislinguish rights

lion

lefrs).

.

Roots

are longer

and morc sl€nder than the ruots ofthe

pemianent

molars.

The roots are

ertrem€l '

narrow mesiodistally and very broad

lingually.

.

Roots are very div€rg€nt

and l€ss curved. There is little or no root

trunk.

Primar.r_Marillary

PermanentMaxillary

l'irst Molar First )Iolar

space

is

the

size

differential befiveen the

primary postc.ior teeth

/.

anine,

jirst

and

rnolar.s), andlhe

permanent

canine and first and sccond

prcmolar-

Usually

the sum oflhc

primary

widths is

greater

than that of

their

permanent

successors. So when these

primary teeth fall

out,

is usually a slight amount

ofspace

fdbout

3.I

mm

per

side

in

the

nnndibular arch and |.3nm

per

i

the ma\illan,

orc,/r.This space is often used to help relievc crowding.

Ifnothing

is

done to

pre-

this spacc, thc

permanent first 1nolars almost always drift fonvard

to close it-



bitewing

radiographs

periapical

radiographs

anterior

periapical

radiographs

molar

periapical

radiographs

58

@yrigbt

O 20ll-2012

second

molars

first

molars

second

molars

59

Copyrighi O

201

l-2012



bitewing

radiographs are

the

most

frequently taken views in

pediatric

dentistry

They

are

used

to

detect interproximal caries

between molars. The

film

is placed

in the

tab and the

patient

bites on the tab

to secure the film. The cone is

positioned

ten

per-

horizontal

plane

and is

directed toward the contact

areas ofthe

molars.

One

film

on each side in the

pdmary

and mixed dentitions. When second

permanent

molars

are

two films

are

necessary

on each side. The distal

surface

ofthe

cuspid

should

be in-

in the radiograph and together with

all

posterior

teeth, as well as the distal surface

of

posterior

molar in

the mouth. Note: A size 0

film

is

used

with

small

children.

A size

film

is used as soon as the

patient

can

tolerate

the larger

film.

child

should have his

/

her

first

pediatric

visit

by their

first

birthday.

Following

that,

if

the

teeth are spaced far apart and there is no

clinical evidence ofdecay, bite-wings are not

until the

establishm€nt of contacts on the

posterior

teeth.

At

age six a child should

their first

panoramic

x-ray in

order to

get

all vital information on developing teeth, roots

possible

malocclusion. X-rays for

growth

and development depend

on the

patient's

of

tooth eruption. The frequency

of

radiographs

should depend on the child's risk for

Situations that

make

a child at higher

risk

for decay include lack

of

fluoride in the

high sugar diet, history ofcavities,

poor

oral

hygiene, and many others.

L

The

nice

thing

about

panoramic

x-rays is that they are taken

without

placem€nt

ofthe film

in the mouth

so it does not alarm the nervous child.

2. Children are often

"entertained"

by

the

panoramic

unit.

3.

The

drawback of

a

panorex

is that there is a loss

of image detail

(it

is

hqrd

to

diagnose

early carious

lesions).

Bite-wing

x-rays

are

required

for

the

diagnosis

ofcarious

lesions.

Primary

mandibular first

molar that

needs sectioning

for removal.

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

car€ful

in

extracting

th€se teeth. The succedaneous tooth bud may be in close

proxim-

This is

especially

true when

placing

the beaks of forceps into bifurcations ofprimary mo-

in

older children.

The most

frequent

cause of

fiacture

ofroot

tips in extracting a

primary

molar is

between the

aDex

and the bifurcation.

1. lfa

permanent

tooth bud is accidentally extracted while removing a

primary

molar,

the best treatment is to imm€diately orient th€ tooth bud, replant the bud

using digital

pressure,

and suture.

2. The

best

way to extract a

primary

molar

that has the

permanent

tooth bud

close to

(a,s

in the

photo

above) it i.s to section the iooth and remove the

pans

in-

dividuallv.



first

molar

central incisor

first molar

60

Coplrigbt O 201l-20|

2

6t

Coplrighl O 201|

-2012



that

you

may need

to know for boards:

.

At

birth,

thejaw

is large

enough to accommodate

all

primary

teeth

ifthey

were to

erupt simultaneously.

.

At birth, the

width of

the

face has reached the greatest percentage

of

its adult size

(as

opposed to height and depth).

.

At birth,

the

palat€

is

prett"v

flat,

in adults,

it

is vault-shaped

(this

occurs b1'deposi-

tion ol alveolar ctestal

bone).

.

At

birth,

a newbom cannot

differentiate

between sour, salt, or a

bitter taste.

.

At birth,

the

cranial vault is

very near the size

it

will

eventually

attain in adulthood

(as

compared

to

the

cranial

bqse,

mandible, mid-face,

etc.). The

brain

and

the

cranial

base 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

of

abuse or neglect

is not necessary.

.

Failure to report suspected

child

abuse may result

in significant

legal ramifications

for

the dentist, including a

fine,

jail

sentence, and

civil liability.

.

Neglect:

Definition

from the American

Academy

of

Pediatric

Dentistry

is

the

"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

and

infection."

.

LThe first

perman€nt

tooth to erupt is the

manditrular

first

molar, followed

shortly thereafter

by

the maxillary

first

molar

2. The

lirst

permanent

tooth to begin calcifying is the

mandibular first molar

kt

bifth).

3.

The first succedaneous tooth to erupt

is the mandibular central

incisor.

The n.randibular

first

molar and the

maxillary first

molar

are

not

succeda-



PEDIATRIC DENTISTRY

Ordinarily, a 6-year-old child would have what

teeth

clinicallv visible

in

the

mouth?

(20) primary

teeth

and

4 permanent

first

molars

pdmary

teeth and

2 permanent

mandibular central incisors

primary

teeth,

2

permanent

mandibular

central incisors,

and

4 permanent

first

PEDIATRIC

DENTISTRY

When attempting

a MO Class

II

amalgam

preparation

and filling

on a

primary

tooth,

you

encounter a

very large

mesial

marginal

ridge

that

resembles r cusp.

You also notice a transverse

ridge

from mesiolingual

to mesiobuccal cusp

that

is

rather

large.

This tooth

proves

difficult

to

restore,

which tooth

is

it?

first

molar

molar

second

molar

second

molar

63

Cop)rr8lrt

(]

201l'l0l:



.

The permanent

mandibular centrals

erupt between the ages

of

6-7

.

The permanent

maxillary

centrals erupt between the

ages of 7-8

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).

transverse

ridge separates the mesial

portion

from the remainder

ofthe occlusal surface.

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

Distal

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



PEDIATRIC DENTISTRY Prim Dent

Match

the

primary

molar tooth

on

the

left

with

the

appropriate

occlusal

picture

on

the right.

m

@

ffi

w

right first

molar

right

second molar

maxillary

right

first molar

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

scared

her l0-year-old

cousin

g€ts

hit in

the face and looses a

tooth.

She calls

you

and

says that

her cousin lost his

permanent

mandibular

first

molar.

Once she

tells

you

more

about the

root morphology of

the

tooth,

you

realize

it

is a

primary

tooth

and the

child simply

lost his:

canine

first

molar

second

molar

maxillary

first molar

55

Copyrighl

aO:0ll-1012

PADIATRIC

DENTISTRY

Prim Dent



Primary

mandibular

right first

molar

Primary

mandibular

second

molar

Primary

maxillary

right first

molar

Primar]

marillary

second

molar

t',1

ffi_l

ffi

W

w

[=-]

ffil

[,q

ru

m]

ff_l

FIII

L]

ingual

ffi

m

M

ru

esial

m

ml

I

tJ

I

^

u

MI

M

Iii

r

*{

|

lL

rl

Distal

The permanent

mandibular first molar has a morphology that closely resembles the

pd-

mandibular second

molar

Note: Amalgam

prep

outlines on these two teeth also re-

one another.

include:

.

Relative

size

ofthe

distal

cusp.

The

primary molar

has

its mesiobuccal,

distobuccal,

and

distal cusp almost equal in size. The distal

cusp ofthe

permanent

molar, however, is

smaller

than

the other tu,o cusps.

.

From the buccal aspect, the

primary

mandibular second molar has a narrow mesiodistal 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 deyiations

from the

permanent

teeth

are

the

first

molars.

2. The

primary

second molar has the

greatest

faciolingual diameter

ofall

primary

teeth.

Occlusal

Not

{4.'



primary mandibular

central

incsor

primary

mandibular lateral incisor

primary

maxillary

lateral incisor

primary

marillary

central incisor

maxillary

third molar

maxillary

second molar

maxillary first

molar

mardibular

second molar

66

CopFight O20ll-2012

67

CopyriShl O

20ll-2012



Primar)

marillart.

right

central

incisor

T-=:--'l

t/ \l

le"l

Incisal

Labial

Lingual Incisal

primary

mandibular lateral incisor rcscmblcs thc

primary

mandibular central incisor except that

is slightly longcr and wider The cingulum and the mesial and disral marginal ridgcs are more

pro-

and the fossa is

nol

as shallow. The root cuNes

toward

the distal at

thc

aDcx.

general.

the

primar-r-

second molars are

larger than the

prinrary

first

molars and

resemble the

ofthc

pcrmancn{

firsl lnolats-

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

primary

maxillarv central

incisor

rcsemblcs the

permanent

maxillarv

central

in shapc. It is rnuch

in size than thc permancnt maxillary

central and has a morc

pronounccd

ccn,ical

linc. The

crown

only

antcrior tooth

in

cilhcr dcntition to have a shortcr inciso-ccr1ical hcight than thc mcsio-dis-

width. This tooth crupts rvith no mamelons,

and the labial surface is convex anci smoolh.

BB

KK

abial Lingual

Primary

maxillary

right

lateral

incisor

7\

lY./l

Labial

Lingual

Incisal

primary

maxillarv lateral incisor is

similar to thc central incisor e\cept i is smallcr Anothcr dif--

is that it is longer than it is wide- The incisal

cdgc

ofthc

primary maxillary latcral incisor is more

on the mesial and distal sides than thc straight incisal

cdgc

olthc

ccntral

incisor.

prirnaa_v

mandibular

central incisor more closel)' resemblcs thc

permanont

mandibular Iateral in-

centml incisor counterpart. The crown ofthe tooth is slightly wider than the

pernanent

Iat-

incisor

lhc

shape and foml of thc incisal edge is

a

lmost cxactl-v thc samc as that of the

pcnnancnt

The root is slender and rather Iong. Mesial and distal surfaces of the root are flat. while linSual

Iabial

surfaccs arc convcx.

primsrl

-=

l:l

,1, , .

".

;

:..'

m m

primar)

ltll lvl i1j

rl

"

'

l\i I llJl

mandiburar

@

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)



DENTISTRY

Prim Dent

A

10-1/2-year-old

patient

comes

into

your

oflice.

You

are

not

sure

whether

his

maxillary

canines are

permanent

or

primary.

Which of

the

following

statements will help

you

determine

whether or not

they are

permanent

or

primary

canines?

cusp of the

primary

maxillary canine is

much

shorter than the cusp

of

the perma-

ent

maxillary canine

cusp ridge on the

primary

maxillary

canine is shofier than

the

distal cusp

idgel this is opposite

ofall

other canlnes

cusp on the

primary

maxillary

canine is much longer and sharper than

the

cusp on

permanent

maxillary

canine

primary

maxillary

canine is much narrower and longer than the

permanent

maxil-

canine

PEDIATRIC DENTISTRY

The

occlusal

form of

the

varies

from

that

ofany

tooth in

the

permanent

dentition,

primary

mandibular first molar

primary

maxillary

first

molar

primary

mandibular

second

molar

primary

maxillary

second

molar

69

Copynght

a9

20ll-2012



significant dilferences

between the

p

mary

maxillary

canine and

the

permanent

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

[r

t

I

abial

--r'--1

t()l

I

I{

I

I

lf

I

tul

Labial

[f

l,tl

L_l

Lingual

Th€ Primar

td

I

f

Y

I

tl;l

tul

I ingual

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

ill(,

,|

Buccal Lingual Occlusal M€sial

Distal€sial

BE

ncisal

Nlcsi.l

i\Iandibular Right

Caninc

t-ll t--f

l

\v|

\/l

tti|ul

llesial

Distal

Distal

Incisal

Distal



70

Copyrighl

@

201l

-2012

necrotic

pulp

deep carious lesion adjacent to the

pulp

periapical

radiolucency

irreversibly infected due to caries or

trauma

71

Cop)'rightO20ll-2012



is treated the same

way as

you

would treat the adult

patient.

At

age eleven the root

a

maxillary

central

incisor

should be completely formed, therefore

an apexification

is not

indicated. If the root were not

fully

formed,

then an

apexification

should

be started. This

involves the placement

of

calcium hydroxide

pastes

into

to stimulate continued apical closure.

fact that the tooth

is

painful

and there is swelling is a contraindication

to

a

pulpo-

You need

healthy

pulp

tissue in the root

for

success

of

a

pulpotomy. Il the tooth

then

a

pulpectomy procedure

would

be

contraindicated

and the

only

be

to extract the tooth.

Apexogenesis

is a

vital pulp therapy

procedure performed to encourage continued

development

and

fomation

ofthe

root end. This term

is frequently used to

vital

pulp

therapy

perfotmed

to

encourage

the

continuation

of

this

process.

(Mineral

Trioxide

Aggregate)is frequently used

for this

procedure.

The

best

sign for success ofapexogenesis

is

continuous

completion ofapex.

Pulp therapy is

generally

contraindicated

in

children

who

have serious illnesses

Ieukemia, cancer

pdtients,

etc.).

pulp

caps arc

those

procedures

whcre,

at the first appointmcnt,

all of the superficial

oarious

is excavated. Thc

caries that is estimatcd

to be approximating a

potential

pulp exposure is left in

oo h ifit

js

still sufficiently

healthy

(i.e.

,

affected

-

not i

fected

dentin) Alt 1p

&essing is

placcd in

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-

If

no c\posures arc

seen

and

the tooth

has

been asymptomatic,

the

treatment

is

considered

and

a pemranent

rcstoration is

placed.

However,

the single appointrnent

procedure has also

in

popularily

and is

probably the most common

approach in curent use

ln

the singlc

appointment

permancnt restoration

is

placed

at the first appointnlellt,

with

Periodic

monitoring of

the

hrdroxide,

hybrid ionomcr matcrials,

or

glass

ionorncr

maierials are often

the dressings of

for indirect

pulp

therapy-

The ftlling material

is

placed

over the

pulp dressing

on the first ap-

/.,.g,

conposile,

glass

iononel h -brid ionomer,

or amalgatt).

The

preoperative x-ray ofthe tooth to be

treated by indirect

pulp therapy

must not indicate

ofthe

pulp.

In addition,

the tooth should be

asymptomalic

and no

periapical

change

bc obsen'able

on

the x-ray.

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

and restoration

ofa tooth treated

with indirect

pulp therapy:

.

Absence

of

subjective

con.,pl:dints

(toolhaches)

.

After 6- l2 months,

periapical

and

bitcwing

x-ray reveal deposition

ofnew secondary

dentin

.

Place

a

pcrmanent restoration

if no exposure

r.rf thc pulp chamber is

present after

rcmoval ofthe

temporary restoration and

remaining soft dcntin.

For the

primary

dcntition,

a

glass ionomer, hybrid

ionomer, compositc,

compomer, amalgam,

or stainless steel crown

may be uscd

For the

permanent

dentition. composite,

amalgam, stainless steel

crown, or

cast

crown

restorations

may be selected.



A

four-year-old

child

presents

with

acute

pain

associated

with

a

primary

mandibular

second

molar that

has a large carious lesion

with

pulpal

involvement. Radiographically,

there is

periapical pathology

on the

distal root.

child

is

very

cooperative and is able

to tolerate long

appointments,

What

is

the

preferred

choice

of therapy

for

the

primary mandibular

second

molar?

and drainage

tooth endodontics

(pulpectomy")

72

Copyright

c

20lr

-20t2

Pulp

Tx

Which treatment

is

the

proper

one

for

a Cl&ss

II

fracture

ofa

permanent

tooth with

an

immature

apex?

calcium hydroxide

to exposed

dentin and

restore

tooth

with a

permanent

estoration

73

Copynghr O 20ll-:012



first

and

probably

most important indication for

primary

tooth

endodontics

(pulpectomy)

is space

Ofcourse,

the best space maintainer is the natural primary tooth.

Saving

the tooth is very

so

that

a space

maintainer will not

be

necessary

Constructing a

space maintainer in

cases

second primary mola6 are lost before

eruption

offirst

permanent molars is extremely difficult.

there is

periapical pathology

and the

child

is four

years

old,

the treatment ofchoice is

pulpec-

If there wasn't any

periapical pathology,

a formocresol

pulpotomy

would be

indicated.

If the

were

older and

there was a

periapical

radiolucency

but

successful

pulpectomy

could not be ac-

the treatment of choice would be extraction with

placemetrt

of a space maintainer. This

prevent

damage

to the

surrounding bone and

the

developing

permanent

tooth.

for the

primary

d€ntition is a rclatively

quick

and easy

procedure for treating teeth with

tissue, which cannot be treated

with

a

pulpotomy.

A high-spccd bur

is

used

to

gain

access into

pulp

chamber and

Hcdstrom

files

arc

thcn

used

for

filing

thc

canals.

The

canals are

irrigated

with

to wash out

any remaining tissue and loose

dentin.

Thc canals and chamber are then filled

oxide er.rgcnol.

A

post-operative

x-my

is

taken to evaluate

the

condensation

procedure. The tooth

using a stainless stccl cro\r,n.

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

for

primary

tooth endodontics

(ptlpectomv),

.

Floor

ofthe

pulp

opening into thc bifurcation

.

Radiographio indication ofextensive

intem

al

resorption

(tooth

has beenweakenetl lo

the

exlenl

dt

it cannol support

a stainless

sleel

crci,n)

.

More than 2/3

ofthe

roots have been resorbed

.

Teeth

without

accessible canals

/corrnoa

l7'

jirst

primary nolars)

an

older child

with

a

fully forrned

apex:

Ifthere

is

a

pinpoint

exposure

and it's been

while

(da-y)

since tl're

lracture,

the treatment ofchoice

would

be

conventional

root canal

using

gutta-percha.

If

it

is

seen

immediately, then

a direct

pulp

cap

with

calcium

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

temporary

restoration. Ifcxposurc is large or the injury was several hou$ or days ago,

perfbrm

a

calcium hydroxidc

pulpotomy.

Oncc apex closes, do

pulpectomy.

CalciLrm

hydroxide

pulpotomy.

Once

apex

closes, do

pulpectomy



PADIATRIC

DENTISTRY

Pulp Tx

The

lirst

indication for

a

pulpotomy

is

carious

invasion

deep enough

to

cause

mechanical exposure

of

the

pulp

or inflammation of

the

coronal

pulp.

Infl*nmation

or infection

ofpulp tissue beyond the

coronal

pulp

contraindicates

a

pulpotomy.

first


first statement is false; the second statement

is true

statements are true


74

Copyrighl O 20ll-2012

PEDIATRIC

DENTISTRY

Direct

pulp

caps

(DPQ

involve direct

placement

of

the capping

material

on the

pulp.

is

the agent

that is

most

trequently

used.

varnish

ionomer

75

Copyright e 20ll-2012



are

sev€ral specific

indications

and contraindications when you are considering a

pulpotomy.

first indication

for a

pulpotomy

is carious invasion deep

enough

to

cause

mechanical

exposurc

of

pulp

or inflammation ofthe coronal

pulp.

However. it is vcry important

that thc

inflammation

and/or

not have extended beyond the

coronal

pulp

tissuc.

Important: The

success

ofa formocresol

lpotomy for

a

primary

tooth

depends

primarily

on a vital root tip.

for

thc pulpotomy procedure

in the

primary

dentition include the following.

All

of

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

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 fixation

rs

complcte.

.

Once

the

formocrcsol pellcts

are

rcmoved (after

live

inutes),

ZOE

is

used

to

obturate the pulp

chamber It is placed directly on the exposed

pulp

tissue.

.

Tooth

is rcstorcd

Formocresol willcause suface fixation ofthe

pulpaltissue

accompanied by dcgencration ofthe

pulp

caps

fDPCi

usually

are not done in the

primary

dentition.

In fact, most

den-

teach

that

the

DPC

is a

contraindicated

procedure in

pdmary

teeth.

Howevet

used

in

the

primary

dentition,

it

occasionally

is used for

primary

teeth if

exfoliation

will

occur

in the near future

(up

to

six months).

Wten

the tooth will

normally

in

less

than six

months, treatment

with

a

DPC

sometimes

is

selected

eliminate

the

time, complexity,

and expense associated

with

a

pulpotomy procedure.

pulp

capping

is

primarily

used on

permanent teeth. The reason

it is not

widely

on

primary

teeth

is

because

ofthe

alkaline

pH

ofCaOH.

CaOH can

affect

(irritate)

pulp

either

mildly

or most often severely.

With

a

mild

irritation, there is a

mild in-

reaction

which

will

resolve itself and regroup as reparative dentin.

With

se-

irritation, there

is

a

probability

ofinternal resorption.

ln

pdmary teeth this severe

resulting in intemal

resorption happens more

often

than not. In

permanent

teeth

occurs,

because the severe inflammatory

response

will

cause reparative dentin

form.

point:

Primary

teeth

do

not

respond

well

to direct

pulp

capping

procedures. Poor

prognosis

is the reason

most

clinicians

avoid DPC's

on

primary

teeth and

move

to the

pulpotomy procedure when primary tooth pulps are exposed during cavity

A

situation where it might be appropriate

to perform

a

direct

pulp

cap

instead

ofa

Occasionally

you

will

have

a

small surgical

exposur€

of

the

pulp

on a

pri-

and the tooth

is

not

going

to

be

in the child's mouth for

an

extended

period

of

-

perhaps six months at the most

you

could consider

the direct

pulp

cap in such a



76

Coplrighr O 2011-2012

following strtements

are

true

llXC.lgP?

one,

Which

one is

the.EXCfPtlOi2

of

primary

teeth is

not as

defined

as

that

of

permanent

teeth

therefore

amalgam

preps

can be more conservative

and dentin are

thicker in

primary

teeth, therefore amalgam

preps

are deeper

pulpal

homs

of

primary

teeth are longer and

pointed,

therefore amalgam

preps

be conservative

to avoid

a

pulpal

exposure

molars

have

an

exaggerated

cervical bulge that

makes

matrix

adaptation

more

difficult

occlusal table

is narrower

on

orimaw

molars

77

Coplridl

@

20ll-2012



procedure

for the diluted formocresol

pulpotomy

is the same

as

that

ofthe

traditional

pulpotomy:

nonsaturated fbrmocresol cotton

pellets

moistened with diluted formocresol for five minutes to the

stumps and check for acceptable fixation before

proceeding

with

obturation.

You may experiencc

dilTiculty in obtaining initial fixation with the diluted formocresol

compared

with the full-strength

Your

options

arc to repeat the

topical application ofthe fomrocresol

or to

proceed

with

pri-

endodontics

rpalpc,

rolrvl

or crtraction.

altemative

pulpotomy

proccdures

that have been developed as

potential

replacemcnt

proccdures

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

pulpotomy

agent. [t does not invade systemically to the same degree as fomocresol

fM.v?rJ/.

This factor,

along

with

its

potentialJy less

toxic

form, has favored its

use

in

some areas.

A two percent solution

ofglu-

taraldehydc

is used on cotton

pellcts to fixate the pulp. Thc moistcncd

cotton

pellets

are

placed

on the

pulp

stumps for four

minutes. The pulp

stumps

will

be

pinkish in

color

when the tissue is fixed.

.

Ferric

Sulfat€ Pulpotomy: onc ofthc

main

attractions

offcrri.

sulfate

is that the material is not as-

sociated

with toxicity

and

mutageniciry Thereforc,

a

milder

agent

is

being

placed on vital

pulp

tissue

in

children.

A

15.5

pcrccnt fcnic

sulfatc solution

is

uscd. Suitablc solutions

are available commercially.

The

material most often used

is the

Ultradent

astringent

solution.

A

slringe

with

2-3 ccs

offerric sul-

fatc

solution

is

dispcnsed

into the tooth

pulp

chamber. Only a small amount is neccssaryJust cnough

to achieve hemorrhage control. Typically the color ofpulp tissue treated

with ferric sulfate

is red

or

slightly darkish red.

Thc fcrric

sulfatc

is

lcft

in

placc

for

approximatcly

l5-20 seconds and then the

pulpolomy preparation

can bc rinsed to remove excess medication.

This is a very rapid

procedure,

es-

pecially

in comparison with othcr

pharmacothcrapcutic

approachcs to

pulpotornies.

.

]lineral

trioxide

aggr€gate

(MTA):

has

shown

clinical

and

radiographic

success

as

a

dressing ma-

terial

following

pulpotomy in

primary

teeth after a shofi term evaluation

pcriod and has a

prornising

potential

to become a replacement for fomocresol in

primary

teeth.

Furthcr long term clinical 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 amalgam

are shaflower

(0.5

mm into dentin, 1.5 mm

overall).

The thickness ofcoronal dentin in

rceth is abuul one-halflhat ofFermanenl leelh.

morphological characteristics of

primary

teeth affect the way restorative

procedures

are

ln

particular,

the

morphology

of

primary

teeth

necessitates

modifications in

compared

to

the same type

ofprocedure

in

permanent

teeth. Some

ofthese mod-

are subtle, but they

still

are important.

For

example,

the depth

of

Class

I

cavity

in

primary

teeth is shallower than occlusal restomtions in

permanent teeth. This

due

to

the relatively larger

pulp

chamber in

primary

teeth. Ifthe

primary teeth were

prepared

a

depth

that is

common

for

pernanent

teeth, the dentist would be much

more apt to

expose

pulp.

In addition, the enamel cap is thinner in

primary

teeth than in

permanent teeth.

Con-

depth

for

a

preparation

on a

primary

tooth

can be much

less than the

of a

preparation

for

a

permanent tooth.

important

morphologic considerations of

primary

t€eth include:

.

Primary

molaIS

have an

exaggerated ceryical

constriction which requires special care in

the

formation

ofthe

giogival

floor in

Class

ll

preps

.

Enamel

rods

in

the

gingival third

ofpdmary

teeth

extend

occlusally ftom

the

DEJ,

elimin-

ating

the

need in

Class

ll

preps

for

the

gingival

bevel which is always

required when

preparing

Class

lI

preps

on

permanent

teeth

When

preparing

a Class ll amalgam

prep

on a

primary

tooth,

there are

several

for the

proximal

box

preparation:

.

The

proximal

box should be broader

at

the

cervical

than

at

the

occlusal

aspect

.

The

buccal, lingual, and

gingival

walls

should all break contact

with the adjacent tooth,

just

enough to allow the tip

ofan

explorer to

pass

.

The buccal and lingual walls should create a 90-degree angle

with the enamel



PEDIATRIC DENTISTRY

Restorative

The

success rates

for

rnandibular

nerve blocks are

lower in children than in

adults

because

of

the

lnatomy ofless

developed

mandibles.

The anterioposterior

position

of the

mandibular

foramen

is about the same

or

slightly

more mesial

in children than

in

adults.

first


first

statement is false; the

second

statement

is

true

statements are

true


76

Copynghr

rl20ll-2012

PEDIATRIC DENTISTRY Restorative

trulbous,

conically

shaped

primary

teeth also affect the

amount ofextension

ofthe

occlusal

outline

of

the

preparation.

The

general

rule

is that the occlusal

outline

is

about of

the

intercuspal

dhtance,

betw€en the

buccal

and

lingual

cusps, on the occlusal surface

of

primary

molars.

79

CopyriSht O 201 I 2012



success

rates for mandibular newe blocks are higher in

children than

in

adults because

ofthe

analomy

less

developed mandibles. The anterioposterior position

ofthe mandibular

foramen is about

the same

more

distal

in

childrcn

than

in

adults. However,

the vertical

position

ofthe

mandibular

fora-

jn

young

children is closer to the occlusal

plane

when

compared with

that in

adulls.

In adults,

it is lo-

roughly

ten millimeters above the occlusal

pLane.

In

young

children,

it is located somewhere

belween

millimelers

above

lhe

occlusal

plane

and slightly below the occlusal

plane.

Therefore,

local

anesthctic

can more easjly diftusc

inferiorly

liom the site ofdeposition olthe solution to thc

target

area. For

child,

the slringe barrel should bisecl lhe

primary

molan on the opposite side ofthe injection. Note: An

irjection

techniquc

is the most

common cause ofproblems with

getting

a child

palient

numb.

mandibul'r

arch, the only

guaranteed

way lo

accomplish

prolound pulpal

anesthesia

is 10 perform

inferior alveolar ncn'e block. Primary incisors. however.

can be anesthetizcd using

suprapcriostial in-

-

which

ancsthetizes branches

olthc

incisive ncrvc.

Not€: Local

infiltration

can be uscd fbr

anes-

m.xillary

primary

teeth. Adequate diffusion of thc local ancsthetic readily occurs in childrcn

their bones are less dense than those ofadults.

Young

children

don't always understand what

"numb

lip"

means when

you

ask them this fol-

a mandibular

block.

The best indicator

ofa

profound

block

would

be

to probc the labial-attachcd

between

rhe latcral incisor and

caninc

with

an

explorer

Ifthis

js

done

without

a

reaction from

the

hetshe is

"numb."

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

vi-

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 pediatric

dentistry.

.1.

The lwo most commonly used topical anesthetic agenls in

pediatric

dentistry

are:

.

20

70

Benzocaine

gel

or liquid

.

2 -107o Lidocaine

gel

or liquid

5.

Remember to wam the child not 10 bite lhe

"numb"

cheek or

lips.

Cive

the waming during

the dental appointment

as

*ell

al

lhe

end

ofthe

appointment.

Important:

Class

II

amalgam rcstorations for primary

tceth are

prone

to isthmus fractures. Some

even

go

so far as to recommend removing

tooth sffucture at the axio-pulpa)

line

angle. so that

bulk ofamalgam can bc obtajned to strengthen the isthmus.

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

and

tliiurcs.

.

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 \4ill

allo\\ more

complete condensation

ofthe

amalgam

material into

the

extremities ofthe

preparation.

.

hl

Class

Il

prcparations,

the facial

and

lingual walls

ofthc

proximal

box should bc carried to 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

deeper

in this

area.

This is due to the

cenical colstriction found in this arca on

p

mary molars.

.

Problcms

with open contacts duc to interproximal restorations can be avoided with

good

matrix

and

wedge placement. It is important to

avoid open contacts.

.

The

critical clcmcnt

in filling

all

intcrproximal

resto.ations

in

terms

of

achieving

good

contacts,

$hether you

are restoring one or two adjacent teeth, is to push

the wedgc t'ar enough

into the

inter-

proximal

space

to

achicve

slight

separation

ofthe

teeth.

Finally,

a

good

visual

check

ofthc

matrix

adaptation

before the

tooth is restored will yield

consistently excellent results.



IEDIATRIC DENTISTRY

Depth

cuts can be used

as a

gauge

to

help establish the

depth of

the occlusal

reduction

when

preparing

a

primary

tooth

for

a stainless steel

crown,

Approximately ofthe

occlusal surface should be removed.

to 1.5

millimeters

to

3.5

millimeters

millimeters

millimeters

80

Copynghr

i(-r

:01

I-1012

PEDIATRIC DENTISTRY Restorative

Alf of

the

folfowing

statements are

true

EXCEPT

one.

Which

one

is the

EXCCPZOM

decay

in primary teeth

is an infectious

process

that

can

be very

painful,

spread,

affect the development

ofthe

adult

teeth

decay in primary teeth most

often means there

will

be dental decay in the adult

teeth are slightly more opaque on x-ray

film

than permanent teeth

because ofa

content

decay

in

primary

teeth tends

to

progress

more

rapidly from initial

surface de-

to involvement ofthe dentin

enamel layer ofprimary teeth is thinner in

all

dimensions as compared to

perma-

ent teeth

81

copyright

(c

20lI :ol2



stainless steelcrowns on

primary

teeth are a fast,

predictable,

durable. and relatively inexpen-

teeth have a limited lifespan

compared

to the

permanent

dentition;

a

rcsult,

a restoration

nceds

to

last

only until exfoliation. Bccausc

primary tecth arc smaller lhan

per-

a

given

amount ofdecay causes

the tooth structure to

become

thinner and

lcss

stable than

be

in a larger permanent tooth. The larger

pulp

space ofprimary teeth limits

the depth

of amal-

preparations;

these factors result in less stable Class II amalgam

rcstorations among

primary

mo-

loss of a Class II amalgam can lead to the mesial migration of

posterior

teeth with a

loss

ofarch

length.

used

types ofstainless steel crowns:

l.

Prctrimmed

crowns

2. Precontoured

crowns

rubber dam is

placed, tooth prcparation can begin. There are three basic steps

to tooth prepa-

stainless stccl crou'ns:

ocolusal reduction, buccal and lingual reduction/beveling.

and

proximal

.

Depth cuts can be uscd as a

gauge to help establish the depth ofthe occlusal rcduction.

Approximately

1-1.5 millimeters ofthe occlusal surface should

be removed.

.

The next step involves the buccal and

lingual reduction/beveling part ofthe

preparation. It is

bcst to

slightly reduce the cewical bulges of some

tccth

(rsua\'by

approximate\, l- 1.5

nillimeters)

jnst

abovc rhe gingival tissue. Note:

In

the case offirst

primary molars, the buccal bulges

often are very

promineat.

[t is so]netimes

necessary to remove them in order to

get

thc

preformed crown to fit over

the

buccal

promincnce.

.

Rounding

all

line angles

and

point

angles is

rccommended

.

Fitting the stainless steel

crorvn. Stainless stcel crown margins should

be

placed

rjght at or slightly

belo$ thc

height

ofthe

ftee

gingiva.

Fortunately,

the advent

ofnew

preformed

crowns

has made most

tlrmmlng

unncccssary.

The most common

eror in

preparing

teeth for stainlcss crowns

is ao leave an

intcrproximal

This has been a

popular

question

on national board examinations

for decades. A

prcparation 1lith

wil)

not allow

the stainless steel crown to scat complctely

because it often

will

get

caught on the

This is false;

primary teeth are slightly less opaquc on x-ray

film than

pemancnt

teeth because

of

inorganic content.

Remember: Ttere

must

be

30-6070 loss in mineralization

before caries is .a-

:raphically cvidcnt

with

standard

D-and

E-speed

intraoral

films.

Thereforc,

the

clinical

progress

of

lesion

is

advanced,

sometimes

significantly,

compared

with its radiographic

progress.

has been uscd

as a restorative material sincc early

in the nineteenth ccntury

In the

past,

as nou'.

periodically has been the object of confoversy.

The

cause

ofthe confoversy

often has been

mercury content. Currently,

amalgam also is bcing challenged

by the introduction

of other

re

storative

Tha ncw mate als have

many feafures that are more desirable than

those of amalgam.

Point: Thc

usc

ofamalgam

is declining

rapidly in

pediatric

dentistl-1".

rnator force behind the decrcasing use

ofamalgam in

pediatric

dcntistry

is the devclopment ofal-

e

materials rvith supcrio.

features. Some

ofthe

newer

materials

have

the following excellent

fea-

lhev are casy to nse,

they release fluoridc,

they are tooth oolored, they adhcrc

to enamel and dentin,

their

durability

is satisfactory

ionomers arc among

the most notablc ofthe

newer materials being uscd as

altematives to amal-

Ionomen

aftach

to both dentin

and

enamel as well as telease fluoridc-

They are composed

offlu-

silicate powdcr

and

polyacrylic

acid.

They

are

used

for

small

Class

I

and

very conservative

II

preparations

fthq,are

nol rery stro

g).

hfbrid

ionomer

materials

truly revolutionized

pcdiatic rcstorative dentistry

\lhen they were in-

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

materials

contain resin and ionomcr

matcrial. They are more likc composite

materials than

are like ionomer matcrials.The

most important advantage ofcompomers

over hybrid

ionomers is

ofthe material.

Note: The hybrid ionomers rclcasc

morc fluoride to the adjacent

tooth struc-

inhibitors than the compomers.



a2

CopFiglt O 201l-2012

Listed bclow

are the usual events

in

the histogenesis

of

N

tooth.

Pkce

them

in

their correct

seq[ence +

from

.wbet

hsppens lirst to

what

happens lart.

ofthe first

layer

ofdentin

of

odontoblasts

ofthe first

layer ofenamel

ofthe

inner enamel

epithelial

cells of the enamel organ

83

Copyndi

O

20ll-2012



development begins with

incrcased

cell activiry in

gowth

centers ir the

tooth

germ.

A

groMh

center

is an area ofthc tooth

germ

where the cells are

particularly

active. These lobes are

primary

centers

and are

primary

sections of

fomation in the

development ofthe crown

of a tooth. They arc

by a cusp on

postedor

teeth and mamelons and cingula on ante or

te€th.

They

are always

by developmentrl

grooves,

which

are

very

prcminent

in the

posterior

t€eth and form sp€cific

With anterior teeth,

their

presence

is much less noticeable

and

these lobes are separated by what

known

as developmentel depressions.

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

mamelons are

wom olf

afler the tooth comes

into functional

position.

The

presence

ofmamelons in

or

an

adult is evidence

of malocclusion. Most likely there is an anterior open

bite relationship

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

of

the tecth as well as

the

anterior open

bite relationship.

Coprriehr

2000 2004 Unrvcsity of WashinElon ALI

nehh.eseryed Acce*

ro

rheAdrs

ofPodiatic

Dentislry is

govemed

by

a licens. Untuthonzcda.ccsror

rel)(xlucion is forbidden

{ilhou

$epnorwtten

pcmlns.n

ol thc

Uni .rsdy

of

\hshinston. r_or infom,ton,

contacr:

lic.nsc{dlu washingron cdu

development

is dependent on

a

series ofsequential cellular

interactions between ep-

and

mesenchymal components

ofthe

tooth

germ.

Once

the ectomesenchlme

in-

oral epithelium

to

grow

down into the ectomesenchyme and

become a tooth

the

above

events occur.

, --,..

.

l. Some

texts include the deposition

ofroot dentin

and cementum

as #5 in the

histogenesis

ola

tooth.

2. Korffs fibers

is

a

name

given

to

the ropelike

grouping

of

fibers in the

periphery

ofthe

pulp

that seem

to

have something

to

do

with

the

formation

ofthe

dentin

matrix.

Histogenesis means the formation and d€velopment

of

the tissues

of

the

in this

case

the

tooth.



stage

stage

stage

8a

Coplrighl

O

201I

'2012

functions to

shNpe the

rcot

(or

rcots)

rnd

induce

dentin

in

the

root

area so

that

it is continuous

wi h the

coronal

dentln?

papilla

sac

sheath

85

Cop''right O

201 I -201 2



Initiation

(sixth

to seventh weekr): ectoderm

lining

the

stomodeum

gives rise

to oral

and to the dental lamina, adjacent to

deeper

ectomesenchlme,

which

is

influ-

by

the neural

crest

cells.

Induction

is

the main

process

involved.

Congenital

ofteeth

(anodontia)

and supernumerary teeth result from an interruption in this

Bud

stage

(eighthweek):

growth

ofthe

dental lamina into bud that

penetrates growing

Proliferation is the main

process

involved.

Cap

stage

(ninth

to tenth weeky': enamel organ forms into a cap, surrounding the

of

the dental

papilla

from the ectomesenchyme, thus forming the tooth

germ.

and morphogenesis are the main

processes involved. Dens

dente,

gemination, lusion,

and

tubercle lormation

occur during

this

phase.

Bell

stage

(eleventh

to n'elfth

u,eeks):

final

shaping

ol

tooth, cells differentiate into

tissue

forming cells

(ameloblasts,

o(lontoblasts,

cementoblasts,

andfhroblasts)

the

enamel organ.

Histodifferentiation

and morphodifferentiation are the main

proc-

involved. Macrodontia and microdontta

(i.e.,

peg

lateral

incisors),as

well as

dent-

imperfecta and amelogenesis

imperlecta

occur during

this stage.

Apposition

(varies

per

tooth):

cells that were

differentiated into specific tissue-form-

cells begin

to deposit the specific dental

tissu€s

(enomel,

dentin,

cementum,

and

Enanel

dysplasia, enamal hypoplasia, concrescence, and the

formation

ofenamel

occur during

this stage.

Cafcification

(varies

per

tooth)i mineralization.

Begins

at

cusp

tips

and

incisal

edges

proceeds

cervically.

Trauma or excessive systemic

fluoride

ingestion

may

cause

Eruption

(varies

per

tooth)

Attrition

(varies

per

tooth)

slnrclure

responsiblc for root dcvclopmcnt is the cervical loop.

The

cervical

loop is the most

ponion

ofthe

enarnel organ,

a bilayerrim that consists ofonly IEE

1funer

etld

el epithe

and

OEE

(outer

enamel epithelium).

cerrical loop begins to

grow

deeper into the surrounding

mesenchyme ofthc dental sac, elon-

and

moving

au,ay

lrom

the

newly

completed crown

arca

to

enclose

more

ofthe

dentalpapilla

form Hertwig's

epithelial root sheath

lHtRt.

crown

fomlation, thc root shcath

grows

down and shapes

the root

of

the tooth and induces

ofroot dentin.

Unilonrr

growth

of

this

sheath

will

result in thc formation of a single-

tooth, while medial outgrowths or evaginations of this sheath

will

producc

multi-rootcd

Cementum,

which develops from the dental sac, forms on the

root after the disinte-

of

Hertwig's epithelial root sheath. This disintegration allows

the undiflcrentiatcd cclls

of

sac to cornc in contact

with the newly formed

surface

ofroot dcntin, inducing

these

cells

The cementoblasts

then

disperse

to cover thc root dcntin area and undergo

cementoid.

a tooth clinicaliy erupts

in the mouth, one-halfto two-thirds ofthc root

has usually devel-

For

primary

leeth, the roots are complcted between

I

1/2

and 3

years

ofagc, 6 to

18

months

The intact root

ofthe

primary

tooth

is

short

livcd.

Thc roots remain

fully

fomred

only

aboul three

years.

Thc roots ofthc

pennanent

teeth arc completed

between

l0

and

l6 years

of

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'



Tth Trauma

EDIATRIC DENTISTRY

A

three-year-old

patient

reports to

your

oflice

with

an

intrusion

injury

on

teeth #E and #F

(see photograph).

You

inform

the

child's

parents

about

the

current standard ofcare regarding intruded teeth, Which of the

following

statements best describes the

current understanding

regarding

intruded

primary

teeth?

intruded

tccth

should be extracted

intruded

teeth should bc left to reerupt

approach to intrusron injuries

primary

tceth

is

controversial. Some

authors

the field

advocate extraction and some advo-

leaving

the tooth to

reerupt

intrudcd

tccth should bc

gcntly

moved

position

with

gauze

and stabilizcd by

Copynghr 2000-200,1

Unryc^ry

.1

\\'rsh,ngiJn Allrieihrc\.ned Acc$s

ro

rhcArlasofPcd,ati. D.nristry is gor.m.d hy

a

lircnsc unalthonrcd

scccss

or

rcprodu.rion

^

lbrb'ddcn

*lrhout

thc

tnor

*rnlen

p.mn*,on

orrhc Univcr

nryof\\rshrngbn Fo

nfom,arion.cdnra.t lic.ns.'iru$r{h,ngloncdu

Copyrighr ,il 201 l

'201

2

PEDIATRIC DENTISTRY Tth Trauma

Discolored

primary

teeth

thal

are

symptom-free

and

show

no

radiographic

changes are best

treated by:

treatment

of the

pulp

tissue

follorved

by

the

placement

of

ZOE

paste

in

the

root

space

87

Copyright C 20ll-2012



opinion

is divided whethcr

it

is best to extract intruded

teeih or to

leave them alonc to reerupt.

h is

best

to inform parents when

the choice

oftreatment

approach is

disputcd by thc expefts. It certainly

is

you

to indicate a

preference

over which slralegy o selcct in cach case, and to

provide

reasons

Bur

parents

need to be

part

ofthe

process

whcn the

choice oftherapy

is morc scientifically unsettlcd. Par-

researchers and authon do nor advocate repositioning and

splinting

intruded

primary

tecth-

For ),,hlional

Board

purposes,

the

conect

treatment

is to administer no

treatment and lct the tooth

attention

should be

given

to

sofl{issue

damage.

Howevet

as

in the

case

ofall luxation injurics

x-ray oflhe area should be taken. Re-eruption usually occurs in 2

-

4 months. Ifthe inhuded incisor is con-

the

permanent

footh

bud,

the

primary

iooth

should be extracted.

Noto: Damagc to the succedaneous

tooth, including hlpoplastic

defects,

dilaceration

ofthe

root, or

arrest

oftooth

development,

has been

luxation

injuries: It

is important to take

a

radiograph to rule

out any

fractures and for comparison

pur-

during later examinations. And it is important \,vith all luxation injuries

to

evaluate

them to make sure

luxaled tooth

is

not intcrfcring \lith thc

paticnt's

occlusion.

This is most apt to occur

$

iih

Iingually lux-

maxillary teeth. Consequently, taking a radiograph and checking the

palienfs

occlusion

arc

both

neces-

Primary endodont;cs

(pu[pectom)l

o( exrqction

would

only be

necessary if the tooth became necrotic later

The

primftry

objective oftreatmeDt in these

injuries is

to maintrin

periodonlal

ligrm€nt vitality.

thc first six

months after

the injury

you

may

obsenr'e

that there is

pulpal

necrosis which usually man-

as a

gra,v

or

gray-black

color change

in the

crowr of

the involved

primary

tooth at any

time

alter the in-

The roodl can rhen be endodontically treated,

ifn€c€ssary,

as

long

as lhe

tooth is sound in the socket and

pathologic

root resorption is evident.

Note: lfthe

tooth is

asymptomatic,

leave it alone.

Repositioning

displaced

primary

teeth that are mobile is not recommended. ExFaction

is

recom-

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-

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.

ee1h

will

olten d^rken

(hecome

grat)

after injury. This is due to

pulp

bleeding and the ditfusion of

into the dentinal tubules.

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 r.sLrh

ofrrauma

to the

primarJ"

dertition,

you

should not expect to have

problems

with thc succcssors

rhe cro*n is not calcified.

In this casc.

you

will

scc hypocalcification in lhe tooth.

This is Inost

com-

$

rrh rhe mandibular

incisors.

ht

pocalcification refers to

quality

deficiencies of enamel.

These

delects

can

be directly related to

in the mineralization ofthe organic

matrix in

enarnel

fomration. The

same

factors that cause enamel

also cause hypocalcification. Thc majority of localized defccts occur subsequcnt

to localized in-

and rauma. Excess exposure

to

citric acid

resulting from habitual

sucking

on cilrus li1rils can

produce

hypocalcified lesions thal mimic the hlpocalcification type ofanlelogcnesis

impqrfccla.

reactions ofa

tooth to trauma:

.

Pulpal

hlperemia: it

is the

pulp's

initial

response to trauma. Due to capillary congcstion.

May lead to

necrosis.

. Pufpsl

bleeding

/irternal

hemoffhage):

as a

resull ofhyperemia,

the

capillarics in

thc

pulp occasionally

hcmo.rhage. lcaving blood

pigmenrs

deposited in th€ dentinal hrbules. Teeth

will often discolor

(rlarken).

ho\\ever. a color

change

does not mean that the tooth is nonvital.

pafiicularly when the discolomtion occurs

$

ithin

1

to 2 days after

the

injury

Color

changes that

occur

wecks or months after lhe injury are more

prone

indicarilc ofa

nccrotic

pulp.

.

Pulp

canal obfiteration

(calciJic

metarflorplrosrr: thc

pulp

chambers are

gradually

obliterated by

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

chamber

or canal. It can

progress very rapidly,

destroying a

rooth

within

months.

.

Replacem€nt resorption

(dzblosit:

results

after

ineversible injury to the PDL. Akylosed

primary

teeth

should

be extracted

ilthey cause

a

delay in or ectopic eruption ofa developing

permarcnt tooth-



PEDIATRIC

DENTISTRY

Tth Trauma

An eight-year-old

patient

pres€nts

to

your

o{fice

with

a

small

pulp

exposure on the

permanent

maxillary left

central

incisor,

resulting

from

a

fracture

ofthe tooth. The injury

is about one

hour

old.

Your

clinical

and

radiographic

examinations

show there are no

other

injuries. What

is the

indicated

course

of therapy at

the

time

of

the emergency?

a direct pulp

cap and

proceed

with a glass ionomer

band-aid restoration

pulpoton.ry

therapy

immediately

endodontic

therapy immediately

for

endodontic therapy

as soon as

possible,

once the

initial

anx-

the

traumatic

episode

has abated

88

Coptright.e20ll20l2

PEDIATRIC DENTISTRY Tth Trauma

A

nine-year-old

patielt

has

fractured

th€

root of

the

permanent

maxillary

right

lateral

incisor. There is no

other identifiable

injury.

The

fracture

occurred around

the

middle of

the

root

What

is the

indicated

course

of therapy at this time?

endodontic

therapy immediately

the tooth,

and

the root remnant

ifpossible

ifthe

tooth

seems

fairly

stable

the tooth to the adjacent two

or

three teeth

89

Copyrignr

l20ll-2012



ofpermanenlt teeth resulting in small

pulp

exposures, and where the

cxposurc

is ofrccenl

dura-

(usuoll)'

less lhan t\,to hours), are lreatcd with

direct

pulp

caps and a

glass ionomer

band-aid build-up

the time

oflhc

emergcncy appointmcnt. It is not necessary,

however, to build-up the

hybrid

ionomer or

ionomer band-aid to thc original morphology

ofthe

tooth,

which might result in unnecessary manip-

ofthc tooth. Partial

pulpotomy

thcrapy is indicated in

cases

r\here the

exposure

is ol-longerdura-

(e.9..

longer than

t\o

hours). It

generally

is not used incases where the injury is ofrecent duration.

therapy usually

is not

appropriate at the emergency visit for small

pulp

exposures ofrecent du-

And, hopefully, the direct

pulp

cap will result in rnaintaininS the vilality ofthe

tooth,

making cn

therapy unnccessary over the longcr term.

.

-

..

..

L

Permanent tecth

with

largc,

open apices.

which

have

been fraclurcd

wilh rcsulting

large pulp

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 when

the apices are

already

closed.

l.

Traumatic

injurics:

a loolh with an open apex is more likely to

ha\e

a

good prognosis.

This

concept is one

ofthe

mosl

importart

in the assessmenl

ofpolential

outcomes

in traumatic inj

uries

to lceth. An open apex allows

a

better blood supply to the

pulp

ofthe toolh nnd

helps 1be pulp

of

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. lhe

toddler 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 poor

and.

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 very

young

children.

6. Remember: Recently traumatized leeth

may givc

false

negativ€

rcsponses

to

pulp vitality

tests. This impaired

nene

conduction

may

be

temporary or

permancnt,

only time

willtell.

is fhe appropriatc immcdiatc choicc ofthcrapy lbr most root fracture

injuries ofperma-

recth. Endodontic

therapy may

be

needed later if{hc tooth

becomes

necrotic. Doing nothing

be tempting ifthe tooth sccms

quitc

stablc. Howcvcr, splinting thc tooth

u,illprovide additional

\\ hile

eating;

and it

rvill

reduce the chance for additional

injury

to an already

compromised

lmportant: Fracturcs in

the

middle

third

ofthe root

have the

poorest prognosis.

Howevet

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 three

months.

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 tooth

ifyou

are conlionted

with

a

frachrre in this

area. The reason is

that

more

surface area

of

lhe root is in an approximatc

position

with thc alvcolus

with this type

ofinjury

5.Thcse teeth should be

monitored aggressively,

with follow-up clinical

and radi-

ographic

evaluations

every

three

to six months

lbr

the

firsl

year.

Any

sign

ofnecrosis

or

resorption waEants initiation ofroot canal therapy immediatell

6. Root fractures

involving

primary

teeth arc relatively uncommon because

the morc

pliable

alveolar

bone allows displacemcnt ofthe tooth.

7. Splinting is

not

rccommcnded in the

primary

dentition.

8. Fractured

maxillary

anterior

leeth

occur

most

often

in children with Class

II,

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 orthodontic

wire

or

a 30

-

to 60-pound test monofilamcnt fishing linc can be used.

lt should be left

in

place

for

l-2

weeks nraximum to

prevent

akylosis.



PEDIATRIC

DENTISTRY

Tth Trauma

What

is the most

reliabl€

method

to determine the

pulp

vitalify

in

the case ofa

recently traumatized primary

tooth?

pulp

test

intraoral exam

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

associated

with tooth #K.

If

tooth

#K

were

extraeted, what

type of

space

maintainer would

be

needed?

and

loop

space

maintainer

shoe space maintainer

(fixed)

sboe space maintainer

(removable)

rnd

loop space maintainer

Copyrighr

200G2004

Univenit ofWadlingron.

All righrs reseNed

Access to thc Arlas

ofPediaric Dcntisr)

is

go\enred

by a liccnse.

UDaudronzed

access

or reproduclion 6 tbrbiddcn

wrthoul

rhe

prior

wrilren

pemNsion

oi

rhe

UnNersny

of\}hsbinSton. For infomarion.

conract: I'cense(au {asfi ington

edu

91

Copyright C

20ll-:0ll



teeth

will

not respond

to

vitality

testing.

Pulp

vitality

testing is not routinely

in the

primary

dentition. This is because

primary

teeth do not respond to such tests

and

because

the test requires a relaxed and cooperative

patient

objectively reporting

ofblood

within the

pulp

chamber a short time after injury can often

be

detected

the exam. Shining

a

bright

light

on

the facial

surface and

holding the mirror to

view

the lin-

will usually show

a

reddish hue which is indicative of

pulpal

hyp€r€mia.

Ifthis

color

after several

weeks,

it

is

often

indicative

ofa

poor prognosis. Electric pulp

are

seldom

reliable to

determine

pulp

vitality iftaken

immediately

aft€r the

injury

The

test

is

the

most reliabl€ t€st, especially in

primary

incisors.

Failure ofa tooth to re-

to heat

is indicative

ofpulpal

necrosis,

In

young

children,

in

cases

ofavulsed and replanted

permanent teeth with open apices,

blood

supply

is usually regained

within the first 20

days after

replantation but

nerve

sup-

lags behind.

section: The chiefcause of failure

of

replantation of

perma-

external root

resorption.

shoe space maintainer is used. In this way, the space maintainer can be constructed so that

first

permanent

molar can erupt against the distal shoe and space will be maintained

for

the devel-

appliances

are

not chosen since they are easily lost and damaged.

Copyrighl 2000-2004

Unilcnny

of

washinSlon.

All

nghrs

6.tucd

Ac.ess

ro

ft.

Atlas

of

Pediadc

Ddtisrry's

gormedby

r

lice.*

U.au$onzcd

&cess or rt'odu-

tion

is

rbrbiddd vithour the

prior

*itn

pcmission

ofrhe

UnileF

sn, oawlshi.eton

For

inlbma

lio.conractliccnsc(@u wasningron

appliance is called a distal shoe space maintainer ora distal extension space

maintainer.

It

is

used

prevent

unerupted

first

pemanentmola$

from moving mesially with the

premature loss

ofsecond

pri-

molars. Tle example shown is a crown with a distal extension segment soldered

to the crown. The

segm€nt is extended into the tissue against the unerupted first

pemanent molar. The distal exten-

also

called

a

distal

shoe, is used

when

the second

primary molarc

are

lost

prior

to

the

eruption

of

first permanent molars

(i.e.,

very

premature

loss).

reflects

the

eruption ofa

tooth

in an abnormal

position.

The most

frequently found

ec-

teeth are the ma,xillary first

perman€nt

mola6 and canines, follow€d

by the mandibular canine,

second

premolar,

and

the maxillary lateral incisors. Ectopic

eruption

and impaction should

differentiated. In the latte. case, the tooth cannot eruptbecause something

impedes it and not because

its

ectopic

position.

In the absence ofrecession,

the reatment ofa heavy maxillary fienum with a diastema is delayed

the

permanent

canines have erupted. Ifthe midline diastema has not closed after

the

canines

have

orthodontic closure is accomplished fimt and a frenectomy is

performed afterwards.



Space Mgmt

What

cement is the

best choice

for

cem€nting a lower fixed

bilateral

holding arch in

place?

phosphate cement

eugenol cement

cement

92

Copyrighl

er

20ll

-2012

PEDIATRJC

DENTISTRY Space

Mgmt

right removable unilateral

appliance

removable

bilateral

appliance

right

band

and loop appliance

shoe space

maintainer

Copynghr

ao 201l-2012

ofa

six-year-old

female

reports that her daughter

has

complained

of

a

spontaneous

pain

on

the

upper right

side ofher

mouth. Your

indicates a

large

lesion

on the

distal

aspect

of

the

primary

maxillary

right first

molar which

extends to the

pulp.

All

other maxillary

teeth

are

present

and are

noncarious. You decide

that extraction

of

the

tooth

is

warranted.

What

type of

space

maintainer

will

you

advise for the

patient?



ionom€r cement is the best choice, and it is especially helpfirl to

choose

among the newest

gen-

glass

ionomer cements. The

glass

ionomer

cements are

very

user

friendly since they mix easily

easily in the mouth. Once in the mouth, they

also set-up

rapidly. They have low solubility

therefore do not dissolve and leave voids between the tooth and the band. The ionomercements also

well, especially since

they form

attachments to both the tooth and

the

band.

Zinc

phosphate

ce-

is

still

used by many

practitioners,

and

it

provides

acceptable cementation.

However, it is not the

pafiicularly

since

it is more

soluble than

glass

ionomer cement.

ZOE and IRM are not lut-

cements and should not be used for band cementation

photograph

shows

an example of a fixed bilateral space maintainer The

patient is four

years

of

Tte

appliance

is

cemented

on the two-second

primary

molan. Fixed bilateral space

maintainen on

mandibular

arch

often

are

called

lingual arch

spac€

maintainers. Mandibular fixed bilateral space

generally

are

prefened

by clinicians overremovable space maintainers.

Fixed appliances are

to maintain and they are less

likely

to be

removed,

damaged, or

lost by

the

child.

mandibular lingual arch space maintainer is used very commonly

in the

primary

dentition and the

where bands

can

be cemented to

primary

or

permanent

mola6

respectively. This is one

most ubiquitously

used space

maintainers. It

prevents posterior

teeth

from tipping mesially and can

be used

to

prevent

lingual movement ofincisors following

the

premature loss ofa

primary

canine.

is even

used

on occasion in the

permanent

dentition whe.n bicuspids are

missing

and

maintaining

space

Drior to orthodontic and/or Drosthetic

theraDy.

space maintainer is

indicated to

prevent

mesial movement

ofthe second

primary

molar. A band and

space maintainer

is the best choice. It is especially important to start space maintenance

therapy prior

eruption

phase

ofthe first

permanent

molar,

since

the force oferuption ofthe

permanent

molar will

a lot of

prcsswe

to

push the

second

primary molar forward. The eruption

phase

ofthe

pemanent

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

of

Pedi.tnc

De.lisry is

sovmed

by

a license.

Unauthorized acce$

or ieproduction is for-

bidden

wiihour

the

prior

wins

pcmission

of

rhe

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

reproduction

is

forbidde.

vnnout th.

prior

Mitton

pmission

of

rhe

Uiiveuity of

Washinglon. For infomalion,

con-

l&l: license(au.washingion.edu

photograph

shows

two

band

and loop space maintainers, an example ofthe bilateral

use

offixed

uni-

band and loop space

maintainers. These arc very common

q?es

ofunilateml

space

maintainers,

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

appliance

should be constructed

ASAP after the tooth loss.

3.

Lingual eruption of

permanent

incisors

is

a

very

common

problem

in the early mixed

dentition. These

incisors

almost always

move labially

until

they contact another tooth.

4. The fateral ectopic eruption of

pemanent

central incisors

(maxillary

or mandibular)

often causes

early exfoliation of

p

mary lateral incisors

(maxillary

or mandibulor). Thls

often

results in

a

midline deviation.



The

photograph

shows a

maxillary fixed

bilateral

space

maintainer.

This

type

of

space

maintainer

also is

known

as a:

appliance

appliance

appliance

appliance

Copyashl 2000

2004

Univ$sily ol lashington.

A1l rights reseNed. Access

to

lhe

Atlas ofPediatric

Dentisrry

is

govemed

by a license.

Uiaufiorized

acces

or

reproduction ; forbidden n rrhoDr

tlie

prior

wilren

pemision

ofrhe

Uni

ve6ity

of

\rrashinglon.

For

infom.tion.

.onrdcr: licensca4,u.washington.edu

94

Copynghl O

20ll-2012



small

acrylic

button

that will rest

against

the

palatal

tissue

with

this appliance. Some

clinicians

ob-

to

the button since it can create tissue iritation. Therefore, it is important that

patients

and

parents

be in-

sule thatthe

patient

meticulously flosses underthe acrylic button. The Nance appliarce

(Nance

Arch) is wed in situations

where

premature

bilateral

loss

of

maxillary

primary

teeth has occurred.

is an important

responsibility

ofthe

general

dentist and

the

pediatric

dentist. Inadequate

anagement can cause

problems

that are long lasting and severe. The

prcmature

loss ofprimary teeth

cause loss

ofarch

lcngth, resulting in crowding of the

permanent

dentition, impaction ofpernanent teeth,

difficulties, malocclusion,

and other

problems.

Note: The

best spac€

maintainer is a

primary

tooth,

nature's best space maintainer is lost

prematurely,

space management is needed

to maintain the space

development ofthe dental

arches.

1.

A ricketts retainer

is a

rctainer often uscd

ifthc

top

of

the mouth is supposedly taller

than

average.

2.

A herbst appliance

is a splint with tubcs and hinges to hold the mandible

forward

so

il will

grow

and

push

the maxilla back so

it won't

grow.

It's for kids that won't wear their headgears or lo

help headgears

work

better

3-

Frankel appliances

are used to

correctjaw

imbalances and

crowding

problems.

.

.

..

,

l. The loss ofa

primary

canine can cause the lingual collapse ofthe

permanent

incisors, loss of

arch length,

increased overbite, increased ov€det and midline deviation

to the side

ofthe

canine

loss. Note: Bilateral

loss

ofthe

primary

canines

causcs the same

things.

,w

2-

Factofi to consider

in

planning

space

maintenance:

.

Amount of resorption

ofprimary

roots: ifmore than one-founh ofthe rcot rcmains, space

maintenance is likely necessary; ifless than one-fourth ofthe root

remains and ifno bone is l€ft

between

lhe

primary

tooth and

permanent

tooth, space maintenance

is likely unnecessary

.

Amount of bone covering the

permanent

toothi Ifthcro is no bone, no space

maintenance

is oecessary;

if

there is

bonc, space

maintenance is

usually

indicated.

Note: If therc is any

doubt,

us€

a space

maintainer

to

prevent

space loss.

.Amount

of

root d€velopment: the average tooth erupts through

ihe

gingival

tissue

with one-

halfto two-thirds root formation

.

Time elapsed since

tooth loss: Most space loss occurs within lhe first 6

months

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Pediatric Dentistry Dd2011-2012

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