-
M|jor Topic Abbreviation Major Topic AbbreviationAbnormrl teeth
Abn Tth Primarv Dentin Prim DntBehavior Management Behav Mgmt Pulp
Treatment Pulp TxDiseases & Conditions Dis & Cond
Restorative RestorativeDrugs Drugs Space Management Space
MgmtFluoride Fluoride Tooth Development Tth DvGeneral Information
Gen Info Tooth Trauma Tth TraumaMiscellaneous Misc.
PEDIATRIC DENTISTRY Abn Tth
The photograph shows an example ofin a five-year-old girl.
. Amelogenesis imperfccta
. Dentinogenesis imperf-ecta
. Fluorosis
. Enamel hypoplasia
Copyriglr 2000 200.1Unrve6iry ofWashingron. Allnel)rs resened
Accessro rheArlasofPediatrrc Dennsrry is golemed b! a license.
Unau$onretl access or reproduction isforbidden without rhe prior
wrilten pemission ofthc Unive.sity oflrashington l]or infomation,
contact: license(au.washingron.ed!
1
Copyright.C 201 I l0l2
-
Dentinogenesis imperfecta 1D1, is an autosomal dominant trait.
its frequency of occurrcnce is about 1 in8000. This inherited
dentin defect originales during the histodilferentiation stage
oftoolh dcvclopment. Thcpredentin matrix is defective resulting in
amorphic, diso.ganized, and atubular circumpulPal dentin. Teeih
areblu-gray or bro$n and abrtde rapidly. Occasionally, these teeth
become abscessed as a result ofexposureofpulp homs caused by wear.
Full covcragc is the t.eatmnt of choice. Both the primary and
permanentdenlitions are afTected in dentinogenesis imperfecta.
lmportant: Radiogmphs ofa preschool child with dentino-genesis
impefecta will show obliteration olth pulp chrmbers with secondary
dentin, a chamcteristic find-ing. Roots of teth usually are
narrower tnd appar more fragile. Crowts gcnerally appear more
bulbousthan usual due to the smaller roots. Denlinogenesis
imperfecta can be subdivided into three basic tlTres:
. shields Type I: occurs with osteogenesis imprfcta. There is
brittle boncs, bowing ofthc limbs. and bluesclera. Periapical
radiolucencies, bulbous cro\rns, oblitcrated pulp chambers and root
fraclures are commonTeeth have amber translucent color Primary
teeth affected more than permanent leeth.. Shields Type II: also
kno\\'n as heredittry opalescent dentin, tends to occur as a
selarate entify apartfiom osteogenesis imperticta. Same
characteristics as T)?e l. Both primary and permanent teeth
affectedequally.. Shields Type III: quite rare, demonsrates ieeth
with a shell-like appearancc and muhiple pulp exposures.
Amelogenesis imperfect! is one ofthe major defects of enamel. It
is a hcreditary disease characterized byfaulty deve)opment ofthc
enamel. There is normal pulpaland root morphology. Thcrc are four
major catcgoricsaccording to the stages oftooth development in
wbich each is thought to occur
. Hypopkstic Type: occur in the histodifferentiation stage
oftooth development. There is an insullicientquantity ofenamel
formed duc to areas ofthe enamel organ that are devoid ofinner
enamel ePithlium, caus-ing a lack ofcell differentiation into
ameloblasts. Affects both primary and permanen! dentitions The
af-fected teeth appear small with open contacts, clinical crowns
contain very thin or nonexislenl enamel.. Hypomaturation Type:
det'ect in enamel matrix apposition and is characterized by teeth
having normalenamcl thickness but a low value ofradiodensiry and
mincral content-. Hypoplastic or Hypomaturation Type with
Taurodontism: is an examplc of inherited defecls in bothapposition
and histodifferentiation stages in enamel fomation. The enamcl
appears motile with a ycl_low-brown color and is pitted on the
facial surfaces- Molar tceth demonstrate taurodontiim.
Hypocalcification Typc: is an example ofinherited def'ect in the
crlcification stage ofenamel formation.Quantitatively, lhe enamel
is normal, but qualitatively, the matrix is poorly calcified. Thc
cnamcl is softand liagile and is easily fractured., exposing the
underlying dcntin, which produccs an unesthetic appear-ance,
-
Abn Tth.PEDIATRIC DENTISTRY
What condition is depicted in the radiograph below?
. Concrescence
. Gemination
. Fusion
. Dens-in-dente
2Copyrighr e 20ll-2012
PEDIATRIC DENTISTRY Abn Tth
What condition is depictd below?
. Enamel hypoplasia
. Erythroblastosis fetalis
. Nursing bottle caries
. Dentinal dysplasia
Cop)rrghl 1000 200:l Un Lve6tt]' ol Washrgton AU aghts reserved.
Acce$ lotheAtlas ofPediafic Dentisrry is lovemed br a license.
Un.urhorired accessorreprcduction is forbidden wirhout the
prior*nuen pemissior ofthe Univelsityof Washingron. !'or
irfomarion. conraci: licenseaau.washington.edu
3Coplighr a{i 20ll-2012
-
The tcrm Dens-in-dente (also called clens inNaginatus) means a
"tooth within a toothri and resultsliom the invagination ofthe
inner enamel epithelium. Most frequently involves the maxillary
lateral in-cisors. The clinical significance ofthis anomaly results
folm potential carious involvement through com-municatjon ofthe
invaginated portion ofthe lingual surface ofthc tooth with thc
outside environment.The enamel and dentin in the invaginated
portion can be both dcfective and abscnt, allowing dircct cx-posure
of thc pulp.
Dens evaginatus is an extra cusp. usually in the central groove
or ridge of a posterior tooth and in thccingulum area of central
and lateral incisors. In incisors, these cusps appear talon-shaped.
It resultsfrom the evagination of inner enamel epithelial cells.
This extra portion contains not only enamel butalso dentin and pulp
tissue, therfore, care must be taken with any operative
procedure.Gemination is a proccss in which a singlc tooth gcrm
splits or shows an attempt at splifting to form twocompletely or
partially separated crowns. This process results in incomplete
formation ofnvo teeth. Likcfusion, it is also more common in the
primary dentition. It results in a bifid crown with a single
pulpchamber. It most frequently occurs in the incisor region.
Concrescence is a twinning anomaly invoJv-ing the union of two
teeth by ccmcnfllm only. Its etiology is thought to be hauma or
adjacent tooth mal-position.Fusion ofteeth is a condition produced
when t$,o tooth buds arejoined together during development
andappear as a macrodont (a single large crown). It is morc common
in the primary dentition. It may involve$e entire length of two
leeth (enamel, dentin, and cemenlum) ot jvst the rcot (dentin and
cenenlum).Thiscondition is usually seen in the incisor area.
Although fused teeth can contain two separate pulp cham-bers. many
appear as large bifid crowns with one chamber Note: A radiograph is
needed to confirmrvhether thcre is fusion or gemination.
. I . Taurodont teeth are chamcterized by a significantly
elongated pulp chamber with short
Not{dt stuntedroots resulting from the failure ofthe proper
Ievelofhorizontal invagjnation ofHer-t\r ie's cpithclial root
sheath.
.a - l. dilace.ation refers ro an abnormal bend ofthe root
during its developmcnt; it is thought
to result from a traumatic episode, usually to the primary
dentition. It is a consistcnt findingin children with congenital
ichthyosis.
Enamcl hypoplasia lEIl) is a defect in tooth cnamcl that results
in less quantity ofcnamelthan normal.The defect can be a small pit
or dent in the tooth or can be so widespread that the entire tooth
is smallandlor mis-shaped. This type ofdcfcct may cause tooth
sensitivity may bc unsightly or may be more sus-ceptible to dental
cavities. Some genetic disorders cause all the teeth to have enamel
h)'poplasia. EH canoccur on any tooth or on multiple teeth. It can
appear whitc, yellow or brownish in color with a roughor pifted
surface. In some cases. the quality ofthe enamel is affected as
well as the quantity.Environmental and genetic factors that
interfere with tooth formation are thought to be responsible
forLH.
. Environmental factors:. Severe infections such as exanthemous
diseases and fever-producing disorders particularly dur-ing the
first year of life. Syphilis (caused 6t Treponeua pallidum)
produces classic pattems ofhy-poplasia including Hutchinson's
incisors and mulberry molars. Rubella embryopathy has a
highcorelation with prenatal enamel hypoplasia in the primary
dentition.. \eurologic defects as seen in children with cerebral
palsy and Sturge-Weber syndrome. Fluorosisi excess ingestion
ofsystemic fluoride. Nutritional deficiencies: particularly
vitamins A. C, and D, along with calcium and phosphorus. Other:
children bom premafurc and children who have received excess
radiation cxposure as*ell as children rvith asthma*** Causes
ofenamcl hypoplasia affecting individual tecth include local
infection. localtrauma,iatrogenic surgcry as seen in cleft platc
closure, and primary tooth overretention. Turner's hy-poplasia is a
classic example ofhypoplastic defects in pemanent teeth resulting
from local infcc-Iion or trauma to the primary precursor.
. Genetic factors: amelogenesis impcrfecta (see ca #1)Treatment
options depend on the severity ofthe EH on a particular tooth and
the symptoms associated1\'ith it. The most conservative treatment
consists ofbonding a tooth colored matcrial to the tooth to
pro-tect it t'rom further wear or sensitiviry [n some cases, the
nature ofthe enamel prevents formation of anacceptable bond. Less
conservative treatment options, but frequently necessary include
use ofstainlesssteel crowns, pe(nanent cast crowns or extraction of
affected tccth and replacement $ ith a bridge or im-planr.
-
. One part per million
. Two parts per million
. Three parts per million
. Four parts per million
. Tell-show-do (ZSD)
. Positive reinforcement
. Disfiaction
. Non-verbal communication
1Copynght O 2011-2012
5Cop"ighi O 201 I -201 2
-
The role offluoride in caries prevention is a very important
one. Indeed. one oflhe most significant contribu-tions ofworld free
enierprise systems to the health of people is to market fluoridated
tooth paste. Huge re-ductions in caries prevalcnce have been made
in the populations of numerous countries where
fluoridatedtoothpastcs arc uscd rcgularly.One major reason for the
decrease in decay rates is that low concentralions offluoride are
prescnt in peoples'mouths and this is very etlective in the
remineralization ofdemineralized teeth. For examplc, over ninety
per-ceni ofihe toothpastes sold in thc United States contain
fluoride. This amounts to a massive public health un-dertaking by
rhe private sector Tle significant impact on decay rates
demonstrates thc importancc offluoridcin caries prevention.
The mechanism ofaction for fluoride in caries abatement is
sho*,n in the following list:. Increased resistance oflhe tooth
structurc to demineralization.. Enhanced remineralization ofearly
carious lesions.. Impaired cariogenic activity ofdental plaque,
through disnrplion ofbacterial melabolism and function.
The studics and surveys link fluorosis to three factors:.
Fluorosis is more common in geographic areas where the endemic
levels offluoridc in lhe drinking waleris higher than three parts
per million. Fluorosis is associated *,ith fluoride supplementation
at inappropriately high levels. Tle use offluoridated tooihpaste
has been implicated in fluorosis
Important: Excessive fluoride levels in drinking water are
associated with fluorosis. Fluoride levels in elcessofthree parts
per million begin to pose a risk for fluorosis. This has been
demonstrated in numerous sludiesover decades ofresearch and in
various geogmphic setiings around ihe world.Remember: Dentin
Dysplasia is another group ofinherited dentin disorders resulting
in characteristic l_eaturesinlol\ing the circumpulpal dentin and
root moryhology. Two typs:
. Shields Type I: normalprimary and permanent crown morphology
with an ambr ffanslLrccncy. The rootstend to be short and sharply
constricted. Primary and permanent dentitions demonslmte multiple
radi-olucencies and absenl pulp chrmbers.. Shields Type II: primary
teclh are ambr-colored closely resembling dentinogcnesis Tlpe I and
II. Per-manent teeth are normal in appearance but radiographically
demonslrate thislle-tub-shaped pulp cham-bers with multiple pulp
stones. No periapical radiolucencis are sen.
Child palients usually will not know what to expect during
dental appoinhrents and many will be at anaqe $ hen thev have
considcrablc fcars ofthe unknown. The TSD shategy is dcsigned to
deal with thoserssues.
- This approach is the backbone ofthe educational phase
ofdcveloping an accepting, rclaxcd childdcnlal paricnt.- The
effectiveness of the TSD approach depends on using language the
child can understand. Thismcans tha! r\c must use words or
anecdotes that are age appropriate so the child can concepfualize
theidea \r'e are trying to convey.-\Ian"- children are helped by
watching procedures done on thcmsclves in the mirror during thc
pro-cedure. It is imponant to provide an explanation ofwhat is
occurring as the proccdure continues.-\1an! children tcnd to be
fearful ofthc unknorvn, especially in clinical situations. Being
able to watchthe procedure in the hand-held mirror seems to diffuse
anxiety.- This approach $orks espcially well when trcating a child
with a different cultural background.
Important: The clinical cxamination ofthe infant and toddler
should be accomplishcd with thc par-ents'assistance in a
non-threatening environment. Most often. it is neither necessary
nor recom_mended that the dcntal chair be used. The parent and
dentist sit facing cach other in a knee-to-kneeposition. supporting
the child l'ith the head cradled on the dentist's lap.Remember:
. Aggressive behavior in the dental office is usually a fear
rcaction
. Tle most realistic approach to managing a difticult child in
the dental office is to aftempt to re-condition the hild through
techniqucs ofapplied psychology
Aversive conditioning: is a form ofbehavior training or
modification jn whioh a noxious evcnt is uscdto punish or
extinguish undesirablc behavior. Examples include HOME. voice
control, etc.
. Most pediatric dentistry graduate programs do not teach HOME
(hdnd-over-moulh exc.tcIse) ^s
an
acceptable behavior management technique. Should always be
followed by positive rcinforcement (i.e., patient pruise, use
oftokens or "stick'ers, 'elc./ for improvcd bchaviors. Need parents
consent ifusing HOME or any aversive conditioning technique
-
. Use restraint
. Use the hand-over-mouth technique (HOME)
. Permit the child to express his feax
. Avoid all reference to the child's fear
. Tell-show-do
. Voice conhol
. Positive reinforcement
. Distraction
. Nonverbal communication
6Cop]'right O20ll-2012
7CopFght O 201I -2012
-
All behavioral pattems afe motivated by anger and fear. The
crying child is NOT an abnormal child.Anger is easier to treat than
fear. Fear is most likely to be exhibited by a young child on his
first visit tothe dentist. This is related to the anxicty over
being separated from a parent. The parent, not the dentist,has the
greatest influence on the child's reaction at this inirial
visit.
. The angry child:- Separate the parent and thc child- Place the
child in the chair abruptly and be firm- Use the "hand-over-mouth"
excercise 11]OMtl - get the parent's permission lll- Display
authoritv and command respect ofthe child by continuing with
trcatment ifhe/she is
uncooperative- Comfofl parenl at lhc cnd oflh. ! rsrt-
Compliment child at the end ofthe visit
. The fearful child:- Have the parent stand quietly behind the
chair- Dentist must be consistent jn tonal quality- Permit the
child to express his fears - identify the fear- Change the child's
focus off fear- Lastly. sedation
CIassifi cation of bchavior:. Cooperative: children with minimal
apprchcnsion and respond well to behavior shaping. Lacking
cooperative ability: children are deficient in comprehcnsion and/or
communication skills(i-e., re^ roung children and children wilh ce
ain disabililies).. Potentially cooperative: chid.en are capable
ofbehaving but are disruptive in the dental setting.
- Uncontrolled: characterized by temper tantrums. Typically 3-6
years ofage.- Defiant: characterized by "l don't want to" attitude
or passive resistance. All ages.. Timid: typically preschool and
younger grade school children. Hide bchind parent or put handsovcr
thcir mouth and face.. Tense-cooperative: coopentive but are very
nervous. "White-knuckler" patients because theygrip the dental
chair arm rests so tightly.. Whining: they whinc throughout the
\r'hole appointment.
Bhavior shaping means providing the child with cues and
reinforcements that dircct them toward de-sirable bchavior.
Positive reinforcement al every stage ofthe treatment proccss is
rccommended, to in-dicate to the child that he is making successful
steps in the process ofreceiving treatment. The frequentuse
ofpraise dudng a child's appointment, when the child performs an
appropriatc behavior is essential.Note: Positive reinforcement may
be verbal or nonverbal and should be immediate and spccific to
thcdesirablc bchavior.
obie.live!
TcllShos-Do Explanat(rns tarlored tocognitne lc\cl. folloscd
bydemonnral'on. iollowcd by
. Allry fea$, slappaxcrrs resporsc
. Giv expecrations ofcomm!n'catc re8ard'es
Modulalion on vo'cc !olume,ronc or pace lo influcnce anddirecr
pancnt s bch6vio.
avoidaco bchaviors. Sstablish au$ority
Proccss of shapingpalicnf sbchatior lhreugh appropriatcly
Di\cnin8 palrcnl s attcnnon liompcrc.i!cd !nplcasant
p.occdurc
Dccrcalc likclihood ofmp|easarr prcprcn or
Convcying reinforcem.nl andBUidinS bchavjor throush
contact,posrurc. and facial cxprcsions
Enlare effectivdes
lrv ma!.u8emert |e n-
-
. Speak slowly and in very simple terms
. Listen carefirlly to the patient
. Schedule long appointments
. Ask the patient if there are any questions about anything you
will be doing
E
Copyrighl O 201l-2012
. The age and maturity of the child
. The past medical and dental experiences that might influence
the behavior of thechild
. The physical status ofthe child
. The length of time and amount of manipulation necessary to
accomplish the surgery
. All ofthe above
9Coplright O 201l-2012
-
*** This is false; you should keep appointments short.
In addition the following procedures are also helplul when
treating mentally retardedchildren:
. Cive a tour to the patient before attempting to do any
treatment. Introduce thepatient to the office personnel.. Give only
one instruction at a time, Reward the patient rvith compliments
after thesuccessful completion of the procedure.. Schedule the
patient early in the day. The staff, the dentist, and the patient
are lessfatigued at this time.
In treating mentally retarded children, the following is usually
found:. They can be controlled in the same ways as normal
children.. They respond similarly to normal children ofthe same
mental age.. They respond inconsistently, have short attention
spans, and are restless andh1-peractive when undergoing dental
care.
Important: The dentist should assess the degree of mental
retardation by consulting thepatient's physician belore starting
dental treatment.
The age and maturity ofthe child often determine the t)?e
ofanesthesia best suited for the intended pro-cedure. Childrcn
bcloll the age ofrcason gcnerally are best managed undcr general
anesthesia, since asLght amount ofdiscomfort is always associated
with the administration of a local anesthetic. It is veryimponant
to have total anesthesia before starting the procedurc. Usc both
buccal and palatal infiltrationon maxillary teeth and block
anesthesia on mandibular teeth with infiltration, ifnecessaryThe
ven young patient is best managed under general anesthesia, usually
ofthe inhalation type o. incombination with small doses of
intravenous barbiturates. The most common premedication prior
togeneral anesthesia is Versed.\ot: Premedication wi!h a
barbiturate may cause pandoxical excitement in a young
child.Remember: After extracting a tooth on a child patient, the
biggest post-operative concern is the pre-\ enrion oflip
biting.Frankl behavioral rating scale:
. Class l: child is completely uncooperative, crying, very
difficult to make any progtess
. Class 2: child is uncooperative. very reluctant to
listen/respond to questions, some progress is pos-siblc. Class 3:
child is cooperative. but somewhat reluctant/ shy. Class 4: child
is completely cooperative and even enjoys the experiencc
\hriables that influence the child's behaviot in the dental
settingl. Age: ( l) less than 2 years old: usually are lacking in
cooperativc ability. (2) 2 years old: Tell-Show-Do technique works
well and/or parent in operatory (3) 3-7 years old: generally
cooperative; (4) 8years old and older: usually cooperative..
Nlothr's anxiety: there is a direct conelation bctween the mother's
anxicty and a child's negativebchavior in the dental setting.. Past
medical history: if a patient has had positive medical experiences
in the past thcy are moreapt to have positive dental experiences as
far as behavior is concemed.
Import|nt: The grcat majority of children require minimal
management efforts other than providinginformation on what is going
to happcn (e.g, lell-show-do).
-
. The presence of fxed orthodontic appliances
. A patient with congested nasal pa.ssags or other nasal
obsauction
. A very nervors or anxious patient
. A recently erupted tooth that will not retain a clamp
lo@yriiht O 201 l-2012
. Herpangrna
. Scarlet fever
. Diphtheria
. Mumps
11
Cc''rittu O 20tt:2o12
-
One ofthe main advadtages ofusing a rubbe. dam is that it can
aid in the managemcnt ofthe chiid. Itseems to quict and calm thc
paticnt bccause the dam acts as a separation or barier, both
physically andpsychologically.Other advantages include:
l. Better access and visualization2. Control ofsaliva and
moisture in the operating field3. Decreased operating time4.
Provides protection from aspiration or swallowing offoreign
bodies5. The child bccomes primarily a nasal breather when the
rubber dam is in place. This then enhancesthe effects ofnitrous
oxide ifapplicable.
Nitrous oride sedation for children: for the production of
conscious sedation, the inhalational route islimited to one agent.
nihous oxide. Desirable characteristics ofnitrous oxider it is
analgesic, anxiolytic,and amnestic. Note: Minimum oxygcn
conccntration : 30o; or minimum oxygen flow rate: 3 L/min.Primarv
advantages ofnitrous oxide for conscious sedation in pediatric
dentistry:
. Rapid onset and recovery: because nitrous oxide has a very low
plasma solubility, it reaches atherapeutic level in the blood
rapidly, and conversely, blood lcvcls decrease rapidly when it is
dis-continued.. Ease of dose control (Titration). Lack ofserious
adverse effects: nitrous oxide is considered to be ined and
nontoxic when admin-istered \r'ith adequate oxygen. The most common
side effect is nausea/vomiting.
l- Minimum alveolar concenhation 6rhich i.\ the concentratio
required to ptoduce imno-Xok{, bilin* in 50%' ofpatients) of
nitro.rs oxide is 105%.
',: .-.,'l 2.The total flow rate is 4 to 6 L,'min for most
childrcn.'iii*, 3. The
-aintenance dose during the dental appointment is usually around
30-3596.,1. Upon termination ofnitrous oxide adminishation.
inhalation of 10070 orygen for not lessthan 3-5 is recommended.
This allows difnlsion ofnitrogen tiom thc venous blood into
thealvcolus that is then exhaled as nitrous oxide through the
respiratory tract- Note: This processwill prevent diffusion
hypoxia.
Scarlet fever is an exotoxin-mediated disease arising from group
A beta-hemol)4ic streptococcal infection. Thepeak incidencc
olscarlet fever occurs in childrcn 4 to 8 years old. It is usually
accompanicd by symptoms olsrcp throat. such as sudden onset of
fever, sore throat, headachc, nausea, vomiting, abdominal pain,
musclcpain. and fatigue.An enlargement ofthe fungiform papillae
extending above the level ofthe white desquamating filiform
papil-lae ei!es an appearance ofan unripe strawberry. During the
course ofscarlet fevet lhe coating disappears andrhe enlargcd red
papillae extend above a smooth denuded surface, giving the
appearance ofa red strawberryor raspberr). Penicillin is the drug
of choice, Early diagnosis and ffcatmcnt are important to prevcnt
com-plications, \\hich include local abscess fomation. rheumatic
iever, anhritis. and glomcrulonephritis.Hrpangina is a viral
infection, usually ofyoung childrcn, characterizedby mouth ulcers,
but a high fever, sorethroai. and headache may precede the
appearance ofthe lcsions- The lesions are generally ulcers with a
whiteto whitish-gmy base and a red border - usually on lhc
roofofthc mouth and in the throat. The ulcers may bevery painful.
Generally, there are only a few lcsions. Thc disease usually runs
its coursc in less than a week.Treatment is palliative. The cause
is often an infection by a strain ofcoxsackie A virus.Diphtheria is
an acute, contagious disease caused by rhe bacterium
Corynebacterium diphrheria, characterizedby the production of a
systemic toxin. The toxin is panicularly damaging to the tissuc
ofthe hart and CNS.Immunizrtion against diphtheria is available to
all children in the U.S.Other conditions to know:
. Puberty gingivitis: chamcterizcd by thc enlargement
ofinterdental areas, spontancous or easily stimulatedbleeding.
Treatment includes profcssional cleaning and improved oral
hygiene.. Herpes simplex infectio i
- Primary herpetic gingivostomatitisi HSV-l infection, usually
occurs in children under 3 years old.Vast majority are
subclinical.- Acute hrpti gingivostomatitis:
. I f diagnoscd with in 3 days of onsei, acyc Iovir suspcns ion
should be prescribed. I 5 mg&g five tim esdaily for ? days..
All patients, including those presenting more than 3 days after
disease onset, may receive palliativecare, including plaque
removal, systemic NSAIDs, and topical anesthelics.
. Recurrent herpetic simple\ (Herpes labialis): vesicles located
at the mucocutaneousjunclion ofthe lips.comers ofthe mouth. and
beneath the nose. Associatcd wilh cmotional stress.. Rcurrent
aphthous ulcer: painful ulcers on unattached mucous membranes.
-
. It is also called Vincent's infection, Vincent's angina or
"trench mouth"
. It is a gingival disease chaxacterized by painful hyperemic
gingiv4 punched out ero-sions ofthe interproximal papill4 covered
by a gray pseudomembrane with an accom-panying fetid odor
. Risks include poor oral hygiene, poor nutrition, smoking, and
emotional stress
. It usually affects children
. Fusiforms and spirochets, as well as Prevotella intermedia,
have been implicated inthe etiology ofANUG
12Coplrighi O 20ll-2012
. Hard and soft palates
. Soft palate only
. Alveolar process only
. Hard palate only
13CopFighl O 20ll-2012
-
ANUG is an acute fusospirochetal infection ofthc gingiva. It
involves a progressive painful infection with ul-ceration, swelling
and sloughing otrofdead tissue from the mouth and throat due to the
sprcad ofinfection fiomthe gums. It is usually associated with poor
oral hygiene and is most common in conditions where there
iscrowding and malnutrition. It is rare in preschool children.It
can be easily diagnosed because of the involvemnt of the
interproximal papillae and the prescnce of apseudomembranous
necrotic covering ofthe marginal tissues. The clinical
manifestations of the disease includeinflamed, painful, bleeding
gingival tissue: poor appetire; fever; general malaise; and a fetid
odor. Treatmenrincludes debridement. hydrcgen peroxide mouth
rinses, and antibiotic therapy.Not: Atrophic gingivitis is
characrerized by gingival recession without a corresponding rate
ofalveolar boneloss. Minor marginal and papillary gingival
inflammation is found. The predominant clinical finding is the
re-cession.P odontal disase in adolescents: the clinical and
histologic manifestations ofgingival and periodontal dis-ease in
adolescents arc similar to those seen in adults. Bone loss from pe
odontitis does occur in a small per-ccntage ofteenagers, but the
predominant condition noted in thi! age group is
gingivitis.Pedodontal disease in children;
. A primary characteristic ofaggressiv periodontitis that
differentiates it from chronic periodontitisis the rapid
progression ofattachment and bone loss that is evident. Aggressive
periodontitis may belocalized or generalized. The classic form
oflocalized aggressive periodontitis was initially refenedto as
'periodontosis" and then as "localized juvenile periodontitis
fl-lP/. Localized aggressive peri-odontitis 11,-rP) is the new
classification designated to replace LJP.. LAP is defined by
several distinguishing characteristics: onset around the time
ofpuberty, aggres-sive periodontal destruction localized almost
exclusively to the incisors and first mola6, and a fa-milial pattem
ofoccurrence. A. is the dominant bacteria in LAP, other
microorganisms that havebeen associated with LAP include P
gingivalis, E. coftodens, C. rectus, F. nucleatum, Bacillus
capil-lus. Eubaclerium brachy, and Capnocytophaga species and
spirochetes. Important: The one ouFslanding negative feature is the
rclative absence of local factors (plaque) to explain the
severeperiodontal desfuction which is present.. Generalized
aggressive pcriodontitis 1G.1P) is di{Tcrcntiatcd from thc
localized form by the extentofinvolvement around most ofthe
permanent teeth, and it is considered to include rapidly
progress-ins neriodontitis.
Four Classes of Cleft Palate:. Class l: involves only the soft
palate.. Class II: involves soft and hard palates but not the
alveolar process.. Class III: same as Class Il but with alveolar
process involvement on one side ofthe premaxilla.. Class IV:
involves the soft palate and continues through the alveolus on
bothsides of the premaxilla.
*** Females mor often affected
Four Classes of Cleft Lip:. Class I: a unilateral notching ofthe
vermillion not extending into the lip.. Class l[ same as Class I
but the cleft extends into the lip but not to the floor of
thenose_
. Class III: same as Class II but extending into the floor ofthe
nose.
. Class I!': any bilateral clefting ofthe lip whether incomplete
notching or completeclefting.
*** Males more often affected
-
Dis & Cond
Ectodermal dysplasia is chrracterized by a lack of sweat
glands,sparse hair, dry skin, a concave nasal bridge, and:
. Oversized crowns
. Elongated roots
. An enlarged mandible
. The absence ofteeth
14Copyright aq l0ll-2012
PEDIATRIC DENTISTRY Dis & Cond
Thc child below is most likely suffering from what ondition on
the lower face?
. Chicken pox
. Primary herpetic gingivostomatitis
. Scarlet fever
. \4umps
Coplrighl 2000-2m4 Universily of [/a$ ington. All rights
leseNed.Access to rle Ades ofPediatric Dentistry is govemed by a
license.Undurhorized access orreproducrron s forbidden w'rhoul rhe
pflorwritteD pemission ofthe Unile6ity of washington. For
infomarion. conlacr: licensea.!u.washin8ton.edu
15Coplright C 20ll-1012
-
Ectodermal dysplasir is a sex-linked recessive trait. Although
both sexes arc affected, more males are af-fected than females. It
is characterized by a lack of sweat glands, sparse hait dry skin, a
concave nasal b dge,and the absence ofteeth. There may be complete
failure ofthe teeth to develop (anodontia\ ot oligodontia (par-tial
akodontia). Alveolar bone development is lacking because of the
absence ofpermanent teeth. Note: An-hidrotic ectodermal dysplasia
is characterized by the conical shape ofthe antedor teeth free
photo belov,).ltis also characterized by lack of perspiration
caused by the partial or complete absence ofsweat glands.
Copydghl 2000-2m4 Unive6ity ofwasbington. All n8his reseNed.
Access lo lhe Ad6 of Pe-diatric Dnrisiry is govemed by a license.
Unauthorized access or reproduclion is fo.bddenwirhout the prior
lritien pmission oflhe Univelsiry ofWashington. For infomation,
con-lact: license(4u.washinglon.edu
Cfeidocraniaf dysplasia (or d)'sostosis) is a ftre condition
inherited as an autosomal dominant and chamc-terized by partial or
complete absence ofthe clavicles, defective ossification ofthe
skull, and faulty occlusiondue to missing. misplaced, or
supernumeBry teeth. lt is equally common in males and females.
Prolonged r-tention ofprimary teeth and delayed or complete failur
oferuption ofpermanent teeth are characteristic fea-tures. The
presence ofnumerous supemumenry and unerupted permanent teeth is
very common.Remember: Supemumerary teeth are most often found in
the maxillary midline region and are called mesio-dens.
Supemumerary teeth are also frequently found distal to the
maxillary molars and in the mandibularpre-molar resion,
Gingivostomatitis is a disorder involving sores on the mouth and
gingiva that result from aviral infection (HSV-|). k is
characterized by inflammation ofthe gingiva and mucosa andmultiple
mucosal ulcerations. This is a very painful condition. The patient
often does not wantto eat or drink. The major concems are
hydralion, secondary infection, and prevention ofcon-iagion. This
disease is selfJimiting, and the acute phase generally lasts 7-10
days. Oral fluidsare very important in childrcn so that they do not
become dehy&ated.lmportant: Pimary bcute) herpetic
gingivostomatitis generally affects chil&en under theage
ofthree. There are prodromal symptoms (ever, mqktise, irritobility,
headache, dyspha-gid. \'omiting and lymphadenopathy) that occur l-2
days prior to the local lesions (ulcers) rnthe oral cavity.The
treatment in children should be directed toward the reliefofthe
acute symptoms so thatfluid and nutritional intake can be
maintained. Symptomatic treatrnent for pdmary herpes con-sists of
rinsing with a 50:50 suspension of Benadryl Kaopectate and/or
Viscous Lidocaine.The anti-viral drug used most frequently today to
shoften the duration and severity ofth pri-mary infection is
acyclovi (Zovirax).It is prescribed (400 mg. q.i.d.) for I -2
weeks.Important: The main dillerential diagnosis for primary
herpetic gingivostomatitis in pa-tients with predominately gingival
involvement without or with few discrete lesions is
acutenecrotizing ulcerativ gingivitis (ANUG). Patietts etith ANUG
also present with a suddenonset ofa sore mouth. Howevel ANUG can be
differentiated fiom primary herpes by the factthat in ANUG the
interdental papillae are necrotic while in primary herpes, the
interdentalpapillae are intact. In individuals with primary herpes
manifesting multiple oral ulcerations,aphthous stomatitis must be
considered in the diagnosis. However, primary herpes can be
dis-tinguished from aphthous stomatitis by lesion location and
history. Aphthous ulcers occur onlyon mobile or unattached mucosa
and there is a history of recurrnce. In contrast, primaryherpetic
lesions occur on both mobile and attached mucosa and there is no
history ofpreviousepisodes. Most patients with aphthous stomatitis
do not have systemic symptoms such as feyer.
-
. The first statement is true; the second statement is false
. The first statement is false; the second statement is true
. Both statements are true
. Both statements are false
16Coplrighr O 20tl-2012
. Extremely high, extremely low
. Relatively the same as the general population, extremely
high
. Extremely low, relatively the same as the general
population
. Extremely low, extremely high
17Coplnght I 201 l -201 2
-
Cellulitis may be caused by a necrotic primary or permanent
tooth. It often causes con-siderable swelling of the face or neck,
and the tissue appears discolored. lt is a very seri-ous infection
and it can be life-threatening. The child will appear acutely ill
and may havea very high temperature with malaise and lethargy.
Note: The most common causativeorganisms are Group A Streptococci
and Staphylococcus aureus.
Important: Cellulitis in a child is harder to treat because
dehydration occurs more fre-quently, rapidly, zurd severely in
children thim in adults.
If it involves the submandibular, sublingual, and submental
space it is called "Ludwig'sangina." In this condition, the tongue
and floor ofthe mouth become elevated and thepatient's airway is
obstructed and swallowing is impossible. The treatment for
cellulitisshould include having the child go to the hospital if the
signs and symptoms warrant il.In the case of Ludwig's angina, it is
mandatory.3 clinical stages of odontogenic infection:
l Periapical osteitis: occurs when the infection is localized
within the alveolar bone.Although the tooth is sensitive to
percussion and often slightly extruded, there is nosoft tissue
srvelling.2. Cellulitis: develops as the infection spreads from the
bone to the adjacent soft tis-sue. Subsequently, inflammation and
edema occur, and the patient develops a poorly lo-calized swelling.
On palpation the area is often sensitive, but the sensitivity is
notdiscrete.3. Suppuration then occurs and the infection localizes
into a discrete, fluctuant ab-SCCSS
Down syndrome is a congenital defect caused by a chromosomal
abnormaliry (trisomr-21 ). The prrmary skeletal abnormality
affecting the orofacial structures in Down syn-drome is an
underdevelopment or hypoplasia ofthe midfacial region. The bridge
ofthenose, bones of the midface and maxilla are relatively smaller
in size. In many instancesthis causes a prognathic Class III
occlusal relationship which contributes to an openbite. The tongue
may protrude and appear to be too large. With age, both the tongue
andthe Iips in people with Down syndrome tend to develop cracks and
fissures. This is a re-sult ofchronic mouth breathing. The eruption
ofteeth in persons with Down syndromeis usuall,'" delayed and may
occur in an unusual order. There is an extremely high rate
ofmissing teeth in both the primary and permanent dentitions. The
roots ofthe teeth in pa-tients $ ith Down syndrome tend to be small
and conical.
The clinical features ofDown syndrome are fairly recognizable
and include:. Delayed physical and mental development. Short.
stocky build. The face is broad and flat, with slanting eyes and a
short nose. The ears are small and low set. Heart defects are
common. Important: SBE prophylaxis is required for dental
treat-ment
The child with Down syndrome is said to be affectionate, fearful
ofquick movements, butcapable of leaming dental procedures. These
children need a comprehensive preventiveprogram. These patients
often have difficulty accepting dental care but cooperation canbe
improved by using gradual exposure to the dental office.
-
. Type I
' Type II
. TYPE III
' TYPe IV
t8Copyflght O 201l-2012
. The first statement is truei the second statement is false
. The first statement is false; the second statement is true
. Both statements are true
. Both statemenls are false
19Coplright O 201I 2012
-
Type I, or insulin-dpendnt diabetes mellitus, is the most common
form in children. Ap-proximately 2 in 1000 children between the
ages of5 and l5 years have the disease. The sus-picion ofdiabetes
usually arises by one or more ofthe following:
. Family history
. Symptoms; polydipsia, polyuria, weight loss with polyphagia,
enuresis, recurrent infec-tions, and candidiasis are common
findings. Glycosuria may be present. Ketoacidosis and coma are
possible
Subjective findings include a history ofpolydipsia, polyuria,
polyphagia' and weight loss.A fasting blood glucose level above 120
mg/dl is indicative of Type I diabetes mellitus.Periodontal disease
is the most consistent oral finding in patients with poorly
controlled di-abetes mellitus, These patients exhibit increased
alveolar bone resorption and inflammatorygingival changes, which
may mimic the clinical manifestations of localized aggressive
peri-odontitis. Xerostomia and recurrent intraoral abscesses may be
present.
The goal oftreatment is to control blood glucose to as normal a
level as possible, thereby re-ducing the potential complications
ofhyperglycemia and ketoacidosis. This generally involvesthe
administmtion ofan intermediate-acting insulin (NPH and
Lente).Dental management ofthe well-controlled diabetic consists
ofthe follou'ing:
. Advise the patient fo eat a normal meal before the appointment
to avoid development ofhypoglycemia. lf the dental procedure is
anticipated to be stressful, consult the patient's physician
re-garding adjustment ofthe insulin dosage. Consider utilization
ofprophylactic antibiotics for sr.rrgery, endodontics, and
periodontaltherapy to minimize risk of infechon. Have a glucose
source available to treat the onset ofhypoglycemia
Hemangiomas are vascular birthmarks in which the proliferation
of blood vessels leadsto a mass that resembles a neoplasm.
Hemangiomas differ from other vascular birthmarksin that they are
biologically active; their growth is independent from the growth
ofa child.Most hemangiomas appear within a week or two after birth.
They are 5 times more com-mon in girls than boys. They are common
on lips, tongue and buccal mucosa. These le-sions appear as flat or
raised, usually deep red or bluish red and
seldomwell-circumscribed. They are removed surgically, others
require no treatment.
L Neuroblastoma is one ofthe most common solid tumors ofearly
childhoodrn rL*t.) usually found in babies or yor.urg children. The
disease originates in the adre-
';,,1r, ..'i:; nal medulla or other sites of sympathetic nervous
tissue. The most common site
';!tt:t;t:"' is the abdomen (near the atlrenal glaru)) but can
also be found in the chest,neck, pelvis, or other sites. Most
patients have widespread disease at diagno-sis.2. A lymphangioma is
a fairly well-circumscribed nodule or mass of lym-phatic vessels.
They occur most frequently in the neck and axilla. These le-sions
appear as red to blue translucent enlargements that are
cornpressible andspongy. They are treated by excisional biopsy.3. A
neurofibroma is a moderately fim, encapsulated tumor resulting from
theproliferation of Schwann cells. They occur on the tongue, buccal
mucosa,vestibule and palate. These lesions appear as solitary or
multiple submucosalenlargements. May become malignant (5-15%).
Multlple lesions are associ-ated with neurofibromatosis (von
Recklinghausen's disease).
-
. Rampant caries
. Periodontal disease
. Overcrowding of teeth
. Supemumerary teeth
. Prominent mandible
. High arched palate
. Bifrd uwla
. Cleft palate
. Severely crowded maxillary teeth
. Class II malocclusion
. Shovel-shaped incisors
. Supemumerary teth
20Copyright @ 201 1,2012
2'lCopyrighl O 201| -2012
-
Achondroplasia is the most common form of short-limb dwarfisrr.
It occurs in all racesand with equal frequency in males and
females. An individual with achondroplasia has adisproportionate
short stature -- the head is large and the arms and legs are short
whencompared to the trunk length. Other signs are a prominent
forehead and a depressed bridgeofthe nose. Many ofthese children
die during the first year of life. Deficient growth inthe cranial
base is evident in many children that survive.
Important: The maxilla may be small with the resultant crowding
of the teeth.
Note: A Class lll malocclusion is vrv common.Rememben The oral
manifestations ofthe following disorders in children:
. Gigantism: enlarged tongue, mandibular prognathism, teeth are
usually tipped tothe buccal or lingual side, owing to enlargement
of the tongue. Roots may be longerthan normal.. Pituitary dwarf:
the eruption rate and the shedding of the teeth are delayed,
clini-cal crorvns appear smaller as do the roots of the teeth, the
dental arch as a whole issmaller causing malocclusion, and the
mandible is underdeveloped.
*** This is falsel a Class III malocclusion is common.
Apert syndrome is a genetic defect and falls under the broad
classification of cranial/limbanomalies. It is primarily
characterized by specific malformations ofthe skull, midface,
handsand feet. Note: The retrusion ofthe midface is often conected
by performing a Lefort III sur-eical procedure.
Remember:
I . Crouzon syndrome is an uncomrnon, autosomal dominant
craniofacial disorder char-acterized by cranios)'nostosis and
dysmorphic facial features.Clinical featurs include:
. Early childhood, no gender predilection
. \laxi1lary hypoplasia, reduced width ofthe dental arch and
crowded teeth
. Shon upper lip
. Short head, widely spaced eyes, shallow orbits and protruding
eyeballs
. Calcified stylohyoid ligaments
. Possible unilateral or bilateral posterior crossbite
2. Rieger's syndrome is characterized by delayed sexual
development and hlpothyroidism.This syndrome has important dental
considerations, which include: hypodontia, an under-developed
premaxillary area, cleft palate and a protmding lower lip.3.
Treacher Collins Syndrome, also called mandibulofacial dysostosis,
is a rare autoso-mal dominant disorder ofcraniofacial development.
The oral manifestations are character-ized by cleft palate,
shortened soft palate, malocclusion, ante or open bite, and
enamelhypopoplasia.
-
. It is generally fatal
. It is best treated by injecting insulin
. They generally recover ifrestrained from self-injury and
oxygen is maintained
. It can be prevented with antibiotics
22Copyrighl O 20ll -2012
. Bifid tongue
. Macroglossia
. Cleft palate and cleft lip
. Anodontia
23Coplright O 201I "2012
-
Of the multiple types of seizures, the tonic-clonic (grantl mal)
type is the most lrighten-ing and the one that most often requires
treatment. Grand mal seizures are manifested infour phases: the
prodromal phase, the aura, the conr.tlsive (icla1) phase, and the
postictalphase.The prodromal phase consists of subtle changes that
may occur over minutes to hours.It is usually not clinically
evident to the clinician or the patient. The aura is a
neurologicexperience that the patient goes through immediately
prior to the seizure. It is specificallyrelated to trigger areas of
the brain in which seizure activity begins. lt may consist of
ataste, a smell, a hallucination, motor activity, or other
symptoms. As the CNS dischargebecomes generalized, the ictal phase
begins. The patient loses consciousness, falls to thefloor, and
tonic, rigid skeletal muscle contraction ensues. This usually lasts
I to 3 minutes.As this phase ends, the muscles relax and movement
stops. A significant degree of CNSdepression is usually present
dudng this postictal phase, and it may result in
respiratorydepression.
Management of the seizure consists of gentle restraint and
positioning of the patient inorder to prevent self-injury ensuring
adequate ventilation, and supportive care, as indi-cated, in the
postictal phase, especially airway management. Single seizures do
not requiredrug therapy because they are self-limiting.Important:
Should the ictal phase last longer than 5 minutes or ifseizures
continue to de-velop with little time between them, a condition
called status epilepticus has developed.This may be a
life-threatening medical emergency. This condition is best treated
with in-travenous diazepam. and transport should be arranged to
take the patient to the hospital.
*** Cleft palate and cleft lip account for halfofthe total
number ofdefects. Of all cases,259'o are cleft palate alone and 7
5To are cleft lip with or without cleft palate.
The lip and primary palate begin to develop at four to five
weeks gestational age. The twomedial nasal su'ellings and the
maxillary swellings fuse to form the upper lip. Failure olrhjs
fusion results in cleft lip. Clefts of the lip are more frequent in
males. Cleft lip in-r olr ement is more frequent on the left side
than the right.
The secondary palate develops at approximately nine weeks
developmental age. Thepaired palatal shelves arise from the
intraoral maxillary processes. These shelves, origi-nallv in a
venical position, reorient to a horizontal position as the tongue
assumes a moreinferior position. The palatal shelves fuse with one
another and with the primary palateanteriorly, which, in tum arises
lrom the fusion of maxillary and mandibular processes.Failure of
fusion results in a cleft palate. Cleft palate is more frequent in
females.
The most severe handicap imposed by cleft palate is an impaired
mechanism preventingnonnal speech and swallowing. The child will
almost always need orthodontic treat-ment once the palate is
surgically repaired. Also, speech therapy will be needed
becausethese patients have problems related to the inability of the
soft palate to close the airflorv into the nasopharynx.
Orthognathic surgery may be needed to correct the generalconcave
appearance of the face. This concave appearance is generally due to
deficientmaxillarv srowth.
-
. Acute myeloid leukemia
. Chronic myelocltic leukernia
. Acute lymphocltic leukemia
. Cfuonic lymphocytic leukemia
uCopynghr O 20ll -2012
. The first statement is true; the second statement is false
. The first statement is false; the second statement is true
. Both statements are true
. Both statements are false
25Coplrighl O 201l-2012
-
Acute lymphocytic (lx-nphoblastic) leukemia is a life{hreatening
disease in which thc cells thatnormally develop into lymphocytcs
(h'mphoblasts) become cancerous and rapidly replace nor-mal cells
in the bone marrow The peak age is around four ycars old, and it is
the form of acuteleukemia that is most responsive to therapy. It
can be successfully trcated, with a 60-80% 5-yearsurvival ratc.
The carly signs of acute leukemia in a child include fatiguc,
palloq weight loss and easy bruis-ing. This will progress to fever,
hemorrhages, extreme weakness, bone and joint pain, and re-peatcd
infections.
Oral findings include:. Gingival oozing, petechiae, hematoma, or
ecchymosis. Oral ulceration, pharyngitis, and gingival infection
which is unrcsponsive to conventionaltherapy. Submandibular
lymphadcnopathy
\ote: Candidiasis is common in children with leukernia because
they are especially susccptiblcto this fungal infection. Nystatin
rinses or popsiclcs are cffcctivc in clearing up this
infection.
Hodgkin's Lymphoma or Hodgkin's Disease is a malignant growth
ofcells in the lymph system.Hodgkin's Discasc is the better known
fomr of lymphoma (the other lyuphomas are groupedinto v,hat is
called the Non-Hodgkin's L1'mphomas). Thc most common symptom
ofHodgkin'sdisease is painless swclling of the lymph nodes in the
neck, underarm, or groin. The commonsymptoms of N-on-Hodgkin's
disease include: painless swelling in the lymph nodcs in thc
ncck,undcrarm, or groin; persistent fever; feeling of fatigue;
unexplained weight loss; itchy skin andrashes; small lumps in skin;
bone pain; swelling in the abdomen; livcr or spleen
enlargement.
Hereditary porphyria is a rare metabolic error resulting in
fai)ure ofthe conversion ofporph)'rins. Theurine is burgundy in
color, and thcre is discoloration ofteeth and boncs. Thc tceth are
reddish-brownand fluoresce undcr ultraviolet light. These features
are characteristic oftissucs containing porphyrins.Idiosyncrasies
in tooth color are important in diagnosing abnormalities in tecth.
Horvevet, color is usu-alll not a reliable diagnostic criterion in
itself. Clinical examination, patient history and radiographs
arecssenrial in making a final diagnosis. The first diagnostic
consideratjon relating to color is whether thecolor or stain in a
particular case is intrinsic or extrinsjc. Prophylaxis utilizing
pumice can be done to re-morc lreen stains orycllow pigmentation
caused by vitamin elixirs, tobacco, or other sources. Ifthe coloris
intrinsic. ir \\'illbc necessary to consider its distribution and
thc paticnt's history, pJacc ofresidence,earl] illnesses. and
family background.Olien thc first evidence ofvariation from normal
in the human dentition is an observable difference inthe color
ofthe teeth. Somc ofthcsc variations are apparent only to the
trained eye, and others arc so ob-\ ious rhat ihev are a cause
ofgreat concem to the parents and/or children. Questions about the
color oft.eth can bc the first signal ofan underlying problcm with
thc dentition or of systemic discasc or an in-herrled
svndrome.Orher causes of intrinsic tooth discolorationl. Children
$ith cystic fibrosis have teeth that are dark in color, ranging
from yellowish-gray to darkbrown. This may be related io the usual
high doscs oftetracycline given to children with cystic fibrosis..
Erythroblastosis fetalis is characterized by an excessive
desfuction oferythrocytes. The primary teethmay have a
characteristic blue-green color.. Tetrac!'.cline therapy oan cause
the crowns of teeth to becomc discolored, ranging from yellow
tobrown and from gray to black. The drug will stain permanent teeth
that have not completed enamel for-mation at the tjme the drug is
given. For erample: Ifa five-year-old child receives tetracycline
therapy.the teeth affected will bc thc canines, premolars, and
second molars. Important: The incisors and firstmolars have already
completed enamel formation.. Amelogenesis imperfectai teeth vary in
color from white opaquc to yellow ao brown.. Dentinogenesis
imperfecta: opalescent teeth.. Dental fluorotis: ycllou ro brown
pigmenration.. Hyperbilirubinemia: jaundicc-likc ycllow-green tint
on the tooth surfaces.
-
. Maxillary posterior teeth, mandibular posterior teeth,
maxillary anterior teeth, andmandibular anterior teeth
. Maxillary anterior teeth, mandibular arterior teeth, maxillary
posterior teeth, andmandibular posterior teeth
. Mandibular anterior teeth, mxillary posterior teeth,
mandibular posterior teeth, ardmaxillary anterior teeth
. Maxillary anterior teeth, maxillary posterior teeth,
mandibular posterior teeth, andmandibular anterior teeth
Copright @ 20l l -201 2
. They occur in women more than men
. They may occur at any age, but usually first appear between
the ages of 10 and 40
. The cause is a coxsackie virus
. They appear to be associated witl stress
. They usually appear on nonkeratinized oral mucosa including
the inner surface of thecheeks and lips, tongue, soft palate and
the base of the gingiva
27CoplriShl O 201I -2012
-
Inappropriate feeding ofchildren can lead to tlpical nursing
pattem decay. The teeth typically are decayed inthe following
order: maxillary anterior teeth, maxillary poste or teeth,
mandibular posterior teerh, andmandibular anterior teeth. The
mandibular incisors are in general less affected since the tongue
covers them.\ote: Nursing-boftfe caries is also called baby bollle
tooth decay (BBTD), bottle-mouth s)'ndrome, eady child-hood caries
/ECC), nursing caries, botle caries and infantcaries.
Nursi[g-bottle caries is a rampant decay thatresults llom sleep
limc bottle-feeding combined with the activity ofStrcptococcus
mutans. The stagnation ofmilk about the necks olanterior teeth and
the fermentation ofthe disaccharide lactose. a susar found in
milk.conlribute to this caries process as \r'ell.Note: ECC
definition by the Amcrican Acadcmy ofPcdiatric Dcntistry: the
presence ofmore than one decayed(noncavitdted or caitecl). missing
(due to decd)r, or filled tooth surface in any primary iooth in a
child 7lmonths /6 rea,.t or younger.Sever ECC:
. Younger than 3 years: any sign ofsmooth surface decay
. Ages 3-5: one ormore cavitated, missing /drle 1() drcd_l'./ or
filled smooth surtace in primary anterior teeth,or, a decayed,
missing, or filled surface (dzf) score ofgreater than.l fdg J),
greater than 5 (ag? 4),otgreater than 6 fdge J).
Prr'entive measurs include:. lnlants should not be put to sleep
with a bottle containing a liquid other than watr. Infanrs should
be encouraged 1o drink fiom a cup prior to their first bifthday.
Infants should bc weaned fiom the bottle at l2-14 months ofage.
Infanls should start to supplemcnt their diet with nonliquids at
4-6 months ofagc. Jurces should only be offered from a cup. oral
hygiene should be started with eruption of the first primary tooth.
\\'rrhin six rnonths ofemption ofthe first toolh (no laterthan
theJirst birthdqi) jt ts ttme for the first den-tal \isit
Remember: Natal tceth are teeth that are already present at the
time ofbinh. They are diflerent fiom neona-ral teeth, which grow in
during the first 30 days after birth. Most develop in the
mandibular incisor area. Fre-quentl). natal teeth are removed
shortly after birth while the newbom infant is still ir the
hospital, especiallyifthe iooth is loose and the child runs a risk
ofaspiration, or "breathing in" the tooth.
*** This is false; the cause is unknown, however evidence
supports they are related to thc focalimmune dysfunction where T
lymphocytes play a major role.These lesions appear as painful white
or yellow ulcers surrounded by a bright red area. Lay pcrsonsrefer
to aphthous ulcers as rrcanker sores". Thcy can be triggercd by
stress, dictary doficicncicste.specially ircn,./blic acid, or
vitomin B l2), menstrual periods, hormonal changes, food
allergies.and similar situations.
Thel Lrsuail_v- begin with a tingling or burning sensation,
followed by a rcd spot or bump that ul-cerates. Pain spontaneously
decreases in 7 to l0 days, with complctc healing in 1 to 3
weeks.lmportanti Recurrent aphthous ulcem and lesions ofintraoral
herpes arc distinguished largely onthcir location. Rccurrent
aphthous ulcers occur primarily on mobile (unaltaclredJ mucosa
whilelesions of jntraoral herpcs occur on tissue bound (aftached)
to periosteum.Three Classifications:
L Recurrent aphtho\s minor ((0.5 mm- 10 mnt in diameter.l are
common, last over 2 weeksL Recurrent aphtholus major (l0-20 mn in
diamelet) arc much less corrmon, last over 2 weeksand heal with
scarring:. Recurrent herpetiform: multiple, small, diffr.rse,
painful, superficial ulcers*** Paticnts $,ith lrequent recurrences
should be screened for diabetes mellitus or Behcet'ssvndrome-
Topical steroids have bccn suggcsted for the relief of symptoms
as follows:Rx: Triamcinolone acetonide (Kenalog in Orabase)Disp: 5
g tubeSig: Dry lesion. Coat lesion with a thin film after each meal
and at bedtimeNlechanism: Dccreases infl an'rmation.Side effects:
Do not use on fungal ulcerations. Do not use for
diabetics*lfsignificant improvemcnt has not occurrd in 7 days,
discontinue treatmcnt and reassess thediagnosis.
-
. Insulin
. Thyroxine
. Calcitonin
. Epinephrine
2ACop)right O 20ll-2012
. The first statement is true; the second statement is false
. The first statement is false; the second statement is true
. Both statements are true
. Both statements are false
29Coplrighl O 201l-2012
-
*** Thyroxine is a hormone secreted by the thyroid gland.
Cretinism is severe hlpothyroidism in a child and is
characterized by defective mental andphysical development. Cretins
have dwarfed bodies, with curvature ol the spine and apendulous
abdomen. Their limbs are distorted, their features are coarse, and
their hair isharsh and scanty. Severe mental retardation is caused
by the improper development ofthe CNS. Note: Ifthis condition is
recognized early, it can be markedly improved with theuse of
thyroid hormones.
Dental lindings in a child with cretinism (hypoth,vroidism)
include an underdevelopedmandible with an overdeveloped maxilla,
enlarged tongue which may lead to rnaloc-clusion, delayed eruption
ofteeth, and deciduous teeth being retained longer. An anterioropen
bite is common and flaring ofthe anterior teeth often occurs. This
may be related tothe abnormal size ofthe tongue.
Additional intraoral findings include: thickened lips due to
glycosaminoglycan deposits,unerupted yet fully developed permanent
dentition.
Remembr: Severe hypothyroidism in adults is called myxedema.
Cystic fibrosis is an autosomal recessive condition. The gene
responsible is on the long armofchromosome 7. lt occurs
predominantly in individuals ofCaucasian origin. The disease
isprogressive and finally fatal, mostly as a consequence
ofpulmonary complications and cor pul-monale.The glands most
affected are those in the pancreas, the respiratory system, and
sweat glands.Cr stic tibrosis is usually recognized in infancy or
early childhood. Early signs are a chronic!'ough: frequent,
foul-smelling stools (steatorrhea); and persistent upper respimtory
inl'ec-irons. The most reliable diagnostic tool is the sweat test,
which shows elevations of bothstrdium and chloride. Note: In CF
cells, salt does not move properly because the protein prod-u of
the CF gene is defective and makes a faulty channel for the
chloride to exit.Oral tindings:
. \asal polyps and recunent sinusitis are common
. \losi patients have a high salivary sodium concentmtion
. The major salivary glands may become enlarged, with associated
xerostomia
. Halitosis is common
. The lorver lip may become dry, enlarged, and everted
. Enamel h$oplasia may be seen
. Both dental development and eruption are delayed
. Tetlacycline staining ofthe teeth was common, but should
rarely be seen norv
. Pancrcatic enzymes may cause oral ulceration ifheld in the
mouthDental management for CF patients:
. Shon appointments are recommended
. Early moming appointments are not recommended
. Patients with CF are best treated in the upright position
. Avoid seneral anesthesia
-
. Smdlpox (Variola)
. German rneasles (Rubella)
. Mumps
. Measles (Rubeola)
30CopyriSnt O 201 l-2012
. Inattention
. Mental retardation
. Hyperactivity
. Impulsivity
31Copyrigbt O 20ll-2012
-
Mersles (also called Rubeola) is a highly contagious viral
illness characterized by a fever,cough, and a spreading rash. It is
caused by a paramyxovirus. The incubation period isI to 2 weeks
before symptoms generally appear The oral lesions are pathognomonic
ofthis disease. These characteristic "Koplik's spots" usually occur
on the buccal mucosa.They are 1-2 mm, yellow-white necrotic ulcers
that are surrounded by a bright red mar-gin.Rubella (or Cerman
measles) is a fairly benign viral disease. The symptoms usually
in-clude a red, bumpy rash, swollen lymph nodes fno.!/ ofien arcund
the ear.s and neck),and a mild fever. Sorne people will feel a
little achy. The virus can manifest in the oral cav-ity as small
petechiae-like spots of the soft palate. The defects of congenital
infectionfrom an infected mother are more severe
-enamel defects, hypoplasia, pitting and ab-
nonnal tooth morphology.Sm lpox (Variola) is an acute viral
disease, it manifests itselfclinically by the occunenceof a high
fever, nausea, vomiting, chills, and headache. The skin lesions
begin as smallmacules and papules which first appear on the face,
but rapidly spread to cover much ofthe body. Oral manifestations
include ulceration of the oral mucosa and pharynx. lnsome cases,
the tongue is swollen and painful, making swallowing
difficult.NIumps is an acute contagious viral infection
characterized chiefly by unilateral or bi-lateral swelling ofthe
salivary glands, usually the parottd (pat'cttitis). Although it is
usu-ally a disease ofchildhood, mumps may also affect adults. The
papilla of the opening ofthe parotid duct on the buccal mucosa is
often puffy and reddened.
Attention Deficit Hyperactivity Disorder (ADHD) is a condition
that becomes apparent insome children in the preschool and early
school years (6e1rreen the ages of 3 dnd 5 but variesv'idely). lt
rs hard for these children to control their behavior and/or pay
attention. lt is esti-mated that between 3 and 5 percent ofchildren
have ADHD, or approximately 2 million chil-dren in the United
States. This means that in a classroorn of25 to 30 children. it is
likely thatat least one will have ADHD.The cause is unknown. The
disorder is l0 times more common in males than f'emales. Typi-cally
affected children, whether intellectually handicapped or not,
perform poorly in school be-cause ofthe inability to attend to
tasks at hand or to sit still during the school day. Note:
lfthereare any questions conceming the ability of the child to
handle dental treatment, contact thechilds'physician. ln most
cases, th child doesn't need any special treatment.Common
Medications used to treat ADHD: The medications that seem to be the
most effec-tive are a class ofdrugs known as stimulants.
. Riralin ( Met hlp h en id ate )
. Concena lMethl'lphenidate extended releqse)
. Adderall (Amphetanirte and dext"oamphetamine)Among the more
serious adve$e reactions ofthese medications are nervousness,
insomnia, andanorexla.
-
. Escherichia coli
. Viridans group Streptococci
. Staphylococci
. Bacteroides
Coplnghr O 20ll-2012
. Oral
. Inhalation
.IM
Cop''right O 201l-2012
-
Penicillin allergy
50 mglkg (rnax. 2 g)20 mg/kg (max 600 mg)
50 mgAg (max 2g)
I 5 mg/kg (rnax 500 mg)
Remember: I lb = .453 kgEndocarditis prophylaxis recommended:
dental procedures known to induce gingivalor mucosal bleeding,
including professional cleaning.Endocarditis prophylaxis not
recommended: dental procedures not likelv to inducegingival
bleeding, such as simple adjustment of onhodontic appliances or
fillings abovethe gingiVal margin. injection oflocal anesthetic
(except.fbr intrctligamentary injections),and exfoliation of
primary teeth.Important: Because ofthe diversity of circumstances
with each patient, it is recom-mended that the clinician consult
with the patient's physician if the complete medicalstatus of the
patient is not fully known or thre is any doubt.
Ninous oxide is a slightlv sll eet smelling, colorless, inen
gas. It must alu ays bc coupled with no less than 2070ox] gen.
Nitrous oridc is quickly absorbcd from thc lungs and is physically
dissolved in thc blood. There is noblotransformation, and thc gas
is raprdly excreted by the lungs \\,hen the concentration gradient
is reverscd. Itis recommended that lhe paricnt be m|intained on
1007o oxygen for 3 to 5 minutes after the sedation pcriod.\irrous
oxide basicallv creates an altered state of awareness with impaircd
rnolor function. It is a ccnralnen!us svslem depressant. h produces
litlle analgesia. The combined vol me ofgases being delivered
/o].r.L., .rr,? nir?r/r/ should be at least 3 to 5 liters/minute,
The operator should encourage the patien! to breathctlrourh lhe
nose \\'ith Ihe mouth closed.Local Anesthesia tbr children: An
important factor is mrximum dosage.
. Deremine the patient s lveight in pounds and convert to
kilograms by dtyidingby 2.2 (2 2 lb = L0 k:
-
. Pentobaxbital
. Secobarbital
. Paraldehyde
. Chloral hydrate
34Coplright e 201I,2012
. 50olo reduction in dental caries
. Moderate dental fluorosis
. An increase in the amount offluoride stored in her bones
. Gastrointestinal problems
CopFight O 201l-2012
-
Chloral hydrate acts on the CNS to induce sleep. At nonnal
doses, the sleep inductiondoes not allect breathing, blood pressure
or reflexes. It may be used before some surger-ies or procedures to
help relieve anxiety and to induce sleep. When used in
combinationwith analgesics, it can help n.ranage pain after
surgery. It has an onset ofaction of 15 to30 minutes when given by
mouth. Important: Children often enter a period ofexcitementand
irritability before becoming sedated. As with barbiturates, pain
may cause paradoxi-cal reactions.
Chloral hydrate is bitter tasting, rvhich can produce management
problems during ad-ministration. A final disadvantage is that
chloral hydrate can induce nausea and vomitingsecondary to gastric
initability.The short acting barbiturates secobarbital (Seconal)
and pentobarbital (Nentbutal) aresedative drugs. They are sometimes
considered for pediatric conscious sedation by oraladministration.
They are of very limited value. They are nonanalgesic. They may
causehyper-excitability rather than sedation in some children.Note:
Chloral hydrate and the barbiturates are classified as
sedative-hypnotics whoseprrncrpal effect is
"edation or sleepiness.
Nlodcrate tluorosis *ill not occur since by agc 15 all ofhcr
dentirion has undcrgone complete enamel calci-ficalion /r ir, rrc
porrlble exception of the third nohrs).r\ 500; reduclion in dental
caries is not probable for the reason listed above as \lell.
l. water 1'luoridation is onc of history's most cffeciive public
hcalth stories. It is perhaps thc\otes mosl successful public
health measure in history.
L II is eflective. safe, inexpensive. and nondiscriminatory. It
is the classic public health meas-ure that u'orks. Survevs havc
shown that community witer fluoridation results iD a reductiorrin
deca) ol abou! fofy b fifty percenr in the primary dentition and
about lifry io sixty pcr-cenr in thc pcrmanenr dentition.L Of rhe
50 largesr cities in the United States, 43 have community watcr
fluoridation. Fluor-idarion reaches 629/0 ofthe population through
public r'"ater supplies. morc than 1,14 nlillionleoplc.-1. \later
fluoridation rnd diet supplernentation mry affect tooth morphology,
while sclfandprofessionally applied topical treatments r,r,ill
not.5. The typcs of lluoride added to different watcr systcms
include lluorosilicic acid. sodiumfluorosilicare. and sodiunr fl
uoride.6 Up to a levcl of I ppm fluoride. thcrc is an inveNc
relation bct['ecn dental decav and fluor-rde concentration. As
fluoride concentration increases beyond I ppm. ihere is an
incrcasedprevalcnce offluorosis and no increase in the reduction
oldental decay.
Pit and fissure sealrnts' Indications:(1) deep. retentive pits
and fissures: (2) stained pits and fissures with minimal appearancc
ofdecalciilcalion or opacification; (3) no radiographic or clinical
evidence ofinterproximal caries in nccd ofresloration on iccth to
be sealed. Contrlindicetions: (l) rampant carics; (2) intcrproximal
carics; (3) wcll-coalcsccd groovesl (4) iDabil-ity to maintain a
dry field. Technique: (l) clean tceth: (2) isolatc leeth with
colton rolls or rubber danl; (3) acid etch tooth surfaces
apply l5% to 409n phosphoric acid for l5 to 60 seconds /air?
r,aries Jt>r prinart or pa manent), rinsefor l0 seconds, dry
with comprcsscd air for l5 scconds. apply scalant, chcck occlusion.
Resin-based sealanls arc most common and have supcrior rctcntion as
compared to glass iolomer-basedseilants. The tag formation in the
enamel is about .10 Fn1-. Any saliva contamination follo*,ing
isolation requires repeafing the *hole proccdure
-
Fluoride
Fluoridation has several mechanisms for caries inhibition.
are enhancement of rmineralization of enamel, inhibition ofand
the incorporation of fluoride into the enamel bydroxyapatite
crystal.
. The first statement is true; the second statement is false
. The first statement is false; the second statement is true
. Both statements are true
. Both statements are false
36Copy.ighr O 20ll'2012
PEDIATRIC DENTISTRY Fluoride
Which of the following fluoride therapies should be recommended
to athirteen-year-old child who is prone to decay and lives in a
community
where the water is fluoridated at an appropriate level?
. Professionally applied fluoride every six months
. Fluoride toothpaste
. Dietary fluoride supplements
. A low concentration fluoride mouth rinse
. A high concentration fluoride mouth rinse
37CopynShr O 20ll'?012
-
: NoteJ,:ti*::il
Fluorides exert their anticaries e{Iect by three different
mechanisms:l. The presence offluoride ion greatly enhances the
precipitation into tooth structure afflu-orapatite from calcium and
phosphate ions present in saliva. This insoluble precipitate
re-places the soluble salts containing manganese and carbonate
which were lost due tobacterial-mediated demineralization. This
exchanse orocess results in the enamel becom-ing more acid
resistant.2. Incipient, noncavitated, carious lesions are
remineralized by the same process.
3. Fluoride has antimicrobial activity. In low concentrations
fluoride ion inhibits the en-zymatic production of
glucosyltransferase. Glucosyltransfemse prevents glucose
fromforming extracellular polysaccharides, and this reduces
bacterial adhesion and slows eco-logical succession. Intracellular
polysaccharide formation is also inhibited, preventing stor-age
ofcarbohydrates by limiting microbial metabolism between the host's
meals. Thus theduration ofcaries attack is limited to periods
during and immediately after eating.
Important: Fluoride mouth rinses have been shown to have the
greatest eft'ect on newlyerupted teeth, making it essential to have
rinsing continued into the teen years to protect boththe second and
third permanent molaru. It seems that fluoride rinses are most
beneficial tosmooth tooth surfaces, although there are some
benefits to pits and fissures as well.
l. Fluorine. from which fluoride is derived. is the l3th most
abundant element andis released into the environment naturally in
both water and air2. Fluoride is naturally present in all water
Community water fluoridation is the ad-dition offluoride to adjust
the natural fluoride concentmtion ofa community's watersupply to
the level recommended for optimal dental health, approximately L0
ppm(parts per million). For warmer or colder climates. the amount
can be adjusted ftom0.7 to 1.2 ppm.
*** Fluoride supplements would be contraindicated since the
community water is fluori-dated at an appropriate level. Remember:
"Rules of6s" iffluoride level is greaterthan 0.6ppm. ifpatient is
Iess than 6 months old, and ifpatient is older than 16, no
supplemental sys-temic fluoride is indicated.Supplemental fluoride
should be administered only from the age of six months, and only
ifthe tbllo$ ing conditions prevail:
. The concentration offluoride in drinking water is less than
0.3 ppm
. The child does not brush his or her teeth (or haw them brushed
b1' o parent or guardian)at least i\ ice a day; and if, in the
judgment of a dentist or other health professional, thechild is
susceptible to high caries activity (ani[' histo4,, caries treuds
and patterns in cotlt-n ntities or geogrqphic areas). Supplemental
fluoride should be given in preparations that maximize the topical
effect,such as mouthwashes.The most common fluoride comoound used
in mouth rinse is sodiumflvortde /0.050,4 sodium fiuoride).
Toothpaste is available with or without fluoride. Toothpaste
tubes containing fluoride are nowlabeled and contain approximately
0.1% fluoride. Some tubes suggest covedng the bristleswith
toothpaste. A'pea-sizd' portion weighs approximately 0.75 g and
contains about 0.4 mgof fluoride; a 'full cover' portion weighs
approximately 2.25 g and contains about 1.0 mg offluoride. Thus,
brushing twice a day would deliver 0.8 to 2.0 mg of fluoride,
depending onwhich regimen is used. lf swallowed. the amount of
fluoride could be excessive and couldcont bute to the development
offluorosis. Important: Children should use only a'pea-sized'amount
oftoothpaste, and be encouraged not to swallow the excess.Note: The
most common forms of fluoride found in toothpastes are sodium
fluoride andsodium monofluorophosphate. Amine fluo de and stannous
fluoride. are less common.
-
. One minute
. Two minutes
. Three minutes
. Four minutes
38Coplright O 201l-2012
. Vasoline is applied to protect ary teeth with sealants
. The teeth should be dry to prevent dilution ofthe fluoride
concentration
. All bacterial plaque must be removed to prevent interference
with fluoride uptake by theenamel surface
. Patients should be placed in a semi-supine position
39Cop)righl O 20l l -201 2
-
Prof'essionally applied topical fluo de agents are applied in
the dental offlce or in other set-tings by health care providers.
Cunently there are four types oftopical fluoride agents that
areused on the teeth by health care providers.
. Acidulated phosphate fluoride 1,4PFl - in geJ. foam, or
solution fonn
.2olo neutral sodium fluoride - in gel, foam, or solution
form
. 87o stannous fluoride - in porvder fbrm supplied in bulk
containers or powder preweightedcapsule fonn; mixed with water
immediately before use. Fluoride-containing vamishes
Each agent has advantages and disadvantages and all are used in
various settings. Several ofthe professionally applied topical
agents carry the ADA Seal ofAcceptance. All the agents areeffective
and can be used in different situations to meet the range
ofrequirements for topicalfluoride agent$ in pediatric
practice.\ote: Acidulated phosphate fluoride /,4PF) is the most
populaf topical fluoride used in pedi-atric of'fices.Important: APF
solutions and stannous fluoride fSNF2,/ should not be used on
patients withporcelain. glass ionomer, and composite restorations.
They have been shown to remove theglaze liom the sud'ace of these
restomtions. Neutral sodium lluoride (Na-Fi is best to use ifthese
restorations are present. Also, APF should be avoided on implant
patients. it may cor-rode the
'urface of titanium implents.Topical fltroride (abng v'ith
occlusal sealants) is the pdmary prcventive agent during
ado-lescence (pa.\t the age o/72l because the entire dentition
except for the third melars normallyerupts by age 13. Theretbre,
fluoride tablets may not be as beneficial.Remember: Caries activity
is directly proportional to the consistency offermentable
carbo-hydrates ingested, the frequency ofingesting fermentable
carbohydrates and the oral reten-tion of f'ermentable carbohydmtes
ingested.
It is best to thoroughly dry the teeth before applying
thetiveness of the fluoride application and prevent dilutiondried
rvith comnressed air or cotton rolls.
fluoride to maximize the effec-of the agent. The teeth can
be
Agent Form Concentration Mode of Applicrtion Special NotsSodium
fluorideOiaF)
pH = 9.2
Solution2%
9.040 ppm0.90% F ion
Painr on Cotton roll isolation absorbsexcess solution
Gclzvo
9,040 ppm0.90% F ion
Paint on or tray Take care not to overfill trayRequest Patient
not to swallow
2%9,040 ppm0.90% F ion
Tray Less amount needed to fill trayLess risk ofswallowing
becauseofconsistency
Vamrsh5ro
22,600 ppm2.36/oF ion
Paint on Sets promptly
Acidulatedphosphatefluoride(APF)pH= 3.0 to 3.5
Solution|.23./.
12,300 ppm Paint on Cotton roll isolation absorbsexcess
soluttonAvoid cemmic and compositeresm rcslorutrons
Gel\.23%
12,300 ppm Paint on or tray Take care not to overfill trayAvoid
ceramic and compositeresin restontions
Foam|.230/.
12,300 ppm Tray Smaller amount needed to filltrayl less FAvoid
ceramic and compositerestn teslomhons
-
PEDIATRIC DENTISTRY Fluoride
You examine a ten-year-old boy in your practice and detrmine
that he hasmultiple carious lesions. The family resides in a rural
area and drinkswell wrter. What is your advice regarding lluoride
supplementation?
. Prescribe fluoride tablets for the patient immediately
. Arrange for a sample of the patient's well water to be sent to
a laboratory to assess theamount ofnaturally occurring fluoride in
the water. Then prescribe the appropriate doseof fluoride
supplementation in lieu ofthe fluoride that is occurring in the
water, if any.
. The child is too old for fluoride supplementation to be
ofbenefit, so you do not recom-mend rt
. None ofthe above
40Copyright aq 20ll-2012
PEDIATRIC DENTISTRY Fluoride
Clinical studies demonstrate that acidulated phosphate
lluorideis most effective at what pH?
. 1.0
.2.5
. 3.5
. 5.5
41Copyright (] 201 I 2012
-
Children who are not receiving fluoride in their water should
receive dietary fluoride supple-ments. However, you want to avoid
having the children receive too much fluoride, so youshould make
sure their water is tested for any naturally occurring fluoride
content ifyou haveany doubts about the amount of fluoride already
in the water You want to avoid fluorosis.Fluoride supplementation
is generally recommended at least until age sixteen years.Note:
Fluoride is particularly efficacious as long as teeth are still
forming.Note: Sodium fluoride is approximately twice the weight of
fluoride. So L I mg of NaF de-livers approximately 0.5 mgs of
flr.roride.
Important: Prenatal fluoride supplements are not approved by the
FDA and are not recom-mended. However, prenatal fluoride does not
cross the placental barrier. No studies to date sup-port the
administration of prenatal fluo des to protect the primary
dentition against caries.
The APF agent is L23 percent fluoride ion, which is over 12,300
ppm. It is acidic. with a pHof3.5. Clinical studies demonstrate
that it is most effective at that pH.APF is formulated in solution,
foam, and gel preparations. Foams and gels are the most use-ful.
since the mate al stays in a fluoride delivery tray while in the
child's mouth. They arealso easier to apply than a watery solution.
All ofthe APF products should be applied for fourminutes in order
to achieve the best results. Note: An APF gel has been developed
which isadr enised as effective with a one-minute application.
However, the four-minute products havenruch greater professional
acceptance and, presently, only four-minute products carry the
ADASeal.Important: You are going to encounter children who gag and
vomit and have problems hold-ing the fluoride trays in their mouths
for four minutes. All experienced care providers realizethat 1ou
are asking for lots ofclean-up jobs and some unhappy children with
spoiled clothesif l ou insist on the four-minute rule lbr all
applications. Parents also are not pleased with theseL)urcomes. The
first fallback position is a two-minute application, and a
one-minute applica-tioll \\ ould be next.\ote: Eighty percent ofthe
absorption offluoride into the enamel occurs dudng the first
tworninutes ofa four-minute application. Consequently, you should
strive fbr at least a two-minuteapplication. However, you should
terminate the procedure immediately ifthe patient is show-ing signs
ofbeginning to vomit. A one-minute application will result in some
absorption, butnot as much as a two-minute application and
certainly not as much as a four-minute applica-tion. Nevertheless,
a one-minute application is better than nothing.Remember:
*** The pH ofAPF is approximately 3.5 /acidrc)*** The pH ofNaF
is approximately 9.2 lbasly'*** The pH of SnF2 is approximately 2
.1 to 2.3 (acidit')
6 years up to at leasr 16 yeals
-
. 100 mg
. 200 mg
. 350 mg
. 500 mg
. School water fluoridation
. Fluoridation ofthe communal water supply
. Fluoride rinses at home
. Frequent dental visits
a2coprridt O 201l-2012
/t3Coplright O20ll-2012
-
The studies and surveys link fluorosis to three factors:.
Fluorosis is more common in geographic areas where the endemic
levels offluoride in thedrinking water is higher than three parts
per million
. Fluorosis is associated with fluoride supplementation at
inappropdately high levels
. The use offluoridated toothpaste has been implicated in
fluorosisIn acute fluoride toxicity, the goal is to minimize the
amount of fluoride absorbed.Therefore, syrup of ipecac is
administered to induce vomiting. Calcium-binding prod-ucts, such as
milk or milk of magnesia, decrease the acidity of the stomach,
forming in-soluble complexes with the fluoride and thereby decrease
its absorption. Note: EMS s,fioaldbe qctivated /91I ).In acute
fluoride toxicity, symptoms may appear within 30 minutes of
ingestion andpersist for up to 24 hours. Patients may experience
some nausea, vomiting, diarrhea,and abdominal cramping. This may be
due to the fact that 90-95% of ingested fluorideis absorbed through
the stomach and small intestines. Fluorides are primarily
elimi-nated from the body by way of the kidneys. However, the
fluoride that does remain inthe body is found mostly in skeletal
tissue. ln acute fluodde poisoning fu,liclr is rqre), themost
common causes ofdeath are cardiac failure and respiratory pamlysis.
Fluoride toxicityshor-rs up in Ihe bones as
o.teosclerosis.Important: The lethal dose of fluoride for a typical
3-year-old child is approximately 500 mgand would be
proportionately less for a younger child and smaller child. To
avoid the possi-bility of ingestion of large amounts of fluoride it
is recommended that no more than 120 mgof sr"rpplemental fluoride
be prescribed at any one time.Not: If a six-yar old child were
receiving fluoridated water in thc amount of 3 ppm,the result would
most likely be fluorosis but not systemic toxicity. On the other
hand, if achild in thc samc age range (6-7) werc receiving 8 ppm of
fluoridated water, thcrc wouldbe a good chancc of systemic toxicity
and moderate to severe fluorosis occurring.
The optimal concentration in the communal water supply varies
with mean arurual tem-perature. In most states, it is I ppm.
Fluoride supplments are recommended if the waterfluoride content is
less than 0.7 ppm.
The school water fluoridation optimal concentration is 4.5 times
that ofcity water sup-plies because of less water consumption at
school.
The US Public Health Seruice (PHS) has, since 1962, recommended
that public watersupplies contain between 0.7 and 1.2 milligrams of
fluoride per liter of drinking water,r-q Z/ to lrelp prevent tooth
decay fsome naturql bater sources havefluoride levels vithinIllis
ra ge. or even higher).Fluoridation is now used in the public
drinking water supplied to about two thirds ofAmericans. The types
ol fluoride added to different water systems include
fluorosilicicacid. sodium fluorosilicate. and sodium fluoride.
Other facts concerning fluoride:. It is deposited in calcified
tissues /.r,te letal).It normally accumulates slowly in bonesas a
person ages.. Proximal tooth surfaces derive the greatest benefit
from fluoridation. It is excretd by the kidney. Dental fluorosis
can occur in permanent and deciduous teeth. The U.S. Public Heatth
Depanment sets the optimal fluoride level at 0.7 to 1.2 ppmfor
public water. The cariostatic effect of fluoride is produced during
the calcification stage of toothdeveloDment
-
. Primary mandibular canine
. Primary maxillary lateral incisor
. Primary maxillary canine
. Primary rnandibular first molar
uCoplrigbt O 201l-20| 2
o Primary lateral incisors and canines
. Primary canines and first molars
. Primary canines and second molars
. Primary cenhal and lateral incisors
. Primary first and second molars
a5CopriShl @ 201l -2012
-
The most common congnitally missing permanent teeth with the
excption of the maxil-lary and mandibular third molars, are the
mandibular second premolars. followed by the max-illary lateral
incisors, and the maxillary second premolars.
, L The naxillary lateral incisor is most often atypic al in
size (peg-shaped,
etc.).,,f{otea.2.Apatientrvhohaspennanentcentralincisors,permanentcanines.andprimaryca-'.!;;;]1i
nines anterior to the premolars most likely has congenitally
missing pemanent lat-
eral incisors.Heredity is most frequently responsible for the
congenital absence ofteeth. 'Ihe roots oftheprimary tooth wiJl
resorb slower than normal without the presence ofthe permanent
tooth. Asa general rule, if only one tooth is or a f!u, teeth are
missing, the absent tooth will be themost distal tooth ofany given
type. Ifa molar tootb is congenitally nissing, it is almost
alwaysihe third molar [f an incisor is missing, it is nearly always
the lateral. If a pretrolar is miss-ing. it almost always is the
second mther than the first. Rarely is a canine the only
missingtooth.
Important: ln the case of a congenitally missing second
premolar, you want to hold ontothe primary second molar as long as
possible. If it is still present it may be ankylosed.\ote:
Cessation oferuption (tooth is out ofocclusion) is most diagnostic
ofan ankvlosed pri-mar] molar,Remember: Space maintenance is of
utmost importance u'henever primary or perrnanentreelh are
congenitally missing or lost prematurely witch results in the l