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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
Copyriglr 2000 200.1Unrve6iry ofWashingron. Allnel)rs resened Accessro rheArlas
ofPediatrrc Dennsrry is
golemed
b a
license.
Unau$onretl
access
or reproduction
is
forbidden without
rhe
prior
wrilten pemission
ofthc Unive.sity oflrashington l]or in
fomation, contact: license(au.washingron.ed
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imperfecta
1D1,
is an autosomal dominant trait.
its frequency of occurrcnce
is about 1 in
This inherited dentin defect originales
during the histodilferentiation
stage oftoolh dcvclopment.
Thc
matrix is defective resulting
in amorphic, diso.ganized, and atubular
circumpulPal
dentin. Teeih are
or bro$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,
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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
Cop)rrghl 1000 200:l
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Lve6tt]' ol Washrgton AU aghts
reserved.
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theAtlas ofPediafic Dentisrry
is
lovemed
br
a
license.
Un.urhorired
accessor
reprcduction
is
forbidden wirhout
the
prior*nuen
pemissior
ofthe
Univelsity
of
Washingron.
'or irfomarion. conraci: licenseaau.washington.edu
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a{i
20ll-2012
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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-
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part per
million
million
million
parts per
million
(ZSD)
reinforcement
communication
1
Copynght
O
2011-2012
5
Cop"ighi
O
201
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-201
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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
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restraint
technique
(HOME)
the child to express his feax
reference
to the child's fear
conhol
communication
6
Cop]'right O20ll-2012
7
CopFght O
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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-
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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).
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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
O
201
l-2012
fever
11
Cc''rittu O 20tt:2o12
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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.
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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
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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
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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
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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.
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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
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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.
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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
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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).
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caries
disease
of
teeth
arched
palate
uwla
palate
maxillary teeth
II malocclusion
incisors
20
Copyright
@
201
1,2012
2'l
Copyrighl O 201|
-2012
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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
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(Variola)
rneasles
(Rubella)
(Rubeola)
30
CopyriSnt
O
201 l-2012
31
Copyrigbt O 20ll-2012
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(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
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coli
Streptococci
Coplnghr
O
20ll-2012
Cop''right O 201l-2012
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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.
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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
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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
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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
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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.
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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
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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
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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
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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
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mg
mg
mg
mg
fluoridation
ofthe
communal water supply
rinses
at
home
visits
a2
coprridt
O
201l-2012
/t3
Coplright
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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
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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
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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
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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
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201
I
-201
2
years
old
years
old
years
old
t7
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-2012
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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.
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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
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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).
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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
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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.
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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
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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
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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
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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
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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-
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bitewing
radiographs
periapical
radiographs
anterior
periapical
radiographs
molar
periapical
radiographs
58
@yrigbt
O 20ll-2012
second
molars
first
molars
second
molars
59
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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.
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first
molar
central incisor
first molar
60
Coplrigbt O 201l-20|
2
6t
Coplrighl O 201|
-2012
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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-
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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:
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.
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
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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
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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.'
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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
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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)
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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
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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
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70
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@
201l
-2012
necrotic
pulp
deep carious lesion adjacent to the
pulp
periapical
radiolucency
irreversibly infected due to caries or
trauma
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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.
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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
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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
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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
statement is true; the second statement is false
first statement is false; the second statement
is true
statements are true
statements are false
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
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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
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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
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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
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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
statement is true; the second statement is false
first
statement is false; the
second
statement
is
true
statements are
true
statements are false
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
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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.
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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
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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.
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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
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O
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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.
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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
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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'
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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
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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-
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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
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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.
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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
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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.
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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?
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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.
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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
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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