PEDIATRIC DENTISTRYPart 1: Developmental Disturbances of Teeth

Development of the Tooth1) Bud stage ( Initiation )

-formation of dental lamina-begins in 6th week of embryonic life-all primary teeth and permt molars arise from dental lamina-permt incisors, canines, and premolars arise from primary predecessor-failures during initiation result in congenitally missing teeth-excessive budding results in supernumerary teeth

2) Cap stage ( Proliferation ) -formation of shape of tooth-peripheral cells of cap form inner and outer enamel epithelium-failure in proliferation results in congenitally missing teeth-excessive proliferation results in cysts, odontomas, or supernumerary teeth depending on amt of cell differentiation

3) Bell stage ( Histo/Morphodifferentiation ) -differentiation into specific tooth types-cells of dental papilla differentiate into odontoblasts-cells of inner enamel epithelium differentiate into ameloblasts-failure in histodifferentiation results in structural abnormalities of enamel and dentin (amelogenesis/dentinogenesis imperfecta)-failure in morphodifferentiation results in size and shape abnormalities (peg incisors, macrodontia)

4) Apposition-ameloblasts and odontoblasts deposit a layer-like matrix (enamel, dentin, etc.)-disturbances in apposition results in incomplete tissue formation (enamel hypoplasia)

5) Calcification /Maturation -enamel is 96% inorganic matter and 4% organic matter/water-calcification begins at cusp tips and incisal edges and proceeds cervically-localized infxn, trauma, and excessive systemic fluoride ingestion may cause hypocalcification

Lobes-lobes are primary centers of ossification in tooth development-lobes separated by developmental grooves in post. teeth and by developmental depression in ant. teeth-all anterior teeth have 4 lobes (3 facial and 1 cingulum)-premolars have 4 lobes (3 buccal and one lingual); mand. 2PM has 5 lobes (3 buccal, 2 lingual)-1st molars have 5 lobes (1 for each cusp)-2nd molars have 4 lobes (one for each cusp)-3rd molars have at least 4 lobes

Formation Sequence (Histogenesis) of Tooth Substances1) Elongation of inner enamel epithelial cells of enamel organ2) Differentiation of odontoblasts3) Deposition of first layer of dentin

-Korff’s fibers in pulp periphery help in formation of dentin matrix4) Deposition of first layer of enamel5) Deposition of root dentin and cementum

-formation of root dentin induced by Hertwig’s epithelial root sheath

Hertwig’s Epithelial Root Sheath-forms when outer enamel epithelium and inner enamel epithelium combine-determines number, size, and shape of roots-when clinically erupted in mouth, roots are usually ½-2/3 formed

Eruption Times for Primary Teeth1) Mand. incisors: 7 months2) Max. incisors: 11 months3) 1 st molar : 15 months4) Canine: 19 months5) 2 nd molar : 23 months-central incisor and 2nd molar erupt earlier in mandible; lateral incisor, canine, and 1st molar erupt earlier in max.-a 6 month variation time is normal

Eruption Times for Permanent Teeth1) 1 st molar : 6-7 yrs2) Central incisor: 7-8 yrs3) Lateral incisor: 8-9 yrs4) Canine: 9-12 yrs

-mand. canine erupts before max. canine5) 1 st PM : 10-12 yrs6) 2 nd PM : 10-12 yrs7) 2 nd molar : 11-13 yrs8) 3 rd molar : 17-21 yrs-max eruption sequence: 1M-CI-LI-1PM-2PM-C-2M-3M-mand. eruption sequence: 1M-CI-LI-C-1PM-2PM-2M-3M-sometimes in maxilla, the premolars may erupt before the canine but not so in mandible-for most teeth, it takes 4-5 yrs for crowns to complete formation, except for 1st molars (3 yrs) and canines (6 yrs)-it takes 10 yrs from start of calcification to root completion (canines is 13 yrs)-teeth erupt thru bone with 2/3 root formed-teeth erupt thru gingival w/ ¾ root formed-calcification to full eruption to interdigitation is about 5 yrs-eruption to root completion is about 3 yrs

Angle’s Occlusion1) Class I: max. 1M MB cusp fits into mand. 1M buccal groove

-max. canine is distal to mand. canine and mesial to 1PM2) Class II: max. 1M MB cusp mesial to mand. 1M buccal groove

-max. canine is mesial to mand. canine3) Class III: max. 1M MB cusp distal to mand. 1M buccal groove

-max. canine is distal to mand. canine

Anomalies of Tooth Number1) Supernumerary teeth

-most common is mesiodens, of which most are palatal-can be: a) supplemental: have typical anatomy b) rudimentary: conical, tuberculate, or molar-shaped-may block normal eruption of permt teeth so if this is case they can be removed-occurs twice as often in males

2) Congenital absence-most common are: mand. 2nd PM>lateral incisor>max. 2nd PM (not including 3rd molars which are highest)-premolar absence treated with orthodontics as if they were removed for txt-lateral incisor absence treated by placing canine in lateral incisor position and built restoratively to resemble laterals

-canines may remain in normal position and lateral incisors replaced prosthetically

Anomalies of Size1) Microdontia

a) ectodermal dysplasiab) hemifacial microsomiac) Down syndromed) Peg lateral incisor

2) Macrodontiaa) facial hemihypertrophyb) otodental syndrome

3) Fusion: union of two teeth/tooth buds (primary or permt; more common in primary teeth)-fused teeth have 2 pulp chambers and 2 pulp canals-results in large crown-occurs almost always in anterior teeth-can be detected by counting teeth b/c fusion results in one less tooth entity in arch

4) Gemination: division of single tooth bud into bifid crown (2 crowns on single root)-more common in primary teeth-b/c it occurs on a single tooth, there will be a normal complement of tooth entities

5) Concrescence: form of fusion w/ cementum contact (only cementum is fused)-usually results from trauma

Anomalies of Shape1) Dens evaginatus: extra cusp (talon cusp in incisors)

-extra cusp has enamel, dentin, and pulp so must be careful in restorative procedures2) Dens invaginatus (dens in dente): caused by invagination of inner enamel epithelium

-termed “tooth within a tooth”-most common in permt max. lateral incisors-if enamel and dentin not formed correctly within defect, a direct communication with pulp can occur-treated w/ small restoration or sealant to prevent pulpal involvement

3) Taurodontism: long vertical pulp chambers and short roots4) Dilaceration: bent/twisted root occurring as result of intrusive or displacement injury to primary predecessor

-dilaceration also common in congenital ichthyosis

Anomalies of Structure1) Enamel hypoplasia : refers to deficiency in QUANTITY of enamel

-no interproximal contact btw teeth-causes: 1) genetic: amelogenesis imperfecta

2) environmental: systemic dx (fever), fluorosis, nutritional defic. (vit A, C, D, Ca, Ph)2) Enamel hypocalcification : refers to deficiency in QUALITY of enamel

-also has genetic and environmental causes3) Amelogenesis imperfect (AI): related to enamel only and dependent on stage of enamel formation (enamel hypoplasia)

-normal root and pulp morphology1) Type I: Hypoplastic (inadequate QUANTITY of enamel)2) Type II: Hypomaturation (inadequate MATURATION of enamel)3) Type III: Hypocalcified (inadequate QUALITY/mineralization of enamel

4) Dentinogenesis imperfect (DI): predentin matrix is defective, resulting in amorphic, atubular dentin-teeth are reddish-brown to gray color-slender roots-small or absent pulp chambers/canals 1) Type I: osteogenesis imperfecta, blue sclera, hearing loss2) Type II: no osteogenesis imperfecta (most common type)3) Type III (Brandywine type): multiple periapical radiolucencies

5) Dentin dysplasia-Shield type I: Normal anatomy. Short, pointed roots. Absent pulp chambers/canals. Multiple periapical

radiolucencies

-Shield type II: Primary teeth similar to DI. Permanent teeth have pulp stones, thistle tube shaped chambers, no periapical radiolucencies

Part 2: Management of Child BehaviorClassification of Behavior1) Cooperative: children w/ minimal apprehension, communicative, comprehending, and willing

-respond well to behavior shaping2) Lacking cooperative ability: children are deficient in comprehension and communication skills

-includes very young children (under 3 yrs) and disabilities3) Potentially cooperative: are capable of appropriate behavior but disruptive in dental setting

a) Uncontrolled: characterized by tantrums; 3-6 yrs oldb) Defiant: “I don’t want to” attitude in children and passive resistance in adolescents

-can be all agesc) Timid: char. by shielding behavior and hesitation

-usually preschool and young grade school kidsd) Tense-cooperative: want to cooperate and try to behave but are very nervous

-typically older children at least 7 yrs olde) Whining: continuous, whining behavior but no crying

Frankl Behavioral Rating Scale1) Rating 1: definitely negative refusal of txt

-forceful crying, fearful, extreme negativism2) Rating 2: negative reluctance to accept txt

-uncooperative, negative attitude but not pronounced3) Rating 3: positive acceptance of txt

-cautious behavior but willing to comply and cooperates w/ dentist4) Rating 4: definitely positive w/ good rapport w/ dentist

-has active interest in dental procedure and laughs/enjoys visits

Variables Influencing Behavior in Dental Setting1) Age

a) < 2yrs: typically lack cooperative abilityb) 2 yrs: wide variance in ability to communicate

-dentist should use tell-show-do technique-may be helpful to have parent in room due to possible separation anxiety

c) 3-7 yrs: most often are cooperative and willing to comply w/ dental procedures-familiarization techniques and behavior shaping strategies are helpful tools

d) 8+ yrs: children try to control apprehension as they get older but stressful situations may cause them to revert to negative behaviors

-behavior shaping and familiarization techniques can still be helpful2) Maternal anxiety

-high correlation btw maternal anxiety and child’s negative behavior-effect greatest on children under 4 yrs old

3) Past medical history-children w/ positive past medical experiences are more likely to be better at dentist-children who have experienced pain in past medical visits will have more negative behavior-previous surgery correlated w/ negative behavior at first visit

4) Patient awareness of problems-if child thinks they have a dental problem, they are more likely to exhibit negative behavior

The Functional Inquiry1) Goals:

a) Learn pt and parent concernsb) Estimate level of cooperative ability

2) Methods:a) Written questionnaireb) Direct interview

3) Sample questions:a) Reaction to past medical experiences?b) Parental anxiety level?c) How ill the pt react to an exam?

4) Functional inquiry review of medical history:a) ADHD e) Is it 1st visit to dentist?b) Learning disability f) Child’s hobbiesc) Mental health disorder g) Parent/guardian commentsd) Drug/alcohol abuse h) Pt’s medications

Behavior Management Techniques1) Goals:

a) perform quality dentistry for ptb) promote positive pt attitude and confidence in themselves in dental environment

2) Pre-appointment strategiesa) brochure or discussion w/ parentb) videotape presentationc) modeling w/ siblings or parents

3) Techniquesa) Behavior shapingb) Aversive conditioning

Behavior Shaping-procedure that slowly develops behavior by reinforcing successive approximations to a desired goal-reinforcement of desired behavior may be verbal or nonverbal (SMILE, WINK, ETC.) which are very effective-reinforcement should be immediate and specific to the desired behavior

-nonspecific behavior (“you are a good boy”) is not helpful and bores pt after several uses-good example of behavior shaping in the Tell-Show-Do technique (most impt behavior management tech.)

-dentist explains a procedure to child using age-appropriate terminology (Tell), familiarizes pt w/instruments and procedures by gentle demonstration (Show), then performs the procedure (Do)-is indicated for children of all types of behavior/cooperation levels

Aversive Conditioning-psychological strategy that uses some form of negative stimulus w/ purpose of extinguishing or improving negative behavior-indicated for children over 3 yrs of age that are momentarily uncontrolled or defiant-not indicated for children under 3 yrs, timid, tense-cooperative, or lack cooperative ability (mentally challenged)-several variations of aversive conditioning exist:

a) voice control (use firm tones)b) hand-over-mouth exercise (HOME)

-aversive conditioning should always be followed by positive reinforcement for improved behavior-communication w/ parent before and after aversive conditioning is a necessity-aversive conditioning exposes dentist to liability so parental informed consent should be obtained prior to use

Miscellaneous Techniques for Behavior Management1) Appt length: studies conflicting regarding appt length on child’s behavior2) Appt time: some dentists believe morning is better b/c pt is rested while others think afternoon is better b/c pt is less active and more manageable

-one study showed no real difference in appt time on behavior

Checking for Cavities in Toddlers1) Parent sits in dental chair and cradles child in their arms to restrain them

-dentist examines child w/ hands on both sides of head while assistant sits on opposite side to restrain legs2) Parent and dentist sit knee to knee and child’s head rests on dentist’s thighs

Attention Deficit Hyperactivity Disorder (ADHD)-involves two sets of symptoms:

1) inattentive behavior2) combo of hyperactive and impulsive behaviors

-arises btw ages of 2-5 usually and affects 2-9% of school-age children worldwide-can persist into adulthood

-cause unknown-common meds:

a) methylphenidate (Ritalin, Concerta)b) atomoxetine (Strattera)c) amphetamine/dextroamphetamine (Adderal)

-side effects of all types of meds are HTN, nausea, and dry mouth-txt modifications include shorter appts and verbal reinforcement

Management of Angry and Fearful Children1) Angry

a) separate child and parentb) place child inc hair and be firmc) use hand-over-mouth technique (GET PARENT’S PERMISSION)d) display authority and command respecte) comfort and compliment pt at end of visit

2) Fearfula) have parent stand quietly behind chairb) be consistent in voice tonec) permit child to express their fearsd) change child’s focus off of feare) if nothing else works, use sedation

Part 3: Local Anesthesia and Nitrous Oxide Sedation for ChildrenLocal Anesthetics and Max Recommended Doses1) 2% lido w/ 1:100,000 epi: 4.4mg/kg

-safest LA to use in pediatrics2) 3% mepivicaine: 4.4 mg/kg3) 4% prilocaine w/ 1:200,000 epi: 4.4 mg/kg

Calculation of Max Dose and Cartridges1) Obtain pts weight in pounds and convert to kilograms

-1kg=2.2 lbs (divide weight in lbs by 2.2)-ex. 44lb child: 44/2.2=20 kg

2) Multiply weight in kg by max dose to obtain max mg dosage-20 kg x 4.4 mg/kg lidocaine= 88 mg

3) Calculate number of mg/cartridge by multiplying % of local anesthetic times 10 then multiply by size of cartridge-2% x 10= 20 x 1.8= 36 mg/cartridge

4) Divide max mg dose by number of mg per cartridge to get max allowable cartridges-88 mg/ 36 mg/cartridge= 2.44 cartridges

Topical Anesthetics-a good, long-lasting benzocaine topical is recommended

-benzocaine has rapid onset-dry the mucosa w/ gauze first, then apply topical for minimum of 30 seconds

Local Anesthesia for Primary Mand. Molars -innervated by IA nerve1) IA block: used for deep caries, pulp therapy, and extractions

-in primary dentition pt, the mandibular foramen located lower than plane of occlusion so should inject lower for these pts than adult pts-syringe should bisect primary mand. molars on opposite side

2) Lingual nerve block: small amt of anesthetic deposited on withdrawal of needle during IA block3) Long buccal block: deposit small amt of anesthetic in mucobuccal fold distal to most posterior tooth4) Infiltration: there is evidence that mand. infiltration for primary molars is effective, especially for restorative procedures, but there is an increased potential for anesthetic failure

Local Anesthesia for Primary Mand. Anterior Teeth -innervated by IA nerve1) Infiltration: effective for primary anteriors, especially for small restorative procedures or extraction of mobile incisors2) IA block: used where regional anesthesia needed, but should supplement w/infiltration

Local Anesthesia for Primary Max. Molars -innervated by PSA for permt molars and MSA for MB root of 1st permt molar and primary molars1) Infiltration: effective for primary 1st molars due to thin overlying bone but less effective for primary 2nd molars due to thicker bone2) PSA block: used for primary 2nd molars in conjunction w/ infiltration

-PSA also used for 1st permt molar w/ local infiltration for MB root

Local Anesthesia for Primary Max. Anteriors -innervated by ASA branch of maxillary nerve1) Infiltration: effective for primary max anteriors

Local Anesthesia for Palatal Tissues-innervated by anterior palatine and nasopalatine nerves-normal restorative procedures or minor extractions can have anesthesia given at free gingival margin or on palatal tissue where already blanched-surgical procedures may require ASA or nasopalatine nerve blocks, but these are painful and should be avoided

Complications of Local Anesthesia1) Overdose: can cause dizziness, blurred vision, seizures, CNS depression, myocardial depression, and death2) Lip/Cheek trauma: due to numb sensation, children can scratch or chew lip/cheek area

-should warn parents and child before leaving office-reassure parent that these wounds heal quickly and w/o complication

Differences Between Adults and Children Regarding Nitrous Oxide Administration1) Children have higher metabolic rate2) Children have higher respiratory rates3) Higher risk of airway obstruction in children due to narrower airways, large tonsils, and large tongue4) Higher risk of desaturation in children due to less capability to expand lungs on inspiration (less O2 reserve)5) Higher heart rate in children6) Lower BP (systolic and diastolic) in children7) Heart rate has greater effect on BP in children (Drop in HR > BP will decrease relatively more in child)8) Drug effects more variable in children

Conscious Sedation-minimally depressed level of consciousness that retains pt’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal commands-inhalation route is most frequently used route for sedation in pedo (N20)

Purposes of Nitrous Oxide Sedation1) Reduce fear, apprehension, and anxiety2) Raise pain reaction threshold3) Reduce fatigue

Minimum Alveolar Concentration-concentration of drug required to produce immobility in 50% of pts-is measure of potency-minimum alveolar concentration of nitrous oxide is 105%

Four Plateaus of Stage I Anesthesia (Analgesia)1) Paresthesia: tingling of hands and feet2) Vasomotor: warm sensations3) Drift: pupils centrally fixed and sensation of floating4) Dream: eyes closed but will open in response to questions; difficulty speaking; jaw sags open

Preparation of Pediatric Patient for Nitrous Sedation1) Place pt in reclined position2) Use tell-show-do3) Describe sensations in advance

Nitrous Oxide Technique Basics1) Bag is filled w/ oxygen and hood placed on pts nose2) Total flow rate is 4-6 L/min for most children3) Percentage of NO is increased in 10% increments until drift plateau is achieved4) Maintenance dose during operative procedure is about 30% NO

-must use no less than 20% oxygen5) Most common complication of NO is nausea/vomiting, which occurs from excessive concentration of NO or excessively long procedure

-NO levels should be reduced periodically throughout procedure, especially after 30 mins time6) Give 100% oxygen for 3-5 mins after sedation period

Signs of Saturation1) Continuously reminding child to keep mouth open2) No response to questions3) Agitation4) Sweating5) Nausea6) Unconsciousness

Diffusion Hypoxia-when NO is discontinued, there is a high outpouring of NO from tissues into lung, which dilutes available oxygen in lungs-can be prevented by giving 100% oxygen for 3-5 minutes following nitrous oxide procedure

Oral Sedation w/ Chloral Hydrate-acts on CNS to induce sleep

-will not affect breathing, BP, or reflexes-dose: 25-100 mg/kg (max single dose is 1 g)-contraindicated in hepatic or renal impaired pts

General Anesthesia for Pedo-age and maturity used to determine type of anesthesia for children-very young children (below age in which they can reason) are indicated for general anesthesia-most common premedication before GA is Versed

Part 4: Restorative Dentistry for ChildrenAnatomical Differences Between Primary and Permanent Teeth1) Thinner enamel (1mm occlusally)2) Pulp chamber larger3) Pulp horns closer to surface4) Enamel rods in gingival 1/3 slope occlusally instead of cervically5) Crown shorter and has greater cervical constriction6) Interproximal contacts broader and flatter7) Enamel and dentin shades whiter8) Occlusal table is narrower9) Exaggerated buccal and lingual cervical ridges10) Long, slender, and divergent roots w/ little trunk11) Shallower anatomy

Primary Tooth Facts1) Largest primary tooth is mand. 2nd molar

-largest permt tooth is max. 1st molar2) Smallest primary tooth is mand. lateral incisor

-smallest permt tooth is mand. central incisor3) Most common congenitally missing primary tooth is primary max. LI4) Most common primary tooth to be retained is mand. 1st molar5) Max. 1M: intermediate btw PM and molar6) Primary Max 2M resembles permt max. 1st molar and mand. 2M resembles permt mand. 1M7) Primary max. canine have longer, sharper cusps and mesial cusp ridge longer than distal cusp ridge (opposite in permt max. canines)8) Primary max. CI is only ant. tooth in either dentition to have shorter inciso-cervical height than mesiodistal width9) Primary mand. 1st molar has prominent transverse ridge

Characteristics of Primary Mand. First Molar1) Resembles no other tooth2) Wide mesiodistally w/ pronounced cervical ridge3) No central fossa4) Difficult class II preparation

Caries in Primary Teeth1) Dental decay in primary teeth can affect development of adult teeth2) Dental decay in primary teeth often means there will be decay in adult teeth3) Primary teeth are slightly more opaque on radiographs than permt teeth due to higher inorganic content4) Decay in primary teeth progresses more rapidly from initial surface demineralization to dentin involvement due to thinner enamel layer

Restoring Primary Molars w/ Amalgam 1) Prep depth is 0.5mm into dentin or about 1.5mm total depth2) No. 330 and 245 burs common (330 is 1.5mm depth and 245 is 3mm depth)3) Rounded line angles decrease internal stresses and prevent breakage of primary teeth4) Occlusal prep extends into susceptible pits/fissures5) Buccal/lingual extensions for class II proximal box minimally break contact6) Buccal/lingual walls converge occlusally7) Gingival seat contact on box is broken8) Isthmus width is 1/3 intercuspal distance

Restoring Primary Molars w/ Composite1) Preps may be more conservative than amalgam2) Class I preps may be limited to carious region if sealant is used as part of restoration3) Class II preps for composite similar to amalgam if caries exists on occlusal and interproximal4) Must maintain dry field for composites

Indications and Contraindications for Stainless Steel Crowns1) Indications

a) Extensive carious involvement e) Mesial lesions on primary 1st molarsb) Pulpectomy/pulpotomy f) Ankylosed primary molarsc) Malformed teeth g) Young permt molars as semi-permt restorationd) Rampant caries h) Fractured teeth

2) Contraindicationsa) If esthetics are concern d) Space lossb) Teeth nearing exfoliation e) Caries extends cervically so coverage of defect is issuec) Lack of mechanical retention f) As permt restoration in permt dentition from extensive crown loss

Preparation of Tooth For Stainless Steel Crown1) Reduce cusps 1-1.5mm2) Reduce proximal surfaces so that contact w/ adjacent tooth is broken3) Remove all sharp line angles4) Usually not necessary to reduce buccal or lingual surfaces as they aid in retention

-may need to reduce buccal ridge on primary 1st molars5) When fitting SSC, greater length needed in region of MF bulge on primary 1st molar

Restoration of Primary Incisors1) Small class III lesions can be restored w/ composite similar to permt incisors2) Compromised or involved incisal edge (class IV)

-w/ significant incisal edge loss, composite crown is good choice-prep includes caries removal, mesial/distal interproximal reduction, and placing undercut 1m incisal to and following free gingival margin-celluloid crown former is trimmed and adapted to margins-at least one vent hole is created on incisal edge to allow escape of excess composite-crown former filled w/ composite and seated

3) Primary incisors w/ extensive loss of tooth structure-may require stainless steel crowns w/ facial aspect removed and replaced by composite

Restoration of Primary Canines-distal surface of primary canines is common place for caries in caries-prone pts-it is often necessary to place lingual or labial dovetails to aid in retention

Part 5: Pulp Treatment for Primary TeethFour Options for Treating Pulpal Involvement in Primary Teeth1) Pulp Capping2) Pulpotomy3) Pulpectomy4) Extraction

Pulp Therapy Indications and Contraindications1) Indications

a) Mobility: indicates loss of vitality if mobility due to bone destruction, root destruction, or both2) Contraindications

a) children who have serious illnesses, b/c serious complications can result secondary to acute infxn if pulpal therapy fails

-ex. Infective endocarditis, leukemia, nephritis, cancer, decreased PMN count

Pulp Capping1) Indirect pulp cap

a) Indications: pt is symptom free, no radiologic evidence of pathology, and minimal caries in area that would cause pulp exposure if removedb) Procedure: remove caries except that right on pulp; place CaOH and base, restore tooth, re-enter in 6-8 weeks to remove rest of caries

2) Direct pulp capa) Indications: small pinpoint exposure that is non-carious and symptom freeb) Procedure: place CaOH over pulp exposure and restore tooth

Pulpotomy-coronal removal of vital pulp tissue1) Indications

a) vital primary tooth w/ carious exposureb) clinical signs of normal pulp canal (no swelling, drainage, or pathologic mobility, no symptoms)c) tooth is restorable

2) Procedurea) Remove superficial and lateral decayb) Remove roof of pulp chamberc) Remove coronal pulp w/ #4 round bur in slow speed w/ light pressured) Place dry cotton pellets to arrest pulpal bleedinge) Five minute formocresol application

-if hemorrhage can’t b stopped, consider pulpectomy or 2-visit pulpotomyf) Build up in ZOE and place stainless steel crown

3) Medicamentsa) Formocresol: most commonly used medicament for pulpotomies

-consists of 35% cresol, 19% formalin in glycerine solution-formocresol may be toxic-acts by direct contact

b) Ferric sulfate-success rates comparable to formocresol and is less toxic

c) MTA-have shown higher success rates than formocresol

Pulpectomy-complete removal of all remaining pulp tissue1) Indications

a) Necrotic or chronically inflamed pulp in tooth that is strategically locatedb) Normal supporting bone

2) Contraindicationsa) Non-restorable toothb) Internal or external root resorptionc) Tooth doesn’t have accessible canals (primary 1st molars)d) Significant bone loss

3) Procedurea) Remove coronal pulp, irrigate chamber w/ NaHClO, remove radicular pulp w/ small fileb) Obtain working length and enlarge canal 3 file sizesc) Fill canal w/ ZOE by using syringe and condensingd) Build up tooth in ZOE and place SSC

Part 6: Space Maintenance Primary Incisor Loss-loss of primary incisor doesn’t cause loss of overall arch length but may cause localized space loss-replacement of lost primary incisor generally done for esthetic and speech, but not for space maintenance-options: a) partial denture (if pt over 3 yrs old)

b) fixed prosthesis (ortho bands placed on 2nd molars and ortho wire w/ tooth fixed to wire runs along arch-used on pts under 3 yrs old or lack cooperation

-if there is LINGUAL ectopic eruption of permt incisors, giving double row of teeth, you can let primary incisors exfoliate if mobile or else you should extract them

-the permt incisors will move labially once this is done-there can be LATERAL ectopic eruption where central incisors erupt into lateral incisor position, causing early exfoliation of a primary lateral

-this can result in midline deviation so other primary lateral should be extracted

Permanent Incisor Loss-space loss can occur very quickly after losing permt incisor-an appliance should be constructed and inserted as soon as possible

Primary Canine Loss-canine loss causes:

a) lingual collapse of permt incisorsb) loss of arch lengthc) increased overbite and overjetd) midline deviation to side of lost canine (if unilateral)

-if canine loss is unilateral, should extract contralateral primary canine-appliances:

1) Lower lingual holding arch

Primary First Molar Loss1) Lost in primary dentition

a) Unilateral: band-loop space maintainerb) Bilateral: band-loop space maintainer on both sides

DO NOT USE LLHA UNTIL PERMANENT INCISORS ARE ERUPTED. PERMANENT INCISORS COMMONLY ERUPT LINGUALLY AND CAN BE TRAPPED BY THE APPLIANCE. 2) Lost in mixed dentition

a) Unilateral: band-loop space maintainerb) Bilateral: lower lingual holding arch (mandible)/palatal holding arch (max.) or Nance appliance

Primary Second Molar Loss1) Lost in primary dentition

a) Unilateral: distal shoe or acrylic partial dentureb) Bilateral: lower lingual holding arch/palatal holding arch, Nance appliance, or removable appliance

2) Lost in mixed dentitiona) Unilateral: bilateral holding archb) Bilateral: lower lingual holding arch/palatal holding arch, Nance appliance, or removable appliance

Factors in Planning Space Maintenance1) Amount of resorption of primary tooth roots

a) More than 1/4 of root remains: space maintenance likelyb) Less than 1/4 of root remains: space maintenance unlikely

2) Amount of bone covering permt tootha) No bone remaining btw permt and primary tooth: no space maintenance neededb) If bone interposed btw primary and permt tooth: space maintenance likelyc) Bone destruction in region of primary molar furcation: should use space maintenance

3) Time elapsed since lossa) most space closure occurs within first 6 monthsb) in molar area, closure occurs by tipping, not by bodily movement

4) Eruption of neighboring teetha) active eruption creates increased space loss

-ex. If 2nd primary molar lost during eruption of 1st permt molar, more space loss results5) Patient age

-pt age should not be factor in planning space maintenance -use a rule of 7s@ for primary molars

a) eruption is delayed if primary molar lost before age 7b) eruption accelerated if primary molar lost after age 7

Part 7: Perio Problems in ChildrenChild vs Adult Periodontium1) Greater blood and lymph supply 7) Lack of stippling2) Alveolar crest if flatter 8) Flabbier tissue3) Gingival pockets depths larger 9) Rounded and rolled gingival margins4) Attached gingiva not as wide 10) PDL fibers run parallel to teeth (run horizontal in adult)5) Cementum is thinner and less dense 11) Alveolar bone thinner6) Gingiva is more red

Gingivitis-very common in children and treated w/ improved oral hygiene-parental participation needed in oral hygiene in children under 8 yrs old due to lack of manual dexterity -parental supervision may be needed in children over 8 yrs due to lack of interest or understanding of consequences-common conditions in children can aggravate gingivitis:

a) mouth breathing c) erupting teethb) crowded teeth d) braces

Puberty Gingivitis-characterized by enlarged, bulbous interproximal gingival tissue on labial aspects of anterior teeth-treatment involves improved OH, removing local irritants, and nutrition counseling

Herpes Simplex Infection (HSV-1)1) Primary herpetic gingivostomatitis

-usually occurs in children under 6 yrs old w/ no previous exposure to HSV-most infxns are subclinical

2) Acute herpetic gingivostomatitis-liquid-filled yellow vesicles found intraorally and periorally -vesicles rupture to form yellow pseudomembrane and erythematous border-located on tonsils, palate, buccal mucosa, and gingiva-also have fever, malaise, and lymphadenopathy-txt: topical anesthetic, diphenydramine, antivirals (acyclovir), and analgesics (ibuprofen)

3) Recurrent herpes simplex (cold sore/fever blister)-usually found on outside lips-recurrence associated w/ stress or local trauma-txt: systemic or topical antiviral, lysine

Recurrent Aphthous Ulcers-unknown cause-presents as painful ulceration on UNATTACHED mucous membranes-heal on their own, but can help pain w/ topical anti-inflammatory and analgesic agents

Minimal Attached Gingiva/Recession-a labial eruption path is most common cause of inadequate attached gingiva-most common txt is free gingival graft, but ortho txt can sometimes result in increased attached gingiva

Abnormal Frenum Attachment1) Maxillary frenum

-if causing gingival recession, frenum can be dissected-in absence of recession, txt of heavy frenum w/ diastema is delayed until permt canines erupt

-if diastema hasn’t closed once canines erupt, ortho closure done first and frenectomy done next2) Lingual frenum (tongue tie)

-if tongue movement is restricted, this can cause improper speech development-restricted tongue movement judged if pt can’t touch maxillary alveolar process

-lingual frenum can also cause recession-cut in either of these cases

3) Mandibular anterior frenum-can cause recession and should be cut

Aggressive Periodontitis in Children1) Localized aggressive periodontitis: previously called localized juvenile periodontitis

-attachment loss in 1st permt molars and incisors-in primary dentition, occurs around primary molars

-attachment/bone loss is rapid-increased A. Actinomycetemcomitans counts-more common in African-Americans-txt: debridement, surgery and antibiotics (metronidazole w/ amoxicillin, tetracycline)

2) Generalized aggressive periodontitis-involves entire dentition-significant amt of plaque and calculus-txt: debridement, surgery, and antibiotics

Acute Necrotizing Gingivitis (ANUG)-painful, bleeding gingival tissues w/ blunting of interproximal papillae

-pseudomembrane forms on marginal gingiva-also presence of fever and bad breath-most common in teenagers and young adults-caused by spirochetes and anaerobes-txt: debridement, oxidizing mouth rinse, antibiotics

Part 8: Dental Trauma in ChildrenStatistics-trauma more common in males in max. anterior teeth

-pts w/ increased overjet more likely to have trauma-no reliable method to determine vitality of recently traumatized tooth

Reactions of Teeth to Trauma1) Pulpal hyperemia: can lead to necrosis from increased intrapulpal pressure2) Internal hemorrhage: capillaries rupture from increased pressure

-can cause discoloration3) Calcific metamorphosis: pulp canal obliteration

-teeth remain vital but can become yellow in color4) Internal resorption: osteoclast action on root

-“Pink spot” perforation can occur 5) External root resorption: due to damage of periodontal structures occurring in severe injuries causing displacement

a) Surface resorption: normal PDL w/ resorption only in small areasb) Replacement resorption: ankylosisc) Inflammatory resorption: granulation tissue forms; radiolucency seen

6) Pulpal necrosis: due to severing of apical vessels or prolonged hyperemia causing strangulation of vessels7) Ankylosis: occurs w/ PDL injury leading to inflammation and osteoclast activity causing fusion of bone and cementum

-clinically, ankylosed tooth has incisal/occlusal surface gingival to adjacent teeth-do not erupt but continue to sink into gingival tissue

Consequences of Permanent Teeth w/ Injury to Primary Predecessor-primary anterior teeth are positioned labial to permt successor, so an injury that forces root of primary tooth into developing permt tooth can cause injury

1) Hypocalcification/hypoplasia2) Reparative dentin formation3) Dilaceration (or bending of permanent tooth)

Tetanus Coverage1) Uncovered children: give antitoxin (tetanus immune human globulin)2) Children w/ previous coverage but outdated: toxoid booster3) Active immunization: no need for booster

-active immunization includes:a) 3 injxns of diphtheria, pertussis, and tetanus (DPT) vaccine during first yearb) booster at 1.5 and 3 yrsc) booster at 6 yrs and then every 4-5 yrs

Traumatic Injury Follow-up-performed at 1, 2, and 6 month intervals post-injury-electrical pulp tests and thermal tests may be unreliable in primary teeth, but teeth may be normal

Concussion and Subluxation1) Concussion: injury to tooth w/o displacement or mobility (no injury of supporting structures)

-PDL inflamed and tender to pressure2) Subluxation: injury to tooth w/o displacement but has mobility (injury to supporting structures)3) Txt: usually no txt needed, but tell pt to use soft diet, good oral hygiene, and chlorhexidine or peroxide rinse

Lateral Luxation-displacement in axial direction-torn PDL w/ contusion or fx of bone-nontender and nonmobile-txt: allow passive repositioning if possible, but if not then actively reposition and splint for 1-2 wks

-active repositioned tooth will more likely have necrosis than passively repositioned

Intrusion-apical displacement into alveolar bone-unless it is determined that the root of intruded primary tooth is impinging on permt successor, it is left alone in hopes it will re-erupt on its own

-should be extracted if endangering permt tooth-tooth should be x-rayed

Extrusion-partial displacement of tooth out of socket axially-the greater the distance from normal position, the greater chance of severing apical vasculature and pulpal necrosis-tooth can be repositioned and splinted for 7-14 days

-endo txt should be done to prevent pulpal necrosis which can cause problems in permt tooth

Fractures1) Enamel only: smooth enamel and check vitality at 1, 2, 6 months due to possibility of concussion2) Enamel and dentin: smooth edges and restore; check vitality at 1, 2, 6 months3) Enamel, dentin, and pulp:

a) vital pulp: pulpotomyb) necrotic pulp w/o internal/external resorption: pulpectomyc) Necrotic pulp w/ resorption: extraction

Avulsion-replanting primary teeth has poor prognosis

-can be considered if within 30 minutes-if replanted, splint, recommend soft diet, give antibiotics, and follow w/ pulpectomy-antibiotics following replantation:

a) doxycyclineb) Pen VK (if susceptible to tetracycline staining in permt teeth)

-PRIMARY TEETH SHOULD NOT BE REPLANTED

Ellis Classification1) Class I: involves little or no dentin

-enameloplasty or bonding2) Class II: involves dentin but not pulp

-CaOH or GI3) Class III: involves pulp

-pulp therapy and restoration4) Class IV: loss of entire crown

-pulpectomy and SSC5) Class V: teeth avulsed 6) Class VI: fracture of root w/ or w/o loss of crown7) Class VII: displacement of tooth w/ or w/o loss of crown8) Class VIII: fracture of crown en masse9) Class IX: traumatic injuries to primary dentition

Root Fracture-root fractures in primary teeth are rare due to malleable bone surrounding rootsa) Fracture in apical half: splint or no txt if mobility minimal

-fxs in apical 1/3 most likely to undergo repairb) Fracture in coronal half: rigid splint or extraction

Splinting-use stainless steel ortho wire which must be passive (not putting pressure on teeth)-fix to teeth w/ composite-long-term splinting of primary teeth increases risk of ankylosis and should be avoided

Part 9: Miscellaneous Topics in PedoTypes of Mouth Guards1) Stock: available at sporting goods stores

-inexpensive but do not custom-adapt to teeth2) Mouth-formed: also available at sporting goods stores

a) Boil-and-bite: softened in hot water and then adapted to teethb) Shell-type: has outer shell that is firm and inner liner that is made from ethyl methacrylate

3) Custom-fabricated: made by dentist from impression and model-fit better and worn more successfully by patientsa) Vacuum-formed: material heated in vacuum molding machineb) Pressure-laminated: has multiple layers of material

-less susceptible to distortion

Antibiotic Prophylaxis for Pedo Patients1) Conditions requiring prophylaxis:

a) Prosthetic heart valveb) Previous endocarditisc) Congenital heart disease (unrepaired, repaired in last 6 months, or has residual defect)d) Cardiac transplant w/ valvulopathye) Compromised immunityf) Joint replacement within 2 yrs

2) Procedures requiring prophylaxisa) Extractionsb) Perio procedures (probing, prophy, SRP, surgery)c) Implant placement and re-implanting avulsed teethd) Endo surgery/RCT beyond apexe) Placement of ortho bands (not brackets)f) PDL injections

3) Dosages for Childrena) Amoxicillin: 50 mg/kgb) Allergic to penicillin

i) Clindamycin: 20 mg/kgii) Cephalexin: 50 mg/kg

iii) Azithromycin: 15 mg/kgc) Unable to take oral meds: Ampicillin 50 mg/kg

Systemic Fluoride Supplementation

Age<0.3pp

m 0.3-0.6ppm>0.6pp

mbirth-6 months 0 0 06 months-3 yrs 0.25mg 0 0

3-6 yrs 0.5mg 0.25mg 06-16 yrs 1 mg 0.5mg 0

-Rule of 6s: a) if fluoride water level is over 0.6ppm, no supplementationb) if child is under 6 months, no supplementationc) if child is over 16 yrs, no supplementation

Fluoride Facts1) Food and Nutrition Board recommends public water supplies be fluoridated when levels are significantly below 0.7 mg/L2) Fluoride intake of 20-40 mg/day can inhibit enzyme phosphatase

-phosphatase needed for calcium utilization in tissues (bones and teeth)3) Fluoride intake of 40-70 mg/day can cause heartburn and pain in extremities4) Fluoride can displace calcium in body, as well as calcium displacing fluoride (calcium treats fluoride toxicity)5) Topical fluoride does not cause fluorosis, only systemic6) School water fluoridation is 4.5x city water7) Greatest conc. of fluoride at outermost enamel layer8) Proximal and smooth surfaces benefit most from fluoride9) Fluoride excreted by kidney10) Toothpaste contains 1100 ppm fluoride (1% F-)

Types of Fluoride1) 2% Sodium fluoride (NaF): neutral pH (~9), acceptable taste, no adverse effects on restorations2) 8% stannous fluoride (SnF2): nonstable, bad taste, stains restoration margins

-pH of 2 (acidic)3) 1.23% acidulated phosphate fluoride (APF): acceptable taste, can cause etching of porcelain and composites

-pH of 3 (acidic)

Fluoride Toxicity (Lethal Doses)1) Adults: 4-5g2) Children: 15 mg/kg

Symptoms of Fluoride Toxicity1) Nausea/vomiting2) Hypersalivation3) Abdominal pain4) Diarrhea5) Cardiac failure and resp. paralysis6) Fluorosis

Fluorosis (Mottling)-enamel hypoplasia char. by chalky white spots or brown staining and pitting of teeth from increased fluoride levels affecting enamel matrix formation and calcification

-excessive fluoride impairs ameloblastic fxn-severity increases w/ increasing amt of fluoride (low-dose, long-term excess)

-children living in temp. zones where water supply contains higher content of fluoride are most affected-is irreversible condition

Treatment of Fluoride Toxicity1) Syrup of ipecac to induce vomiting2) Calcium products (milk, milk of magnesia) to lower acidity of stomach and combine w/ fluoride to decrease absorption3) Call 911 if needed

Thumb-Sucking Habits-common up to age 3-risk of malocclusion= time/day habit performed x duration of habit (weeks, months) x intensity of habit-effects of thumb-sucking:

1) increased overjet (proclined max. anteriors and retroclined mand. anteriors)2) anterior open bite (supraeruption of posterior teeth)3) posterior crossbite (tongue not positioned btw max. alveolus and cheek constriction)4) class II malocclusion

-txt: recommended intervention at age 5-6 yrs if child still has habit

Teething-symptoms: rise in temp, drooling, diarrhea, dehydration, and loss of appetite-symptoms can be reduced by using chilled teething rings w/ possible use of topical anesthetics and non-aspirin analgesics

Natal and Neonatal Teeth1) Natal teeth: teeth present at birth2) Neonatal teeth: teeth erupting in first 30 days after birth-most natal and neonatal teeth (90%) are primary teeth, only 10% are supernumerary

-most (85%) are mand. incisors-supernumerary teeth should be extracted and extremely mobile primary teeth also to prevent aspiration-tooth can be smoothed or extracted if ulcerates tongue or causing problems w/ breastfeeding

Early Childhood Caries (ECC) (Baby Bottle/Nursing Bottle Syndrome)-presence of more than one decayed, missing, or filled tooth surface in any primary tooth in child 71 months (<6 yrs) or younger-severe ECC:

a) any sign of smooth surface decay in child under 3 yrsb) one or more cavitated, missing, or filled tooth surface in primary max. anterior teeth or dmfs score over 4 in child 3-5 yrs

-typical presentation:a) caries on max. incisors and primary molarsb) mand. incisors unaffected b/c tongue covers these teeth during feedingc) child consistently put to bed w/ bottle containing milk or sugar drink

-recommendations:a) infant shouldn’t be put to bed w/ bottleb) child should drink from cup as approach 1st birthdayc) repeated drinking of fermentable carbohydrate beverage from bottle or sippy cup should be avoidedd) oral hygiene should begin at eruption of first toothe) oral health consult should be done within 6 months but no later than 12 months after eruption of first tooth to educate parentsf) should assess mother’s S. Mutans levels to decrease transmission

Child Abuse and Neglect-dentists mandated by law to report any suspected child abuse or neglect

-proof of abuse/neglect NOT necessary-failure to report suspected abuse/neglect may result in legal ramifications (fine, jail, civil liability)-types:

1) Physical: intentional abuse-common injuries include bruises, welts, lacerations, burns, and fractures-50% of abuse in craniofacial region, w/ 25% in oral region

2) Emotional: denial of affection, isolation, extreme threats, corruption3) Sexual: any type of sexual activity, exhibitionism, and pornography4) Neglect: willful negligence to provide for basic needs of child (food, shelter, clothing, medical care, supervision, protection, guidance)

-willful failure of parent to seek and follow through w/ txt necessary to endure a level of oral health for adequate fxn and freedom from pain and infxn

Pit and Fissure Sealants1) Indications

a) deep pits/fissuresb) caries-free surface or incipient lesion

2) Contraindicationsa) rampant cariesb) interproximal cariesc) well-coalesced groovesd) inability to maintain dry field

3) Technique:a) obtain clean pit/fissures

-pumice, air polishing device, toothbrush, 3% H2O2, enameloplastyb) isolation (rubber dam, cotton rolls, dry angles, etc w/ high-volume suctionc) acid etch (37% phosphoric acid) for 20-30 seconds, rinse 30 seconds, dry w/ air 15 seconds

-check for frosty enamel appearanced) bonding agente) place sealant in all occlusal, buccal, and lingual grooves

-avoid excessive sealant and check occlusion4) Types of sealants

a) resin-based sealants are most common and have superior retention compared to glass ionomer sealants

Cleft Palate-combined cleft lip and palate more common than cleft palate alone

-isolated cleft palate more common in females-4 classes:

1) Class I: only soft palate2) Class II: soft and hard palates but not alveolar process3) Class III: soft and hard palate and involves alveolar process on one side of premaxilla4) Class IV: soft palate and continues through alveolus on both sides of premaxilla

Cleft Lip-more common in males-more common on left side than right-4 classes:

1) Class I: unilateral notching of vermilion not extending to lip2) Class II: unilateral notching that extends into lip but not to floor of nose3) Class III: unilateral notching that extends into floor of nose4) Class IV: any bilateral clefting of lip

Clefting-Associated Syndromes1) Stickler’s syndrome2) Van der Woude’s syndrome3) DiGeorge syndrome

Timing of Treatment for Clefting1) Cleft lip at 10 weeks

-child should be 10 weeks old, 10 lbs, and 10 g/dL Hb2) Cleft palate at 9-18 months

Growth Facts1) At age 6, child’s head is 90% of its adult size

-brain and neural tissues are fully developed at age 62) At birth, jaw is large enough to accommodate all primary teeth3) At birth, width of face has reached greatest percentage of its adult size 4) At birth, palate is pretty flat5) From age 6-12, lymph tissue is 200% of its adult mass

Neuroblastoma-most common malignant tumor in neonates

Down Syndrome-has high incidence of perio dx but low incidence of caries-other characteristics:

1) hypoplasia of midface2) prognathic class III occlusion w/ open bite3) macroglossia4) mouth breathers